Every finding on record at Waters of Batesville, The

Based on observation, interview, and record review, the facility failed to store and prepare foods under sanitary conditions for 3 of 3 kitchen observations and label residents' food items appropriately in the Resident Snack Refrigerator for 1 of 1 Resident Snack Refrigerators. Findings include:1.During the initial kitchen observation, on 03/15/2026 at 9:25 A.M., [NAME] 4 was identified as the staff member in charge. The [NAME] did not know if the dishwasher was a high temperature sanitizing dishwasher or a chemical sanitizing dishwasher. The [NAME] indicated they had worked at the facility for only a few weeks. During the observation of the kitchen with Dietary Aide (DA) 6, on 03/15/2026 at 9:26: A.M., the DA indicated she had worked at the facility since October. The following was observed: -A silver cart on wheels, containing a stack of clean meal trays, was littered with brown crumbs and white/gray splatters,-The area around the steam table reservoirs was littered with brown crumbs,-The plate warmer was littered with brown crumbs on the inside around the top edge and at the bottom of the warmer,-The plate warmer had gray streaks running down the sides on the inside next to the plates,-In the dry storage room was observed with DA 6. During an interview, at that time, DA 6 indicated the facility dented can policy was for staff to use them first, but she was unsure,-A clean dish rack containing empty trays was littered with brown crumbs and dark brown/black grit on the rails the trays sat on,-A plastic bin of flour sitting on the floor under a window air conditioner had black grit littered across the top, and-A 25-pound bag of sugar lying on the top of the flour bin was littered with black grit. The kitchen cleaning schedules were posted in the kitchen, and all cleaning duties had been initialed as completed for 03/15/2026. Lunch was to begin being served at 10:50 A.M., both [NAME] 4 and DA 6 indicated they were unaware of the need to check the temperature of the foods on the steam table prior to serving the meal. They indicated they were the only ones working on the weekend. 2. A kitchen tour was conducted on 03/16/2026 at 10:58 A.M., with the Dietary Manager (DM). The steam table temperatures were obtained. The lunch meal was chicken ala king over a piece of toast, broccoli, and mashed potatoes for residents on a pureed diet. The pureed broccoli and the mechanical soft (ground) chicken did not come up to an acceptable temperature, and the staff placed the metal steam table containers on the gas stove to heat them up. During the process of obtaining the steam table temperatures, the DM, while wearing gloves, pulled his pants up several times while using and cleaning the thermometer. The following was observed in the kitchen, on 3/16/2026 after the 10:58 A.M. food temperatures were obtained: -Two sheet cake pans full of bowls with lids. The pans were labeled as Dessert for lunch 03/16/2026. The pans had a black residue caked all around the edges of the pans, -A silver cart on wheels, containing a stack of clean meal trays, was littered with brown crumbs and white/gray splatters,-The plate warmer was littered with brown crumbs around the top and on the bottom of the plate warmer, and-Gray streaks were running down the inside of the plate warmer next to the plates. During an interview, on 03/19/2026 at 10:15 A.M., the Regional Dietary Manager indicated [NAME] 4 and DA 6 were the kitchen staff for breakfast and lunch, and they worked every other weekend. The kitchen had a cleaning schedule for the dietary staff to sign when duties were completed. During an interview, on 03/19/2026 10:56 AM., the Regional Dietary Manager indicated she did not think the kitchen staff performed chemical testing on the dishwasher because the company who supplied the chemicals for the dishwasher managed the dishwasher chemicals. 3.During an observation of the kitchen, on 03/19/2026 at 12:49 P.M., the dishwasher wash cycle ran at 160 degrees, the rinse cycle ran at 160 degrees. During an interview, at that time, the DM indicated the dishwasher was a chemical dishwasher, then he changed his mind and said it was a high temperature dishwasher. The dishwasher ran one wash cycle and one rinse cycle. During an interview, on 03/19/2026 at 1:09 P.M., the DM indicated the dishwasher was a high temperature dishwasher and the rinse temperature should reach 180 degrees Fahrenheit or higher. They had not had any foodborne illness recently in the facility and he would be using disposable dishware until the dishwasher was reaching the appropriate temperature levels. The Dishmachine Temperature Log (High Temp) records for January, February, and March 2026, were provided by the Regional Dietary Manager. The records indicated the dishwasher rinse temperature failed to reach the recommended 180 degrees Fahrenheit for the rinse cycle on the following dates in February: -On 02/01/2026, at Breakfast, Lunch, and Dinner, the rinse temperatures were 160 degrees Fahrenheit,-On 02/02/2026, at Dinner, the rinse temperature was 170 degrees Fahrenheit,-On 02/03/2026, at Dinner, the rinse temperature was 160 degrees Fahrenheit,-On 02/04/2026, at Dinner, the rinse temperature was 160 degrees Fahrenheit, and-On 02/05/2026, at Dinner, the rinse temperature was 170 degrees Fahrenheit. The records indicated the Final Rinse temperature should be between 180 to 195 degrees Fahrenheit. Staff were to circle the temperatures that did not meet the minimum standard and notify the supervisor. No temperatures were circled on the records. The current Food Temperatures at Point of Service policy, with a reviewed date of 07/14/2023, indicated, .Hot foods will be held at temperatures 135 degrees or above . 4.The Resident Snack Refrigerator was observed on 03/19/2026 at 2:05 P.M., with Qualified Medication Aide (QMA) 2, and contained the following: -A bottom drawer contained a brown grocery bag, dated 03/18/2026. Inside the bag was an opened plastic bag of salad mix and two bottles of salad dressing. No resident name or room number was noted on any of the products. The QMA indicated items should be labeled with a resident's name and a date. The current Food from Outside Sources policy, dated 07/25/2023, indicated, .Food from outside sources must be labeled with the resident's name, dated, sealed properly and stored appropriately for the type of food . 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on interview, observation, and record review, the facility failed to ensure residents' food was palatable, attractive, and served at the proper temperature for 2 of 3 meal observations. Findings include:1.During an interview with kitchen staff, on 03/15/2026 at 9:25 A.M., [NAME] 4 indicated lunch was to be served starting at 10:50 A.M. Both [NAME] 4 and Dietary Aide (DA) 6 indicated they were unaware of needing to check the temperature of the foods on the steam table prior to serving the meal. They indicated they were the only ones working on the weekend. During an interview, on 03/16/2026 at 10:49 A.M., Resident 46 indicated the food in the facility was not appealing. He usually ate in his room, and his meal was usually cold when he received it. During an interview, on 03/16/2026 at 11:00 A.M., Resident 32 indicated the food was bad. It was always cold. Staff would warm it up, but she shouldn't have to ask them too. She always ate meals in her room. 2. During the survey from 03/15/2026 through 03/19/2026, an anonymous family interview indicated the food served to the residents was a disaster. During an interview, on 03/15/2026 at 12:10 P.M., Resident 48 indicated the food in the facility was not always good and sometimes cold when it was delivered to her room. Her family member would bring her food from home. On 03/16/2026 at 2:12 P.M., Resident 48 indicated her family member had brought her food from home. There were times when food from the kitchen was cold. During an interview, on 03/18/2026 at 1:36 P.M., Resident 23 indicated there was a lot of concerns about the food all the time. The food was cold a lot and it was not appealing. During an observation, on 03/16/2026 at 10:54 A.M., a test tray was sampled. The tray held a slice of toasted bread with cooked chicken, and broccoli. The bread and chicken were covered with gravy, peas, and carrots. There were bowls of mashed potatoes, puree broccoli, puree chicken, and mechanical soft chicken. The food was cold to taste, bland with no flavor, carrots were hard, and hard and tough to chew the non-pureed food. A kitchen tour was conducted on 03/16/2026 at 10:58 A.M., with the Dietary Manager (DM). The steam table temperatures were obtained. The lunch meal was chicken ala king over a piece of toast, broccoli, and mashed potatoes for residents on a pureed diet. The pureed broccoli and the mechanical soft (ground) chicken did not come up to an acceptable temperature, and the staff placed the metal steam table containers on the gas stove to heat them up. On 03/19/2026 a test tray was obtained from the last hall cart. The cart was taken to the hallway from the kitchen at 11:16 A.M. The test tray was brought to the conference room at 11:23 A.M. and the temperature was tested at 11:24 A.M., by the Regional Dietary Manager. The following was observed: -Regular spinach was 113 degrees Fahrenheit, -Pureed spinach was 110 degrees Fahrenheit, and-Pureed ham and beans was 110 degrees Fahrenheit. During an interview, on 03/19/2026 at 11:24 A.M., the Regional Dietary Manager indicated the food on the steam table should not be served at those temperatures below 135 degrees Fahrenheit. The current facility policy titled, Food Temperatures at Point of Service with a revision date of 06/27/2023, was provided by the Regional Dietary Manager on 03/19/2026 at 3:08 P.M. The policy indicated, .Food will be prepared, held, and served in a manner that preserves nutritive value and palatability.Best efforts will be made to present hot food hot and cold foods cold at point of service.Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(a)(2)

Based on interview, observation, and record review, the facility failed to answer call lights in a dignified manner for 1 of 14 residents reviewed for dignity. (Resident D)Findings include:During an anonymous resident interview, during the survey from 03/15/2026 through 03/19/2026, the resident indicated staff didn't always answer the call light in a timely manner. Sometimes it took an hour for them to come. During a continuous observation, on 03/17/2026 from 2:27 P.M. through 2:43 P.M., the following was observed:-At 2:27 P.M., Resident D was in his room, the resident's call light was on and visible from the hallway, RN 9 left a resident's room a few doors down from Resident 3's room and went to the nurse's station, sat down at the computer, and started typing, -At 2:30 P.M., Resident D's call light was still on, unanswered, a (Certified Nurse Aide) CNA from another hallway, went to a closed room, retrieved a full body mechanical lift, and stopped at the nurses' station and asked RN 9 for assistance. The RN left the nurses' station to assist the CNA,-At 2:34 P.M., Resident D's call light remained on without staff present, -At 2:38 P.M., Resident D's call light remained on without staff present, -At 2:41 P.M., Resident D's call light remained on, RN 9 returned to the nurse's station and sat down in front of the computer. Another nurse came to a medication cart at the nurses' station and was working on the computer, -At 2:43 P.M., Resident D's light remained on, RN 9 got up from the desk and went to the Assistant Director of Nursing's office,-At 2:43 P.M., Resident D's call light was answered by a CNA. During an interview, on 03/17/2026 at 2:52 P.M., Resident D indicated he had his call light on because he needed to use the restroom. He didn't make it and urinated on himself. He also had to have a bowel movement and almost didn't make it on the bedpan. During an interview, on 03/19/2026 at 9:49 A.M., CNA 3 indicated any staff member could answer call lights and they should be answered timely. The current, undated, facility policy titled, DIGNITY, was provided by the Regional Nurse Consultant on 03/19/2026 at 1:18 P.M. The policy indicated, .Residents are to have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or understand what is being said or done by others. The current, undated, facility policy titled, CALL LIGHTS, was provided by the Regional Nurse Consultant on 03/19/2026 at 1:18 P.M. The policy indicated, .It is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance.All facility staff must be oriented to and aware of the call light system.Call lights are to be answered promptly by staff who see that the call light has been activated.Even if you are unable to meet the need of a resident, you can report the need to the appropriate staff member. This citation relates to Intake 2798581. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(a).

Based on record review and interview, the facility failed to accommodate a resident's needs related to transportation for 1 of 14 residents reviewed for accommodation of needs. (Resident D)Findings include:The clinical record for Resident D was reviewed on 03/17/2026 at 9:30 A.M. An admission Minimum Data Set (MDS) assessment, dated 12/12/2025, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, cellulitis of the lower limb (presents of painful, warm, and expanding red inflammation, often accompanied by edema/swelling).A physician's order, dated 12/10/2025 through 12/12/2025, indicated staff were to schedule an appointment for the resident to see a lymphedema (chronic swelling, typically in legs or arms, caused by a blockage or damage to the lymphatic system) specialist. A Progress Note, dated 12/12/2025 at 3:23 P.M., indicated the staff member had tried to call about a lymphedema appointment. There was no answer. A physician's order, dated 12/16/2025 through 12/18/2026, indicated staff were to schedule an appointment for the resident to see a lymphedema specialist. A physician's order, dated 01/09/2026 through 01/12/2026, indicated staff were to schedule an appointment for the resident to see a lymphedema specialist. A Progress Note, dated 01/09/2026 at 1:14 P.M., indicated the Nurse Practitioner saw the resident that day and a new order was obtained to refer the resident to a lymphedema specialist. A Social Service Progress Note, dated 01/13/2026 at 3:11 P.M., indicated the writer contacted the lymphedema office to schedule an appointment. The office indicated there was currently a wait list, but they would attempt to schedule the resident as soon as an appointment was available. The writer would follow-up as needed. A physician's order, dated 02/11/2026 through 02/14/2026, indicated staff were to schedule an appointment for the resident to see a lymphedema specialist. A Social Service Progress Note, dated 02/12/2026 at 11:06 P.M., indicated the writer left a message for the lymphedema office to follow-up on the resident's status on the wait list and to request any updates regarding the appointment availability. The writer was awaiting a return call. A Social Service Progress Note, dated 02/27/2026 at 3:53 P.M., indicated the writer continued to secure an appointment for the resident at a lymphedema clinic. The writer contacted a local office for updated availability and the office reported they were several months behind and continue to have no openings for facility visit appointments at that time. The writer also contacted a local fire department regarding transportation options for the resident to attend a lymphedema clinic in another town. The fire department indicated due to the resident's bariatric weight; the current stretcher was not safe to transport the resident. They indicated they had a new bariatric stretcher ordered to safely transport the resident to appointments and were waiting for it to be delivered. A Social Service Progress Note, dated 03/16/2026 at 2:17 P.M., indicated the writer contacted the transport service to follow-up on the delivery status of the bariatric stretcher. It was reported that it had not been delivered at that time and they would notify the writer once the delivery had been made. The writer would continue to follow-up as needed to support safe transport for the resident. The clinical record lacked indication the physician had been notified regarding the resident not being able to make it the lymphedema specialist. During an interview, on 03/19/2026 at 10:34 A.M, the SSD indicated she had been trying to find transportation for Resident 3 to go the lymphedema specialist. The local office was not taking any new patients. She had found a place in another town, but the resident's wheelchair didn't fit on the facility bus so he would have to go by stretcher. The local fire department the facility utilized had to get a bariatric stretcher for the resident to be transported. They were the only place the facility used to transport residents to appointments. She called them weekly to check on the status of the bariatric stretcher. During an interview, on 03/19/2026 at 2:15 P.M., the Administrator indicated when they were admitting a new resident to the facility, the liaison would send all the resident's information to the facility prior to the admission. The facility would review the information to ensure they had the appropriate equipment to care for the resident. The facility had their own bus they used to transport residents to appointments but could also use a local ride service or the local fire department. There were also other transport services they could reach out to if needed. The current facility policy titled, GUIDELINES TO ENSURE REASONABLE ACCOMODATION OF NEEDS dated 06/20/2023, was provided by the Regional Nurse Consultant on 03/19/2026 at 1:18 P.M. The policy indicated, .It is the intent of this facility to provide, at minimum, reasonable accommodations.for those persons (residents) residing in the nursing home facility. The resident has the RESIDENT RIGHT to receive care and services with reasonable accommodation of needs and preferences except when the health or safety of the resident could be jeopardized. This citation relates to Intake 2737502. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(v)(1).

Based on record review and interview, the facility failed to notify the physician of a change in residents' conditions related to blood pressures and blood glucose levels for 2 of 14 residents reviewed for notification of change. (Residents B and C) Findings include:1. Resident B's clinical record was reviewed on 03/17/2026 at 10:30 A.M. An admission Minimum Data Set (MDS) assessment, dated 10/15/2026, indicated the resident's diagnosis included, but was not limited to hypertension (high blood pressure). The resident's MD orders included, but were not limited to, an order with a start date of 10/18/2025 that was discontinued on 01/03/2026, for hydralazine, 100 milligrams (mg). The resident was to receive the medication three times a day for hypertension. Nursing staff were to notify the MD if the resident's systolic (top number/heart at work) blood pressure was over 180 millimeters of mercury (mmHg). The resident's December 2025 Electronic Medication Administration Record (EMAR) was reviewed and indicated the resident's systolic blood pressure was over 180 mmHg on the following dates and times: - On 12/07/2025 at 7:00 A.M., the resident's systolic blood pressure was 210 mmHg,- On 12/12/2025 at 7:00 A.M., the resident's systolic blood pressure was 186 mmHg,- On 12/14/2025 at 5:00 P.M., the resident's systolic blood pressure was 188 mmHg,- On 12/19/2025 at 7:00 A.M., the resident's systolic blood pressure was 189 mmHg, and- On 12/20/2025 at 7:00 A.M., the resident's systolic blood pressure was 189 mmHg. The resident's EMAR and Progress Notes lacked documentation the MD was notified of the above listed systolic blood pressures. 2. Resident C's clinical record was reviewed on 03/17/2026 at 11:00 A.M. A Comprehensive MDS assessment, dated 02/09/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, diabetes (persistently high blood sugar levels). The resident's current MD orders included, but were not limited to, an open-ended order, with a start date of 01/29/2026, to check and record the resident's blood glucose (BG) level four times a day (8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Nursing staff were to call the MD if the resident's BG was less than 60 or above 350. The resident's February and March 2026 EMAR were reviewed and indicated the resident's BG level was above 350 on the following dates and times:- On 02/01/2026 at 12:00 P.M., the resident's BG level was 376,- On 02/02/2026 at 8:00 A.M., the resident's BG level was 425; at 12:00 P.M., the resident's BG level was 436; and at 8:00 P.M., the resident's BG level was 442,- On 02/04/2026 at 8:00 P.M., the resident's BG level was 360,- On 02/07/2026 at 8:00 A.M., the resident's BG level was 364; and at 12:00 P.M., the resident's BG level was 376,- On 02/11/2026 at 12:00 P.M., the resident's BG level was 400,- On 02/16/2026 at 8:00 P.M., the resident's BG level was 383,- On 02/21/2026 at 12:00 P.M., the resident's BG level was 400,- On 02/22/2026 at 8:00 P.M., the resident's BG level was 479,- On 02/24/2026 at 12:00 P.M., the resident's BG level was 385,- On 02/27/2026 at 8:00 P.M., the resident's BG level was 363,- On 03/04/2026 at 8:00 A.M., the resident's BG level was 399; at 12:00 P.M., the resident's BG level was 395; and at 8:00 P.M., the resident's BG level was 381,- On 03/05/2026 at 8:00 P.M., the resident's BG level was 396,- On 03/06/2026 at 12:00 P.M., the resident's BG level was 376,- On 03/12/2026 at 12:00 P.M., the resident's BG level was 398,- On 03/15/2026 at 4:00 P.M., the resident's BG level was 400,- On 03/16/2026 at 12:00 P.M., the resident's BG level was 398; at 4:00 P.M., the resident's BG level was 392; and at 8:00 P.M., the resident's BG level was 444. The resident's EMAR and Progress Notes lacked documentation the MD was notified of the above listed BG levels. During an interview, on 03/18/2026 at 1:03 P.M., Licensed Practical Nurse (LPN) 8 indicated if a resident had an order to notify the MD related to a resident's blood pressure or blood glucose levels, below or above a certain range, there was a place in the computer for documentation. Nurses would enter the blood pressure or blood glucose levels in the computer and indicate if the MD was notified and if there were any new orders. It would show up in the resident's progress notes and on the EMAR as well. The current, undated facility policy, titled Change in Resident's Condition or Status was provided by the Regional Nurse Consultant on 03/19/2026 at 1:18 P.M. The policy indicated, .The nurse will notify the resident's attending physician when. Any result of a specifically ordered diagnostic test/evaluation that is outside normal parameters. 410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(3) This citation relates to Intake 2788021

Based on record review and interview, the facility failed to initiate a resident's baseline care plan related to dialysis for 1 of 18 residents reviewed for care plans. (Resident 58)Findings include:During an interview, on 03/15/2026 at 12:20 P.M., Resident 58 indicated he was admitted to the facility about three weeks ago and was going to dialysis a few times a week. The clinical record for Resident 58 was reviewed on 03/17/2026 at 9:37 A.M. An admission Minimum Data Set (MDS) assessment, dated 03/08/2026, indicated the resident was severely cognitively impaired. The resident's diagnosis included, but was not limited to, end stage renal disease (chronic kidney disease where kidneys function at less than 15% of normal capacity). The resident admitted to the facility on [DATE]. The resident's hospital records were provided by the Regional Nurse Consultant on 03/18/2026 at 11:08 A.M. The records indicated the resident had received dialysis while in the hospital. The clinical record lacked a baseline care plan for the resident on dialysis. During an interview, on 03/18/2026 at 1:25 P.M., the MDS Coordinator indicated baseline care plans were developed within the first 48 hours of admission and the complete care plan was developed up to 21 days later. If the resident was receiving dialysis a baseline care plan should have been completed. The nurse failed to initiate a dialysis care plan. The current, facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans was provided by the Regional Nurse Consultant on 03/19/2026 at 1:34 P.M. The policy indicated, .It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of admissions.and will address areas of imminent concerns.410 IAC (Indiana Administrative Code) 16.2-3.1-35 (b)(1)

Based on record and interview, the facility failed to follow physicians' orders related to hold parameters for a cardiac medication and monitoring a resident's weights for 2 of 14 residents reviewed for quality of care. (Residents C and D)Findings include:1. Resident C's clinical record was reviewed on 03/17/2026 at 11:00 A.M. A Comprehensive Minimum Data Set (MDS) assessment, dated 02/09/2026, indicated the resident's diagnoses included, but were not limited to, renal insufficiency (kidneys underperforming) and diabetes (high blood sugar levels). The resident's current MD orders included, but were not limited to, an open-ended order, with a start date of 02/18/2026, for Midodrine 10 milligrams (mg). Nursing staff were to administer the resident's medication three times a day (8:00 A.M, 2:00 P.M., and 8:00 P.M.) only if the resident's systolic blood pressure (SBP; top number) was below 100 millimeters of mercury (mmHg). The resident's March 2026 Electronic Medication Administration Record (EMAR) was reviewed and indicated the resident received the medication when their SBP was above 100 mmHg on the following dates and times: - On 03/03/2026 at 8:00 P.M., the resident's systolic blood pressure was 143 mmHg, - On 03/07/2026 at 8:00 A.M., the resident's systolic blood pressure was 130 mmHg; and at 2:00 P.M., the resident's systolic blood pressure was 138 mmHg, - On 03/08/2026 at 8:00 A.M., the resident's systolic blood pressure was 130 mmHg; and at 2:00 P.M., the resident's systolic blood pressure was 127 mmHg, - On 03/14/2026 at 8:00 A.M., the resident's systolic blood pressure was 132 mmHg; and at 2:00 P.M., the resident's systolic blood pressure was 126 mmHg, and - On 03/16/2026 at 8:00 A.M., the resident's systolic blood pressure was 134 mmHg; and at 2:00 P.M., the resident's systolic blood pressure was 126 mmHg. During an interview, on 03/18/2026 at 1:03 P.M., Licensed Practical Nurse (LPN) 8 indicated If a resident had parameters for cardiac medications, she would assess the resident's blood pressure and/or heart rate before she administered the medication. If anything was out of range, she would not administer the medication. There was a place on the EMAR to indicate the medication was not administered and why it wasn't administered. Nursing staff would enter a note and that would show up in the resident's progress notes. If the resident's vital signs were out of range and the resident was symptomatic, she would notify the MD. The current facility policy, titled DRUG ADMINISTRATION--GENERAL GUIDELINES, dated July 2024, was provided by the Regional Nurse Consultant on 03/19/2026 at 1:15 P.M. The policy indicated, .Medications are administered in accordance with written orders of the attending physician. 2. The clinical record for Resident D was reviewed on 03/17/2026 at 9:30 A.M. An admission MDS assessment, dated 12/12/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, respiratory failure (lungs cannot adequately sypply oxygen to the blood or remove carbon dioxide) and cellulitis of the lower limb (infections of the lower leg with swollen (edema), painful, and warm to touch). An open-ended physician's order, with a start date of 01/20/2026, indicated the staff were to weigh the resident daily for weight monitoring. The January, February, and March 2026 EMAR and clinical record lacked indication the resident's weights were obtained on the following dates: 01/24/2026, 01/25/2026, 01/29/2026, 02/08/2026, 02/12/2026, 02/26/2026, 03/02/2026, 03/07/2026, 03/08/2026, and 03/12/2026. During an interview, on 03/19/2026 at 9:49 A.M., CNA 3 indicated if a resident was ordered to have daily weights, then the CNAs would obtain the resident's weight and report it to the nurse. During an interview, on 03/19/2026 at 10:40 A.M., RN 9 indicated if a resident was ordered to have daily weights, then the resident's weights would be documented in the EMAR or in the resident's clinical record. The current facility policy titled, GUIDELINES FOR OBTAINING RESIDENTS' WEIGHTS with a revision date of 07/24/2023, was provided by the Regional Nurse Consultant on 03/19/2026 at 1:18 P.M. The policy indicated, .Accuracy with weight measurement is essential for residents in the long-term-care setting. Weight measurement is used to calculate energy, protein, and fluid needs. Further, weight is an indicator of nutritional and health status and changes in weight can often indicate other medical changes. Inaccurate weight measurements can result in an increased number of unplanned weight changes in the facility—and can affect the plans of care for the residents.Daily weights mean DAILY, 7 days weekly. Weekly weights mean WEEKLY month to month—record and then report to physician per physician order and/or policy. This citation relates to Intake 2788021. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(6).

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines during incontinence care for 1 of 3 residents reviewed for Urinary Tract Infections (UTI). (Resident 18) Findings include:Incontinence care for Resident 18 was observed on 03/18/2026 at 1:58 P.M., with Qualified Medication Aide (QMA) 2 and Certified Nurse Aide (CNA) 3. The staff members gathered supplies, washed their hands, donned gloves, and explained the procedure to the resident. The CNA placed a stack of wet wash cloths on the side rail of the resident's bed. The resident's pajama pants were pulled down to the tops of her knees, and her brief was pulled away from her front. Her legs were close together throughout the process. CNA 3 wiped the front of the resident's periarea (privates) with wash cloths from the front to the back. Several of the washcloths had feces on them. The resident was rolled to her side, QMA 2 held her in place, and CNA 3 removed the resident's brief and wiped the resident's backside. The resident was not dried nor were the folds of her private area parted to ensure they were cleaned thoroughly. The CNA removed her gloves, used hand sanitizer, donned clean gloves, applied a fresh brief, pulled the resident's pants up, removed her gloves, and covered the resident with her blankets. The CNA gathered the trash, washed her hands, and exited the resident's room. During an interview, on 03/18/2026 at 2:14 P.M., Licensed Practical Nurse (LPN) 5 indicated the resident had just completed a regime of Intravenous (IV) antibiotics for a UTI. During an interview, on 03/18/2026 at 2:41 P.M., QMA 2 indicated the process for pericare (incontinence care) for a female, after getting wash rags ready, was to open the labia (folds of tissue), clean one part, flip the rag, clean the other side, flip the rag, and clean the middle. Using a rinse rag, follow the same pattern, then pat dry. They move the resident's legs so they can clean it better. She did not believe Resident 18 had contractures (stiffened muscles, tendons, or other soft tissue). During an interview, on 03/18/2026 at 2:46 P.M., the Assistant Director of Nursing (ADON) indicated the resident did not have contractures. When providing peri-care on a female, the residents legs should be spread apart and their pants taken off in order to get their legs apart. A resident should be wiped until there was nothing on the washcloth. The clinical record for Resident 18 was reviewed on 03/17/2026 at 2:15 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/27/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, Parkinson's disease (progressive, neurodegenerative movement disorder that occures when brain cells that produce dopamine die leading to tremors, muscle stiffness, slowness of movement, and balance issues). The physician's orders indicated the resident had received the following antibiotics for UTIs: -Bactrim 800-160 milligrams (mg) two times a day for seven days, with a start date of 02/25/2026, and -Meropenem Intravenous Solution 1 gram two times a day for seven days, with a start date of 03/10/2026.The current undated Perineal Care policy indicated, .Separate the labia and clean downward from front to back with one stroke .Repeat the procedure until the area is .clean .Rinse .Pat dry with a .towel .410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation and interview, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed, 1 of 1 treatment carts reviewed, and a random observation. (77 Front Treatment Cart, 77 Front Medication Cart, and 39 front Medication Cart). Findings include:1. During the initial tour of the facility, on 03/15/2026 at 9:05 A.M., a medication cup that contained an unknown powder substance was observed sitting on the counter above the desk at the nurses' station, unattended and no staff within sight of the nurses' station. During an interview, on 03/15/2026 at 9:10 A.M., Licensed Practical Nurse (LPN) 10 indicated she was unsure of what was in the medication cup and who placed it on the counter. It may have been nystatin powder (a topical anti-fungal medication). The medication should not have been left out on the counter. 2. During the initial tour of the facility, on 03/15/2026 at 9:05 A.M., the 77 Front Treatment Cart was unlocked. The treatment cart was unattended and no staff were within sight of the cart. The treatment cart contained physician prescribed creams and cleansers labeled with resident names and an assortment of bandages. 3. The 77 Front Medication Cart was observed on 03/15/2026 at 9:13 A.M., with LPN 10. The cart contained a half full Lantus insulin pen belonging to Resident 45. The insulin pen lacked an opened date. Sitting on top of the medication cart were three plastic cups with lids each containing 2 ounces of a dark brown substance, there were no dates or label to identify the substance. During an interview, on 03/15/2026 at 9:15 A.M., LPN 10 indicated the dark substance was chocolate pudding to be used during medication pass and should have been dated. The Lantus insulin pen should have had an opened date, and the treatment cart should have been locked. 4. The 39 Front Medication Cart was observed on 03/15/2026 at 9:25 A.M., with LPN 5 and contained the following loose pills along with a moderate amount of paper debris:- one small round orange tablet,- one small round white tablet, and- one large oval white tablet. During an interview, on 03/15/2026 at 9:27 A.M., LPN 5 indicated there should not be any loose pills in the medication cart. The current MEDICATION STORAGE IN THE FACILITY policy, dated February 2017, was provided by the Regional Nurse Consultant 03/19/2026 at 1:34 P.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations . 410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)410 IAC 16.2-3.1-25(k)(1)410 IAC 16.2-3.1-25(k)(2)410 IAC 16.2-3.1-25(k)(3)410 IAC 16.2-3.1-25(k)(5)410 IAC 16.2-3.1-25(k)(6)410 IAC 16.2-.1-25(o)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to Enhanced Barrier Precautions (EBP) for 1 of 3 residents observed for infection prevention. (Resident 6)Findings include:1.a. A wound dressing change for Resident 6 was observed on 03/18/2026 at 1:07 P M., with Licensed Practical Nurse (LPN) 5. The nurse gathered supplies at the treatment cart, entered the resident's room, and placed the supplies on the over bed table. The table also contained squishy gel toys belonging to the resident. The nurse washed her hands, donned clean gloves, prepared a clean garbage bag, removed a blanket from the resident's right leg, and took the resident's soft boot off, placing it under his heel. The resident's right ankle was wrapped in gauze. The nurse placed scissors, a pen, and the wound dressing supplies on the over bed table. The nurse indicated she had forgotten to bring an Abdominal (ABD) gauze pad for the dressing change, removed her gloves, and left the room to retrieve one. The nurse reentered the room carrying an opened, not packaged, ABD pad in her bare hand. She laid the pad on the over-bed table, washed her hands, donned clean gloves, picked up the scissors, cut the old dressing on the resident's foot, unwrapped the foot, and threw the old dressing materials in the trash. The nurse cleaned the small wound on the back of the heel with normal saline and removed her gloves. She opened the treatment packages, donned clean gloves, administered the treatment, applied the ABD pad to the back of the heel, and began wrapping the heel and ankle with rolled gauze. The nurse dropped the rolled gauze on the floor, removed her gloves, and left the room to get a new roll of gauze. She reentered the room with a new package of rolled gauze, washed her hands, donned clean gloves, and wrapped the resident's right ankle with the rolled gauze. The LPN's hair was touching the resident's foot at times during the dressing change. The nurse applied tape to hold the gauze in place and applied the resident's soft boot. During an observation and interview, immediately following the dressing change, LPN 5 was shown the Enhanced Barrier Precautions sign on the outside of the resident's room door. The nurse indicated she was not aware of the resident being in EBP. The sign indicated staff were to wear a gown and gloves when providing care to the resident. Resident 6 was the only resident assigned to the room. During an interview, on 03/19/2026 at 9:27 A.M., the Assistant Director of Nursing (ADON) indicated Resident 6 had an infection in his wound on his heel awhile back. The clinical record for Resident 6 was reviewed on 03/19/2026 at 9:41 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/17/2025, indicated the resident was rarely/never understood. The resident's diagnosis included, but was not limited to, obstructive hydrocephalus (buildup of cerebrospinal fluid caused by a physical blockage within the brain's ventricular system which can lead to permanent damage). The resident was at risk for pressure ulcers and had one unhealed stage 2 (Partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer) pressure ulcer that was not present on admission to the facility. 1.b. Resident 6 was observed for medication administration on 03/18/2026 at 11:07 A.M. LPN 5 indicated the resident was to receive medication and a nutritional supplement through his feeding tube. The resident's door had a sign that was visible upon entry that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Everyone must wear gloves and a gown when providing care, including device care or use of a feeding tube. LPN 5 entered the resident's room and administered a liquid medication and a container of a nutritional supplement through the resident's feeding tube without donning a gown. During an interview, on 03/19/2026 at 12:48 P.M., the ADON indicated staff were to wear a gown and gloves when providing care for a resident on EBP. That included during a wound treatment, catheter care, or dealing with a feeding tube. The current facility policy, titled 'GUIDELINES for ENHANCED BARRIER PRECAUTIONs (EBP) An extension of Personal Protective Equipment (PPE) with a revision date of December 2022, was provided by the Regional Nurse Consultant on 03/19/2026 at 3:00 P.M. The policy indicated, .It is the policy of the facility to ensure that additional and appropriate PPE (Personal Protective Equipment) is utilized, when indicated, to prevent the spread of Multidrug-resistant Organisms also known as MDROs. Examples of High Contact Resident Care Activities at which time EBP is to be practiced are.Dressing care/changes/management of dressings.feeding tubes. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on interview and record review, the facility failed to prevent staff to resident verbal abuse for 2 of 3 residents reviewed for abuse. (Residents D and F)Findings include:1.During an interview, on 01/29/2026 at 9:22 A.M., Resident D indicated Certified Nurse Aide (CNA) 6 was mean and said bad words to him. He would not specify what the bad words were exactly.The clinical record for Resident D was reviewed on 01/30/2026 at 1:25 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, cerebral palsy (neurological disorders appearing in infancy that permanently affect body movement), diabetes, and renal insufficiency. The resident was frequently incontinent of urine and bowel.In a CONFIDENTIAL WITNESS STATEMENT, dated 01/11/2026, Resident D indicated CNA 6 had said a bad word to him. Resident D had informed CNA 6 he needed to use the bathroom. The resident reported the aide responded, I will come back later; I've got other people to worry about. The resident stated he rang the call light again because by now he had a bowel movement accident while waiting. The resident reported the aide told him, You need to keep your mouth shut and you don't need to get into other people's business. The resident stated while the aide was gathering supplies for his personal care due to his bowel accident, the resident overheard the aide in the hallway say, I am sick and tired of taking care of (Resident D). The resident reported he did not feel well at the time and believed his stomach discomfort was related to the food that had been served that day. The resident also described a separate incident on an unknown date involving the same CNA. The resident reported the aide told him, If you don't do what I want you to do-meaning utilize the call light for assistance, you will need to find another nurse to help.2. During an interview, on 01/29/2026 10:15 AM., Resident F indicated CNA 6 was hostile towards him. The CNA went out of his way to act like he was hurting himself trying to help the resident; and that made the resident feel uncomfortable. The CNA was overly dramatic and made (negative) sound effects when he was helping him. The clinical record for Resident F was reviewed on 01/30/2026 at 1:40 P.M. A Quarterly MDS assessment, dated 10/15/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure and diabetes. The resident was occasionally incontinent of urine and frequently incontinent of bowel. A CONFIDENTIAL WITNESS STATEMENT, dated 01/11/2026, indicated Resident F stated CNA 6, over the past several days, had appeared irritable and a little clumsy. The Resident described the aide's overall demeanor as off stating the aide seems more irritable with everything in general and had been all around grumpy. The resident felt the aide's attitude upon entering his room suggested he may have been upset and was, taking it out on him.A staff member's statement, from the facility's investigation into the incident on 01/11/2026, was provided by the Administrator on 01/30/2026 at 1:12 P.M. The statement, from Qualified Medication Aide (QMA) 3, indicated while administering medication to Resident D, he was visibly upset and said CNA 6 had told him to shut his damn mouth and to not talk when he was talking. The resident tried to explain to CNA 6 what he wanted regarding a personal care item, and CNA 6 replied with, I told you to shut your Damn mouth, and then the CNA left the room. When the QMA went into Resident F's room, the resident indicated CNA 6 seemed to be having a bad day and wasn't in a pleasant mood, which made the resident feel uncomfortable. The resident stated he had never felt like that before and hoped that CNA 6 would cheer up soon. During an interview, on 01/30/2026 at 10:43 A.M., CNA 4 indicated, on 01/11/2026, she had a couple residents say to her CNA 6 had been more stressed out and would get irritated with the residents not being fast enough, like when they were rolling side to side during care. A resident had reported to her that CNA 6 had been rude to her verbally and had been impatient with her while giving her care. This was reported to her before 01/11/2026.During an interview, on 01/30/2026 at 10:08 A.M., CNA 2 indicated in the past, CNA 6 had been snappy with residents, and she had reported it to the Administrator. That instance was around the end of November or the beginning of December.The current undated DIGNITY policy was provided by the Administrator on 01/30/2026 at 10:12 A.M. The policy indicated, .Staff will not speak in a manner that could be interpreted as even minimally condescending/critical or argumentative nor in a volume any louder than is absolutely necessary as this can be interpreted as meeting criteria for abuse.Staff will not use any profanity or vulgar words in the presence of the resident and under no circumstances directed at a resident. This would meet abuse criteria.The current ABUSE PREVENTION PROGRAM policy, dated 10/22/2022, was provided by the Administrator on 01/30/2026 at 10:12 A.M. The policy indicated, .Verbal Abuse.Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their family, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability.3.1-27(b)

Based on record review and interview, the facility failed to update a care plan related to suicidal ideation for 1 of 5 residents reviewed for care plans. (Resident B)Findings include:The clinical record for Resident B was reviewed on 01/29/2026 at 9:51 A.M. An admission minimum data set (MDS) assessment, dated 12/30/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, traumatic brain dysfunction (neurological and physical impairments of physical, cognitive, and emotional brain function) , anoxic brain damage (the brain was completely deprived of oxygen, causing widespread brain cell death within minutes), anxiety, and depression. The resident had little interest or pleasure in doing things nearly every day, the resident was feeling down/depressed/hopeless half or more of the days, the resident was feeling tired or having little energy nearly every day, and the resident was feeling bad about self.The resident was admitted to the facility on [DATE].A Progress Note, dated 12/28/2025 at 3:37 P.M., indicated there was a change in the resident's condition. The resident was a danger to self or others for suicide potential. The resident has asked for Adderall (a central nervous system stimulant). The resident was informed that the medication was not due at that time. The resident started crying and stated, I'm going to kill myself. The resident was placed on 15-minute checks and the physician was notified.The care planned lacked a care plan for suicidal ideation until 01/16/2026.During an interview, on 01/30/2026 at 9:44 A.M., Licensed Practical Nurse (LPN) 9 indicated on the afternoon of 12/28/2025 she was completing her medication pass and the resident had asked for more Adderall. She had told her she was unable to give her more at that time. She started to work with the resident's gastric tube, and she looked at the resident, and her face was blood red and she was crying. She had taken her finger and pointed to her neck and she was mouthing something; she wasn't quite able to understand the resident. She was finally able to read her lips and [NAME] her if she was saying she wanted to kill herself, and the resident said Yes.During an interview, on 01/30/2026 at 10:14 A.M., the Social Service Director indicated the resident came from home. There was a communication barrier with the resident. She couldn't speak clearly. She didn't always talk to staff related to incidents with residents, she was not sure if nursing staff talked to them or not. Residents were care planned for suicidal ideation. If the nurse had asked the resident if they wanted to kill themselves and the resident said yes, then she would consider that suicidal ideation.The current facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans update 09/18/2018, was provided by the Administrator on 01/30/2026 at 11:25 A.M.It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented.The Comprehensive Care Plan will further expand on the resident's medical, nursing, physical functioning, mental and psychosocial needs.3.1-31(a)

Based on interview, record review, and observation, the facility failed to ensure residents received adequate supervision to prevent them from exiting the building and provide One to One supervision for 2 of 3 residents reviewed for accidents. (Residents C and B) Findings include:1.The clinical record of Resident C was reviewed on 01/29/2026 at 10:54 A.M. The resident's diagnosis included, but was not limited to, non-Alzheimer's dementia (a decline in mental abilities) and arthritis. A physician's order dated 11/11/2025 at 6:00 A.M, indicated Resident C had a wander guard on his ankle for risk of elopement from the facility that needed checked for placement and function daily. A Social Services Progress Note, dated 01/16/2026 at 5:31 P.M., indicated Resident C had attempted to follow a visitor out of the facility. The resident's wander guard activated alerting staff. The resident did not exit the facility and was redirected away from the door. 15-minute monitoring of the resident was initiated for 48 hours. The local weather information for the temperature on 01/17/26, was reviewed on 02/06/2026 at 9:00 A.M., at Accuweather.com and the air temperature was between 23 and 34 degrees Fahrenheit. The cdc.gov website, indicated cautioned for elderly persons without food, clothing or heating, are at higher risk for frostbite or hypothermia. During an interview, on 01/29/2026 at 8:45 A.M., Resident C indicated he had told staff he did not want to be at the facility anymore, and they had told him he could not go outside. He then went to a facility door and used a code to exit the facility, and nobody found him outside. He came back to the facility once he got cold and waved at staff through a side door with a window. During an interview, on 01/30/2026 at 10:40 A.M., Licensed Practical Nurse (LPN) 2 indicated she was working the night of 01/17/2026. Around 8:30 P.M. that night she responded to the front door of the facility for a wander guard alarming at the door. After turning off the alarm, she witnessed Resident C in his powered scooter heading down the hallway away from her. Then around 9:00 P.M. she witnessed Resident C sitting in front of the nurse's station with other residents. At 9:45 P.M. staff could not find Resident C, so they began protocol for a missing resident. While searching they discovered him standing outside the doors at the end of 39 hallway. He was standing outside the door waving his cowboy hat at staff. He was wearing his cowboy hat and a pair of black underwear with no shirt on. He was scared, cold, and shivering. During an interview, on 01/29/2026 at 12:03 P.M., RN 3 indicated she had seen Resident C with other residents in the atrium at 9:15 P.M. and then went into another resident's room. At approximately 9:45 P.M. Resident C was found standing outside the doors of the facility at the end of 39 hallway. He was cold and had some small scratches on his arm and a small scratch above his left ear. He was sent to the emergency room, and a few hours later returned with no findings of additional injuries. He did have his wander guard on, and it was functioning. During an interview, on 01/29/2026 at 12:37 P.M., the Maintenance Director indicated that every door but three had an alarm attached to it that if it was opened even with the code, it would sound an alarm that could only be turned off with a key. Of those three doors two of them had a wander guard alarm on them. The wander guard alarm would sound if any residents with a wander guard got to close to the exit door. The only door in the facility a resident could get out of with a wander guard in place, without an alarm sounding was the doors at the back of the Main Dining Room. Those doors only required a punch code to exit, and there was no additional alarm system if the code was entered correctly. During an interview, on 01/30/2026 at 10:22 A.M., the Administrator indicated that the cameras at the facility were not working, and they were not able to determine what door Resident C exited the facility through on 01/17/2026. The resident was able to repeat the code to the door and all of the door codes in the facility have been changed. During an interview, on 01/30/2026 9:56 A.M., the Social Services Director indicated that Resident C did get confused and would exit seek. The day before the incident he was placed onto 15-minute checks, because he had attempted to exit the facility behind visitors. The only current new intervention for Resident C was conducting one on one monitoring with the resident. A current care plan, with the start date of 12/12/2025 and revised date of 12/15/2025, indicated Resident C was at risk for elopement as evidenced by a history of wandering and a diagnosis of Dementia. The interventions included but were not limited to: dated 12/12/2025 monitor doors when staff and visitors come and go. If wandering in potential unsafe area or situation, redirect to a safe area, and reassess regularly. On 01/30/2026 at 10:12 A.M., the Administrator provided a current copy of the document titled Elopement and Missing Resident Prevention with a revision date 04/20/2023. It included, but was not limited to, It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. 2. The clinical record for Resident B was reviewed on 01/29/2026 at 9:51 A.M. An admission MDS assessment, dated 12/30/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, traumatic brain dysfunction (neurological and physical impairments of physical, cognitive, and/or emotional brain function), anxiety, and depression. The resident was sent to the hospital on [DATE] for attempted suicide. The resident was admitted back to the facility on [DATE] and was placed on 1:1 observation where they remained to date. During an observation, on 01/29/2026 at 8:45 A.M., Resident B was lying in her bed. There was a staff member sitting in the hallway outside of her room. During an observation, on 01/29/2026 at 10:00 A.M., Resident B was lying in her bed with her eyes closed. There was no call light within reach. There was a staff member sitting in the hallway outside of the resident's rooms. Across the hall was Resident C's room. Resident C was walking around in his room. During an observation, on 01/29/2026 at 10:29 A.M., Resident B and Resident C were both in their rooms. There was a staff member sitting in the hallway between the residents' rooms. There were no staff present in the main hallway leading to the main entrance. The Residents' rooms were directly across from each other. There were approximately 9 steps from the residents' rooms to the end of the hallway that led to the main entrance and there were approximately 19 steps from the end of the hallway to two exit doors that had push keypads and alarms. If one of the residents walked 9 steps down the hall to the main hallway, they would be out of the staff member's sight. During an observation, on 01/30/2026 at 9:56 A.M., there was a staff member sitting in the hallway outside Resident B and C rooms. The staff member was looking at her phone. There were no staff present in the hallway leading to the main entrance. During an observation, on 01/30/2026 at 1:04 P.M., Resident C was nowhere to be seen in his room. The ADON indicated the resident was in the bathroom with the door closed. The ADON was sitting in a chair in the hallway. Resident B was in her room in her wheelchair with other staff in the room. During an interview, on 01/29/2026 at 11:26 A.M., CNA 5 indicated if a resident was on one to one (1:1) observations they document it on paper. During an interview, on 01/29/2026 at 11:40 A.M., QMA 7 indicated if a resident was on 1:1 observation then she would be informed by the Administrator or the nurse. During an interview, on 01/29/2026 at 2:17 P.M., Resident B's primary care physician indicated if a resident required 1:1 observation then that would mean one staff to one resident. During an interview, on 01/29/2026 at 2:30 P.M., CNA 5 indicated they were providing 1:1 observation for Resident B and Resident C at that time. She was sitting in a chair in the hallway, outside the resident's rooms. If she was unable to redirect Resident C, then she would call for staff assistance. The staff had a messenger app they could call for staff or call the ADON. Resident C never usually went anywhere. During an interview, on 01/29/2026 at 2:34 P.M., the ADON indicated 1:1 observation was having eyes on the resident at all times. The residents could not be left alone at any time. They had one staff member that was assigned to the two residents on 1:1 observation. The staff could always call or text additional staff if they needed help. Resident C was mobile with a walker. During an interview, on 01/29/2026 at 2:51 P.M., the Administrator and the Cooperate Clinical Nurse indicated for 1:1 observation there was a staff member posted where they can visibly see the resident at all times. There were always staff there to intervene if needed. Resident C was easily redirected. During an interview, on 1/30/2026 at 10:14 A.M., the Social Service Director indicated Resident B was placed on 1:1 observation when she returned from the hospital recently and Resident C was on 1:1 observations also for being outside the building. 1:1 observations meant eyes on the resident at all times. She wasn't sure what the facility policy was for 1:1 or if it was one staff to one resident. There were management staff numbers that staff could call for help if needed. They also had a communication line for staff. Resident C was easily redirected. She was not sure what other staff would do if Resident C wasn't able to be redirected and walked up the main hallway. If it were her then she would leave Resident B and follow Resident C up the hallway. During an interview, on 01/30/2026 at 10:25 A.M., RN 10 indicated at that time she was the person in charge for 1:1 with Resident B and Resident C. If Resident C was not redirectable and there were no staff available, then she would have to just let him (Resident C) walk away because she couldn't leave Resident B. At the time of the interview there were no staff in the main hallway leading to the main entrance. The current facility policy titled, Guidelines for One-on-One Supervision dated 05/17/2023, was provided by the Administrator on 01/30/2026 at 8:55 A.M. The policy indicated, .The guidelines emphasize a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes that there may be occasions in which standard approaches are not successful such as redirection and counseling. One to One supervision provides additional supervision and guidance to the resident at times when the resident may have decompensated mentally and/or physically.A staff member will be assigned to remain in direct supervision of the resident during the time that the one to one supervision is utilized.One to One supervision at a minimum involves that the resident remain in direct visual surveillance at all time. This citation relates to Intake 2721930. 3.5-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to prime an insulin pen appropriately prior to administration, monitor blood glucose appropriately, and follow physician's orders related to medication hold parameters for 4 of 21 residents reviewed for Quality of Care. (Residents 37, 29, 22, and 43) Findings include: 1. During a medication administration observation and interview, on 02/06/25 at 10:54 A.M., Licensed Practical Nurse (LPN) 4 removed a Fiasp insulin pen from the 39 Back Medication Cart. LPN 4 indicated the pen had been opened and was for Resident 37 because they were the only resident who used that type of insulin and proceeded to write the resident's name on the pen. The resident required eight units of insulin based on the resident's blood glucose check the nurse had performed. The LPN applied the needle to the insulin pen and turned the dose knob at the end of the pen to 10 units. The LPN indicated she had done that so she could prime the pen with two units. The LPN aimed the insulin pen downwards into a plastic cup and squirted out 2 units. She donned gloves and proceeded to administer the insulin into the resident's abdomen with the door open to the room. During an interview following the procedure, LPN 4 indicated the purpose of priming the insulin pen was to ensure there was no air in the pen and she should have held the insulin pen upwards when priming the pen. The Fiasp insulin package insert was provided by the Regional Nurse Consultant on 02/10/25 at 2:00 P.M. The record indicated, .Priming your FIASP .Pen .Turn the dose selector to select 2 units .Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top .Hold the Pen with the needle pointing up. Press and hold the dose button until the dose counter shows 0 .A drop of insulin should be seen at the needle tip . 38769 2. The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. A current, open-ended physician's order, with a start date of 12/28/24, indicated the resident was to receive Metoprolol (a blood pressure medication) 25 mg, once a day. The staff were to hold the medication if the resident's heart rate was less than 60 or the blood pressure was less than 110/60. The December 2024, January and February 2025 EMAR indicated the resident received the medication when the vital signs were not documented for the following dates and times: - 12/28/24 through 12/31/24, no vital signs were documented, - 01/02/25 through 01/17/24, no vital signs were documented, and - 02/01/25 through 02/10/25, no vital signs were documented. The residents clinical record lacked any vital signs for the above dates. 3. The clinical record for Resident 22 was reviewed on 02/06/25 at 12:52 P.M. A Quarterly MDS assessment, dated 12/07/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, anemia, hypertension, diabetes, non-Alzheimer's dementia, depression, psychotic disorder, and respiratory failure. The current open-ended physician's order, with a start date of 04/27/23, indicated the resident was to receive Carvedilol (a blood pressure medication) 3.125 mg, twice a day. The staff were to hold the medication when the blood pressure was less than 120/70 or the heart rate was less than 60. The November and December 2024 and January, February 2025 EMAR indicated the resident had received the medication when the blood pressure was less than 120/70 or the heart rate was less than 60 on the following dates and times: - On 11/04/24 at 8:00 A.M., when the heart rate was 58 and at 8:00 P.M., when the heart rate was 58, - On 11/11/24 at 8:00 A.M., when the heart rate was 56, - On 11/19/24 at 8:00 P.M., when the blood pressure was 100/56, - On 11/20/24 at 8:00 A.M., when the blood pressure was 116/62, - On 12/09/24 at 8:00 P.M., when the blood pressure was 108/60, - On 12/14/24 at 8:00 P.M., when the blood pressure was 102/68, - On 12/16/24 at 8:00 P.M., when the blood pressure was 105/62, - On 12/17/24 at 8:00 A.M., when the blood pressure was 110/66, - On 01/15/25 at 8:00 P.M., when the blood pressure was 111/64, - On 01/20/25 at 8:00 P.M., when the blood pressure was 103/63, - On 01/21/25 at 8:00 A.M., when the blood pressure was 116/67, - On 01/26/25 at 8:00 A.M., when the blood pressure was 108/59, and - On 02/04/25 at 8:00 P.M., when the blood pressure was 114/59. 4. The clinical record for Resident 43 was reviewed on 02/06/25 at 1:37 P.M. A Quarterly MDS assessment, dated 12/26/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, hypertension, Non-Alzheimer's dementia, seizure disorder, malnutrition, anxiety, and depression. The current open-ended physician's order, with a start date of 11/24/23, indicated the resident was to be administered Midodrine 15 mg, three times a day for hypotension. The staff were to hold the medication if the systolic blood pressure was greater than 120. The November and December 2024 and January, February 2025 EMAR indicated the resident had received the Midodrine medication when their systolic blood pressure was greater than 120 on the following dates and times: - On 11/11/24 at 7:00 A.M., when the blood pressure was 133/70, - On 11/23/24 at 7:00 A.M., when the blood pressure was 124/68 and at 5:00 P.M. when the blood pressure was 126/86, - On 11/25/24 at 7:00 A.M., when the blood pressure was 132/80 at 12:00 P.M., when the blood pressure was 122/68, and 5:00 P.M., when the blood pressure was 136/76, - On 11/27/24 at 7:00 P.M., when the blood pressure was 122/76, at 12:00 P.M., when the blood pressure was 138/77, and 5:00 P.M., when the blood pressure was 122/74, - On 11/29/24 at 12:00 P.M., when the blood pressure was 123/67 and 5:00 P.M., when the blood pressure was 128/78, - On 12/02/24 at 7:00 A.M., when the blood pressure was 134/92 and at 12:00 P.M., when the blood pressure was 126/88, - On 12/03/24 at 12:00 P.M., when the blood pressure was 122/66, - On 12/05/24 at 7:00 A.M., when the blood pressure was 122/88 and 12:00 P.M., when the blood pressure was 134/74, - On 12/09/24 at 7:00 A.M., when the blood pressure was 142/76, at 12:00 P.M., when the blood pressure was 128/76, and 5:00 P.M., when the blood pressure was 134/88, - On 12/10/24 at 7:00 A.M., when the blood pressure was 135/84 and 12:00 P.M., when the blood pressure was 123/72, - On 12/11/24 at 12:00 P.M. when the blood pressure was 138/86, - On 12/13/24 at 7:00 A.M., when the blood pressure was 121/97, at 12:00 P.M., when the blood pressure was 134/86, and at 5:00 P.M., when the blood pressure was 124/82, - On 12/19/24 at 7:00 A.M., when the blood pressure was 122/84, at 12:00 P.M., when the blood pressure was 134/77, and at 5:00 P.M., when the blood pressure was 128/82, - On 12/22/24 at 5:00 P.M., when the blood pressure was 124/72, - On 12/23/24 at 7:00 A.M., when the blood pressure was 142/86, at 12:00 P.M., when the blood pressure was 132/74, and at 5:00 P.M., when the blood pressure was 132/76, - On 12/24/24 at 7:00 A.M., when the blood pressure was 128/78, - On 12/29/24 at 12:00 P.M., when the blood pressure was 123/73, - On 12/30/24 at 7:00 A.M., when the blood pressure was 142/89, at 12:00 P.M., when the blood pressure was 138/72, and 5:00 P.M., when the blood pressure was 122/84, - On 01/01/25 at 5:00 P.M. when the blood pressure was 123/78, - On 01/02/25 at 7:00 A.M., when the blood pressure was 147/106, at 12:00 P.M., when the blood pressure was 130/88, and at 5:00 P.M., when the blood pressure was 138/87, - On 01/06/25 at 5:00 P.M., when the blood pressure was 129/79, - On 01/08/25 at 7:00 A.M., when the blood pressure was 139/96, at 12:00 P.M., when the blood pressure was less than 134/88, and 5:00 P.M., when the blood pressure was 132/77, - On 01/13/25 at 7:00 A.M., when the blood pressure was 151/54, at 12:00 P.M., when the blood pressure was 136/68, and 5:00 P.M., when the blood pressure was 142/88, - On 01/15/25 at 7:00 A.M., when the blood pressure was 132/80, - On 01/16/25 at 7:00 A.M., when the blood pressure was 132/80, at 12:00 P.M., when the blood pressure was 128/74, and 5:00 P.M., when the blood pressure was 132/88, - On 01/20/25 at 7:00 A.M., when the blood pressure was 150/84, at 12:00 P.M., when the blood pressure was 138/77, and 5:00 P.M., when the blood pressure was 130/84, - On 01/22/25 at 7:00 A.M., when the blood pressure was 144/88, at 12:00 P.M., when the blood pressure was 147/83, and 5:00 P.M., when the blood pressure was 132/87, - On 01/24/25 at 12:00 P.M., when the blood pressure was 128/80, - On 01/26/25 at 7:00 A.M., when the blood pressure was 142/88, - On 01/27/25 at 7:00 A.M., when the blood pressure was 134/82, at 12:00 P.M., when the blood pressure was 122/77, and 5:00 P.M., when the blood pressure was 136/89, - On 02/03/25 at 7:00 A.M., when the blood pressure was 122/77, at 12:00 P.M., when the blood pressure was 138/80 and 5:00 P.M., when the blood pressure was 126/88, - On 02/04/25 at 7:00 A.M., when the blood pressure was 121/73, at 12:00 P.M., when the blood pressure was 132/87, and at 5:00 P.M., when the blood pressure was 127/84, - On 02/05/25 at 7:00 A.M., when the blood pressure was 134/79, at 12:00 P.M., when the blood pressure was 128/90, and at 5:00 P.M., when the blood pressure was 132/80, and - On 02/06/25 at 12:00 P.M., when the blood pressure was 128/78. During an interview on 02/07/25 at 11:26 A.M., LPN 6 indicated when a resident had hold parameters on medications, she would check the resident's vital signs prior to administering the medication. If the medication was to be held then she would not administer the medication and mark it on the EMAR that the medication was not administered with what the resident's vitals were. During an interview on 02/10/25 at 10:21 A.M., the DON indicated if a blood pressure medication had hold parameters, then the nurse should check the vitals and hold the medication based on the parameters. If there was a check mark on the EMAR, then that would mean that the medication was administered to the resident. If there was a number, then that determined the medication was not administered. The current, undated, facility policy titled, PHYSICIAN-ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Regional Nurse Consultant on 02/07/25 at 12:15 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . The current facility policy titled, MEDICATION ADMINISTRATION, dated February 2017, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis . 3.1-37(a)

Based on interview and record review, the facility failed to provide the required RN coverage on duty for eight hours a day for 16 of the 21 days reviewed. Findings include: The as worked nursing schedule indicated there had not been an RN on duty for eight consecutive hours on the following dates: - Saturday 07/13/24, - Sunday 07/14/24, - Saturday 07/20/24, - Sunday 07/21/24, - Saturday 08/10/24, - Sunday 08/11/24, - Saturday 08/24/24, - Sunday 08/25/24, - Saturday 09/07/24, - Sunday 09/08/24, - Saturday 09/21/24, - Sunday 09/22/24, - Saturday 12/14/24, - Sunday 12/15/24, - Saturday 02/08/25, and - Sunday 02/09/25. During an interview on 02/10/25 at 09:52 A.M., The Director of Nursing (DON) indicated they did have issues with staffing in the previous months. The current, undated facility policy, titled Registered Nurse Coverage was provided by the DON on 02/10/25 at 9:19 A.M. The policy indicated, .It is the policy of the facility to provide the services of an RN for at least 8 consecutive hours per 24 hour day, 7days weekly . 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to store medications appropriately for 3 of 3 medication carts reviewed and 1 of 1 medication rooms reviewed. (39 Back Medication Cart, Front Medication Cart, Rehab Medication Cart, and the 39 Hall Medication Room) Findings include: 1. During a medication administration observation on 02/06/25 at 10:54 A.M., Licensed Practical Nurse (LPN) 4 removed a Fiasp insulin pen from the 39 Back Medication Cart. The pen was laying loosely in the drawer of the medication cart and not in a plastic bag. The pen was labeled with an opened date of 2/1. The pen was not labeled with a resident's name or anything that would identify who the pen belonged to. LPN 4 indicated the pen had been opened and was for Resident 37 because they were the only resident who used that type of insulin. The LPN proceeded to write the resident's name on the pen and administer the insulin to Resident 37. 2. The Front Medication Cart was observed on 02/10/25 at 9:37 A.M., with LPN 3 and contained the following loose pills: - one small oval peach tablet, - one medium round gray tablet, - one medium round white tablet, - one small oval white tablet, - one small oval blue tablet, - one small oval red tablet, - one small round pink tablet, - one small round white tablet, - one medium round blue tablet, - one large oval white tablet, and - one medium orange capsule. The medication cart had a section of a drawer covered in a spilled substance and several bits of paper were scattered heavily throughout the cart. LPN 3 indicated the pharmacy occasionally came into and audited the medication carts. In-house staff usually kept the carts clean. The LPN was observed destroying the medications with a second nurse. 3. The Rehab Medication Cart was observed on 02/10/25 at 9:53 A.M., with LPN 2 and contained the following loose pills: - one small round white tablet, - one small round pink tablet, and - one large round half of a white tablet. LPN 2 indicated all insulin pens should have a resident's name on them. Per their facility policy, she had to throw the insulin pen away and she proceeded to do so. 4. The 39 Hall Medication Room was observed on 02/10/25 at 10:07 A.M. with LPN 3. The medication refrigerator contained two opened vials of Tuberculin (TB) serum, one with an opened dated of 11/07/24 that was half full and one that was undated that was half full. LPN 3 indicated the TB serum should be dated when opened. It should be discarded after 30 days. The one dated 11/07/24 should have been disposed of. LPN 3 disposed of the outdated serum vial immediately. There were no delivery dates on the serum bottles. During an interview and observation on 02/10/25 at 10:41 A.M., the Director of Nursing (DON) indicated the nurses on the floor administered the TB tests to the new admission residents. They had several new admissions in the last 30 days. This refrigerator was the only refrigerator where they kept the TB serum. The TB serum package insert was provided by the DON on 02/10/25 at 10:49 A.M. The record indicated, .A vial of TUBERSOL (TB serum) which has been entered and in use for 30 days should be discarded .Do not use after expiration date . The current MEDICATION STORAGE IN THE FACILITY policy, dated February 2017, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations . 3.1-25(j) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(o)

Based on record review and interview, the facility failed to notify the physician when a resident's blood glucose levels were out of range for 1 of 21 residents reviewed for notification of change. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS (Minimum Data Set) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident's current MD orders included an open-ended order, with a start date of 04/25/24, to administer 3 units of Humalog insulin, three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The resident also had an additional open-ended order, with a start date of 04/25/24, to check the blood glucose and administer an additional dose of Humalog based on a sliding scale (the amount of insulin administered would depend on the resident's blood glucose level) three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The physician was to be notified if the resident's blood glucose was greater than 351. The November and December 2024, and January and February 2025, Electronic Medication Administration Record (EMAR) and Vitals Reports were reviewed. The blood glucose levels documented when the resident received the scheduled dose of insulin were different from the blood glucose levels documented when the sliding scale insulin was administered, even though both doses of insulin would have been administered together and based off the same blood glucose level. - On 11/09/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 430, but the sliding scale blood glucose documented was 350, - On 11/16/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 377, but the sliding scale blood glucose documented was 350, - On 11/26/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 420, but the sliding scale blood glucose documented was 340, - On 12/06/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 378, but the sliding scale blood glucose documented was 350, - On 12/07/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 358, but the sliding scale blood glucose documented was 350, - On 12/12/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 400, but the sliding scale blood glucose documented was 350, - On 12/14/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 409, but the sliding scale blood glucose documented was 350, - On 12/15/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 563, but the sliding scale blood glucose documented was 349, - On 12/17/24 at 8:00 A.M., the blood glucose documented for the scheduled insulin was 379, but the sliding scale blood glucose documented was 350, - On 12/23/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 551, but the sliding scale blood glucose documented was 304, - On 12/23/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 337, but the sliding scale blood glucose documented was 373, - On 12/29/24 at 7:00 A.M., the blood glucose documented for the scheduled insulin was 376, but the sliding scale blood glucose documented was 350, - On 01/04/25 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 376, but the sliding scale blood glucose documented was 350, - On 01/23/25 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 435, but the sliding scale blood glucose documented was 248, and - On 02/01/25 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 415. but the sliding scale blood glucose documented was 350. There was no indication the physician was notified when the blood glucose levels were greater than 350. During an interview on 02/07/25 at 11:26 A.M., LPN 6 (Licensed Practical Nurse) indicated if a resident received sliding scale insulin with a routine insulin and the blood sugar needed to be reported to the physician due to the call parameters then she would call the physician and document in the EMAR and a progress note that the physician was notified. During an interview on 02/10/25 at 10:21 A.M., the DON (Director of Nursing) indicated if a resident had two insulin orders and one of them had parameters to call the physician then the orders should have the same blood glucose levels documented and the physician should be notified if they were outside the call parameters. The current, undated, facility policy titled, Change in Resident's Condition or Status, was provided by the DON on 02/06/25 at 9:51 A.M. The policy indicated, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status . 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to maintain resident records in a private manner related to personal information posted in a public setting for 1 of 54 residents who resided in the building. (Resident 59) Findings include: Resident 59's room was observed on 02/04/25 at 1:17 P.M. Signage on the resident's door indicated he was in contact isolation and enhanced barrier precautions. Posted on the wall next to the door directly above the resident's name and room number was a document titled, Guidelines for addressing Candida auris. The resident's room was observed on 02/05/25 at 9:20 A.M., The signage remained, including the Guidelines for addressing Candida auris documents posted on the wall above the resident's name and room number. During an interview on 02/05/25 at 9:22 A.M., Licensed Practical Nurse 5 indicated resident information, including resident profile information, medication lists, and diagnoses information was private and confidential, and should not be out for public viewing. During an interview on 02/05/25 at 9:30 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant indicated they were unaware of any documentation posted in public related to the resident's diagnosis. It should not be there and would be removed. The resident's clinical record was reviewed on 02/05/25 at 10:00 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/01/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, cancer, hypertension, and depression. The resident's current MD orders included a current open-ended order, with a start date of 02/04/25, that indicated the resident was in contact isolation for a Candida auris infection. The current, undated facility policy, titled What is HIPAA? was provided by the DON on 02/06/25 at 9:52 A.M. The policy indicated, .PROTECTED HEALTH INFORMATION .any and all health information on a resident or employee that identifies an individual . 3.1-3(o)

Based on record review and interview, the facility failed to follow a acquired a resident's weight related to daily weights for 1 of 4 residents reviewed for nutrition. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual Minimum Data Set (MDS) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. A current, open-ended physician's order, with a start date of 12/28/24, indicated the resident was to be weighed daily. The physician was to be notified if the resident had a weight gain greater than 3 pounds in a day or greater than 5 pounds in a week. The clinical record lacked daily weights on the following dates: - 12/30/24 through 01/02/25, - 01/04/25, - 01/06/25 through 01/07/25, - 01/09/25 through 01/11/25, - 01/13/25 through 01/15/25, - 01/17/25, - 01/20/25, - 01/21/25, - 01/23/25 through 02/02/25, and - 02/04/25. During an interview on 02/10/25 at 11:02 A.M., Licensed Practical Nurse (LPN) 3 indicated the resident was a daily weight. The CNAs (Certified Nurse Aides) would get the resident's weight and let the nurse know. The nurse would document the weight and call the physician if the resident was greater than a certain amount in a day. The current facility policy titled, GUIDELINES FOR OBTAINING RESIDENTS' WEIGHTS, dated 07/24/23, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Accuracy with weight measurement is essential for residents in the long-term-care setting. Weight measurement is used to calculate energy, protein, and fluid needs. Further, weight is an indicator of nutritional and health status and changes in weight can often indicate other medical changes. Inaccurate weight measurements can result in an increased number of unplanned weight changes in the facility-and can affect the plans of care for the residents .Weigh residents at the same time of the day as possible, on the same weight clothing as much as possible-each time they are weighed . 3.1-46(a)(1)

Based on record review and interview, the facility failed to provide Parenteral/IV (Intravenous) site maintenance for 2 of 3 residents reviewed for vascular access sites. (Residents 4 and 38) Findings include: 1. The clinical record for Resident 4 was reviewed on 02/05/25 at 2:36 P.M. An Admission Minimum Data Set (MDS) assessment, dated 01/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, acute osteomyelitis (infection in the bone or bone marrow) of the right ankle and foot. During an interview on 02/10/25 at 8:38 A.M., the Director of Nursing (DON) indicated the resident was admitted to the facility from the hospital and had an infected heel wound with osteomyelitis. The resident had been on IV antibiotics for his wound infection since he was admitted to the facility. During an interview on 02/10/25 at 2:25 P.M., Licensed Practical Nurse (LPN) LPN 2 indicated the resident had a Midline vascular access site in his right arm. He came from the hospital with an access site but then had to have it replaced because it would not flush. Residents with a Peripherally Inserted Central Catheter (PICC) line or a Midline Catheter should have physician's orders to flush the line regularly. The PICC/MIDLINE INSERTION DOCUMENTATION record, dated 01/24/25, was provided by the Regional Nurse Consultant on 02/10/25 at 3:18 P.M. The record indicated a dual lumen PICC line had been removed, and a Midline had been inserted. The Midline was cleared for use. The clinical record indicated the resident did not receive IV medications on January 19, or 20, 2025, due to a lack of supplies. The resident did not receive IV medications on January 22, 23, or 24, 2025, due to the resident's venous access site not flushing. The clinical record lacked documentation the resident's venous access sites had been flushed on a regular basis or flushed before and after medication administration. The Electronic Medication Administration Record/Treatment Administration Record (EMAR/ETAR) for January and February 2025, was provided by the DON on 02/10/25 at 9:19 A.M. The record lacked a physician's order to flush the resident's vascular access sites to maintain patency (open and unblocked) and there was no order to flush the sites before or following the IV medication administration. 38769 2a. The clinical record for Resident 38 was reviewed on 02/06/25 at 10:05 A.M. A Quarterly MDS assessment, dated 12/17/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, amputation, anemia, hypertension, PVD, diabetes, anxiety, depression, infection of amputation. A Progress Noted, dated 12/07/24 at 9:24 P.M., indicated the resident admitted to the facility for a right stump infection and had a PICC line in her right upper arm. A physician's order, dated 12/08/24 through 12/22/24, indicated the resident was to receive Vancomycin (an antibiotic) 1 gram, once a day for a right stump infection. A physician's order, dated 12/08/24 through 01/10/25, indicated the resident was to receive Cefepime (an antibiotic) 2 grams intravenously, twice a day for a right stump infection. A physician's order, dated 12/08/24 at 10:20 A.M., indicated the staff were to flush the IV-midline with 10 mls normal saline before and after infusions. The order had no scheduling details or assigned times to be completed. The clinical record indicated the resident did not receive the Vancomycin on the following dates: - 12/08/24 due to the medication being unavailable, - 12/09/24 due to the resident needing a new PICC line placed, and - 12/10/24 due to waiting on the PICC line verification. The clinical record indicated the resident did not receive the Cefepime medication on the following dates and times: - 12/08/24 at 8:00 P.M., due to the medication being unavailable, - 12/09/24 at 8:00 A.M., and 8:00 P.M., due to new PICC needing placed, and - 12/10/24 at 8:00 A.M., due to waiting on PICC line verification. A Vascular Access And Consultation Reports indicated the resident had a PICC/midline placed on the following dates: - 12/09/24 at 11:25 P.M., - 12/14/24 at 4:10 P.M., - 12/14/24 at 8:00 P.M., and - 01/04/25 at 3:50 P.M. The resident's PICC/midline was discontinued on 01/10/25. The clinical record lacked documentation that the resident's PICC/midline was flushed from 12/07/24 through 01/10/25. 2b. An Infectious Disease Progress Note, dated 12/20/2024 at 5:05 P.M., indicated it was recommended a referral was to be sent for the resident to get a central line (an intravenous line that is longer than a regular IV and goes all the way up to a vein near the heart or just inside the heart.) A physician's order, with a start date of 12/24/24, indicated the staff were to contact the local hospital about getting a central line placed due to difficulty with midline placement, for 5 days. A physician's order, with start date 12/26/24 and end date 12/30/24, indicated the staff were to schedule an appointment with the general surgeon for a central line for 4 days. The December 2024 EMAR and clinical record indicated the following related to the central line: - 12/24/24, the EMAR indicated to see nurse note. There was no nurse note related to the appointment, - 12/25/24 and 12/26/24, EMAR was left blank, - 12/27/24 the EMAR indicated to see a nurse note. The nurse note indicated the physician's office was closed that day, and - 12/28/24 through 12/30/24, the EMAR was left blank. The clinical record lacked any other documentation related to the central line. During an interview on 02/07/25 at 1:30 P.M., LPN 2 indicated if a resident was admitted to the facility with a PICC/Midline the medications would be delivered by pharmacy. They ran three times a day, and the nurse would need to input orders for it to be flushed. There was no reason anyone would have a PICC/Midline without flush orders. To schedule appointments, she would put it on the EMAR, and the nurse would have to check it off like a medication when it was done. If it didn't get done, then the DON would need to follow-up to make sure it was completed. During an interview on 02/10/25 at 10:03 A.M., the DON and the Regional Nurse Consultant indicated when a resident admitted to a facility with a PICC/Midline the nurse would input order for the resident to get flushes to the line. Resident 38 had an order for flushes, but the nurse didn't put in any scheduling details, so it didn't show up on the EMAR to be completed. If the physician gave orders for the pharmacy to dose a resident's medications, then the facility would follow the orders from the pharmacy. The nurse that took the order to increase the Vancomycin to 1.25 grams should have changed the order in the clinical record. Since the infectious disease NP made a recommendation for a central line the facility should have followed up with the physician to get the line placed. The current facility policy titled, Flushing a Peripheral Intravenous Catheter, dated January 2016, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Specific flush orders must be documented .Flushing is performed to ensure and maintain catheter patency, and to prevent the mixing of incompatible medications/solutions .A physician order is required for flushing of a peripheral IV catheter. The order must include: .Flushing agent .Volume .Frequency . The current facility policy titled, Flushing a Midline Catheter, dated January 2016, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Specific flush orders must be documented .Flushing is performed to ensure and maintain catheter patency, and to prevent the mixing of incompatible medications/solutions .A physician order is required for flushing of a peripheral IV catheter. The order must include: .Flushing agent .Strength/concentration .Volume .Frequency . The current, undated, facility policy titled, PHYSICIAN-ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Regional Nurse Consultant on 02/07/25 at 12:15 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to prevent residents from acquiring in house pressure ulcers and weekly assessments of a pressure ulcers for 4 of 6 residents reviewed for pressure ulcers. This deficient practice resulted in one resident's pressure ulcer being identified at a Stag 3 and two residents' wounds identified with deep tissue injuries. (Residents 15, 36, 13, and 70) Findings include: 1. During an observation on 11/16/22 at 2:53 P.M., the Wound Nurse and QMA (Qualified Medication Aide) 9 entered Resident 15's room and explained they were going to change the dressing on her buttocks. They each washed their hands and donned gloves. QMA 9 assisted the resident in turning onto her right side. The Wound Nurse removed the old dressing, removed her gloves and donned clean gloves. The wound was approximately 9 cm (centimeters) x (by) 11 cm x 2 cm deep. The wound bed was pink and red with a half dollar sized amount of slough (yellowish colored dead tissue) in the center. The wound was cleaned with wound cleanser, packed with [MEDICATION(S)] soaked gauze, covered with an absorbent dressing and secured with tape. The clinical record was reviewed on 11/14/22 at 11:22 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/30/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two staff members for ADLs (Activities of Daily Living). The resident was at risk for pressure ulcers. The CNA (Certified Nurse Aide) Bath Checklist, dated 05/25/22, was provided by the DON on 11/16/22 at 9:28 A.M. The checklist indicated the resident had no open areas were documented. The Weekly Skin Check record, dated 05/29/22, was provided by the DON on 11/16/22 at 9:28 A.M. The skin check indicated the resident had no new loss of skin integrity. A Wound NP assessment, dated 05/30/22, indicated the resident had a Stage 3 (full thickness tissue loss) pressure ulcer, measuring 2.8 cm x 1.1 cm x 0.1 cm depth, to her right buttocks. A Wound NP assessment, dated 06/13/22, indicated the right buttocks wound measured 6.2 cm x 4.7 cm and was covered with 100% slough. A wound culture was obtained on 06/13/22. The culture results, dated 06/16/22, indicated there was Heavy Proteus mirabilis (a bacteria) in the wound. The resident was started on [MEDICATION(S)] (an antibiotic) for the positive wound culture. A Progress Note, dated 06/16/22 at 9:00 A.M., indicated the resident was sent to the hospital for a change in condition. The emergency room note, 6/16/22, indicated the resident presented with altered mental status with positive wound culture. History of [CONDITION(S)], non-ambulatory, bed bound, medical decision indicated sever [CONDITION(S)]. The wound was foul in smell and most likely the source of the patient's infection. During an interview on 11/16/22 at 3:14 P.M., the Wound Nurse indicated the pressure ulcer on the buttocks, from 06/13/22, wasn't identified until after the shoulder was healed, It just popped up'. The resident's skin was fragile. 2. The clinical record for Resident 36 was reviewed on 11/15/22 at 11:41 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/28/22, indicated the resident was rarely/never understood. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two or more staff for most ADLs. She was at risk for developing pressure ulcers, and had one, unhealed facility acquired Unstageable pressure ulcer at the time of the assessment. An NP Wound Assessment, dated 08/01/22, indicated the resident had a Stage 2 pressure ulcer to the right upper buttock that measured 2.44 cm x 2.53 cm x 0.5 cm. There was a scant amount of sanguineous drainage. The wound had 100% epithelial tissue. The treatment was to apply Triad (a hydrophilic wound paste that absorbed moderate levels of wound exudate) paste and leave the area open to air. An NP Wound Assessment, dated 08/15/22, indicated the resident's wound to the right upper buttock was healed. The Triad treatment was discontinued when the wound healed. No new interventions were put into place after the wound healed. An NP Wound Assessment, dated 09/08/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttocks that measured 1.22 cm x 1.33 cm x 0.10 cm. There was a moderate amount of serosanguinous drainage. The treatment was to cleanse the wound, apply Medi honey, and cover with bordered gauze. Pressure and Offloading interventions included to ensure compliance with turning protocol and a specialty bed. An NP Wound Assessment, dated 09/29/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttock that measured 0.53 cm x 1.26 cm x 2.0 cm with 5.0 cm tunneling at 9 o'clock. The wound was covered in 100% slough/eschar with a moderate amount of serosanguinous drainage. The wound treatment changed to cleanse the wound, apply [MEDICATION(S)] gauze packing and cover with a bordered gauze. An NP Wound Assessment, dated 10/20/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttocks that measured 0.38 cm x 0.78 cm x 1.5 cm with 4.0 cm tunneling at 9 o'clock. The wound was covered in 100% granulation with a moderate amount of purulent drainage. The wound treatment remained the same. An NP Wound Assessment, dated 11/10/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttocks that measured 0.55 cm x 0.49 cm x 2.0 cm with 4.0 cm tunneling at 9 o'clock. The wound was covered in 100% granulation tissue with a moderate amount of purulent drainage. The wound treatment remained the same. The clinical record lacked the MD notification of the resident's wound increasing in size and wound drainage. A Complete Care Plan was provided by the DON on 11/16/22 at 1:20 P.M. The Care Plan contained the following: - Altered Skin Integrity to the right buttock, interventions included, monitor daily for increase in size, notify MD and family as needed, and treatment per order. -At risk for skin breakdown due to diagnosis [CONDITION(S)] ([CONDITION(S)]) with weakness, incontinence of bowel, and use of a urinary catheter. Interventions included, but were not limited to, Braden scale quarterly and as needed, ensure toileting at least every 2 hours, float heels every shift, keep clean and dry, pressure relieving mattress per facility policy, preventive measures as needed, skin assessment per facility policy, supplements per order. The August 2022 ETAR indicated the resident had received the Triad paste daily from 08/04/22 through 08/15/22. During an interview on 11/16/22 at 3:37 P.M., the ADON/Wound Nurse indicated the resident's wound first started as a Stage 2 pressure on 08/01/22 and healed on 08/15/22. The wound had reopened on 09/08/22 as an unstageable. Her interventions included, a low air loss mattress, turning and reposition per protocol, t-time (toileting time). The staff noticed the resident had a wound and brought it to her attention. 3. During an observation on 11/16/22 at 02:01 P.M., Resident 13 had an area to her coccyx that was pencil eraser size with measurable depth. The wound was pink with no drainage noted. The resident's clinical record was reviewed on 11/15/22 at 9:41 A.M. A Quarterly MDS Assessment, dated 10/18/22, indicated the resident was moderately cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of 2 or more staff members with most ADLs. The resident was a risk for pressure ulcers with no pressure ulcer at the time of the assessment. A Progress Note, dated 08/31/22, indicated the resident had an open area to her coccyx and a new order was obtained to cleanse the wound, apply Medi honey, and cover with a bordered gauze every night shift. The September, October, and November 2022 ETAR lacked documentation the treatment was provided the following dates: - 09/02/22, - 09/03/22, - 09/04/22, - 09/09/22, - 09/12/22, - 09/17/22, - 09/19/22, - 09/22/22, - 09/23/22, - 09/25/22, - 10/05/22, - 10/08/22, - 10/19/22, - 10/22/22, - 10/29/22, - 11/06/22, and - 11/13/22. No weekly wound assessments could be provided for the wound. No wound staging was documented in the resident's clinical record. During an interview on 11/15/22 at 2:01 P.M., the ADON/Wound Nurse indicated wound assessments were completed weekly by the NP and she was unsure why the resident had been getting a dressing change to her coccyx. During an interview on 11/15/22 at 3:06 P.M., LPN 5 indicated it was a night shift dressing change and she was unsure what the resident had going on. During an interview on 11/16/22 at 9:04 A.M., LPN 6 indicated the resident stayed in bed per her choice most of the time. She was incontinent of her bowel and bladder. The resident had developed a wound on her bottom that had a treatment completed on night shift. During an interview on 11/16/22 at 2:30 P.M., the DON indicated a nurse had notified the NP of the resident having a wound and obtained treatment orders. The wound should be assessed weekly, and the resident did not have weekly wound assessments. During an interview on 11/16/22 at 3:09 P.M., the DON indicated the resident treatments should be signed out in the ETAR. If there was a blank in the ETAR then it meant it wasn't done. 4. On 11/10/22 at 9:59 A.M., Resident 70 was observed sitting in a chair in his room. The resident indicated he was at the facility short term after a hospitalization and would be going home soon. The resident did have a wound on his bottom, he was not sure when it developed. There was a current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident deferred an observation of the wound. The resident's clinical record was reviewed on 11/16/22 at 2:46 P.M. An Admission MDS assessment, dated 08/28/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers but had no unhealed pressure ulcers during the assessment review period. The resident utilized a pressure reducing device for his bed. The Facility Admission Assessment, dated 08/24/22, indicated the resident had no skin impairments. A Wound NP Assessment, dated 08/29/22, indicated the resident had a sacrococcygeal (sacrum and coccyx area) pressure ulcer, staged as a suspected DTI (Deep Tissue Injury, a non-blanchable deep red, purple or maroon area of intact skin, non-intact skin, or blood-filled blisters caused by damage to the underlying soft tissues) that measured 5.79 cm x 3.85 cm x 0.05 cm. There was a scant amount of thin, serous (thin, watery fluid) drainage. The wound tissue type was 100% epithelial tissue, wound colors were listed as pink (5.19 cm 2), black (7.70 cm 2), and red (1.55 cm 2). The treatment was to cleanse the wound and apply a [MEDICATION(S)] dressing. The dressing was to be changed every three days. Current preventative interventions included the use of a pressure redistribution mattress, wheelchair cushion, and a specific turning and repositioning program. The August and September 2022 EMARs and ETARs lacked documentation that the [MEDICATION(S)] dressing treatment was ever administered. A Wound NP Assessment, dated 09/15/22, indicated the resident had a sacrococcygeal wound that was previously classified as an evolving DTI, but was now classified as an Unstageable pressure ulcer. The wound measured 3.05 cm x 2.55 cm and was 100% covered in slough/eschar (dead skin). There was a moderate amount of serous drainage. The treatment was to cleanse with a wound cleanser, apply [MEDICATION(S)] and a bordered gauze. The September 2022 ETAR contained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment was administered as ordered. The ETAR lacked documentation of a wound treatment before 09/24/22. During an interview on 11/16/22 at 2:24 P.M., the ADON indicated the wound was present on admission, it started as a suspected DTI. She was unsure as to why the wound treatments weren't on the ETARs, the orders must have been missed. A Wound NP Assessment, dated 09/29/22, indicated the resident had a sacrococcygeal wound that was previously identified as an unstageable wound, and was determined to be a Stage 3 pressure ulcer that measured 1.15 cm x 0.65 cm x 1.20 cm. The wound was 70% granulation tissue and 30% slough/eschar. There was moderate serous drainage. The treatments were daily dressings with [MEDICATION(S)] and calcium alginate. The resident was discharged home from the facility on 11/16/22. The current, undated facility policy, titled S.W.A.T.---Skin Weight Assessment Team---Guidelines Pressure Ulcers was provided by the Administrator on 11/16/22 at 4:19 P.M. The policy indicated, .It is the policy of the facility to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable .a resident .receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .ensure all assessments are timely and accurate .monitor treatments for efficacy . 3.1-40(a)(2) 3.1-40(a)(3)

Based on interview and record review, the facility failed to ensure a resident (Resident F) received the ordered PICC (large central vein access near the heart used to administer medications) line needed for the resident to receive IV (intravenous) antibiotics for pneumonia, and a resident (Resident B) underwent an unnecessary medical procedure to place a PICC line that was not ordered by their physician for 2 of 7 residents reviewed for quality of care. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/30/21 when the facility failed to ensure the appropriate resident received a PICC line. This deficient practice resulted in a resident not receiving a PICC line needed for IV antibiotics, and another resident undergoing an unnecessary medical procedure for PICC line placement. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 02/24/22 at 04:05 P.M. The Immediate Jeopardy was removed on 02/25/22, but noncompliance remained at a lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The clinical record for Resident F was reviewed on 02/23/22 at 3:08 P.M. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP's (Nurse Practitioner) visit progress note, dated 12/30/21 at 10:47 A.M., indicated the resident was seen for his recent admission to the facility on [DATE]. Upon examination, the resident's lung sounds were diminished with rhonci (a low-pitched wheezing, snoring, or squeaking sound heard during auscultation of the chest of a person with partial airway obstruction) in all lung fields. The orders for the resident were given to LPN (Licensed Practical Nurse) 2. The NP's plan for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (an antibiotic) 500 mg (milligrams) IV (intravenously) every day for 3 days, and - [MEDICATION(S)] (an antibiotic) 750 mg/150 ml IV every day for 7 days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for placement of a PICC (Peripherally Inserted Central Catheter) line for antibiotic therapy. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for [MEDICATION(S)] Solution Reconstituted, use 500 mg intravenously one time a day for a respiratory infection for 3 days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for [MEDICATION(S)] ([MEDICATION(S)]) in D5W Solution 750 mg/150ml, use 750 mg intravenously at bedtime for a respiratory infection. A pharmacy delivery manifest, dated 12/31/21 at 3:41 A.M., indicated an IV pump, and the [MEDICATION(S)] antibiotic were delivered at that time for Resident F. During an interview on 02/23/22 at 2:20 P.M., LPN 2 indicated she wrote the initial order in the computer for Resident F to have a PICC line placed on 12/30/21. Normally when a PICC line was placed, the VAN (Vascular Access Nurse) would come into the building, verify the identification of the resident, and perform the procedure. There would need to be an X-ray completed to verify placement of the PICC before they could use it. There were two residents that were going to have PICCs placed, Resident F and Resident H. She relayed that information about the residents to the oncoming nurse when she gave report at the end of her shift. When LPN 2 came in the next day, she was told that a different resident received a PICC. She checked the computer, and she didn't write the order wrong. The night nurse must have directed the VAN to place the PICC in Resident B's arm. During an interview on 02/24/22 at 8:51 A.M., LPN 2 indicated Resident F did not have a PICC line placed on 12/30/21. The resident was very sick when he admitted to the facility and he was not improving, that was why the doctor ordered the PICC line and the IV antibiotics. On 12/31/21 the resident was short of breath and his oxygen levels were low, so she called Telehealth to get an order to send him to the local hospital for evaluation at 11:30 A.M. During an interview on 02/23/22 at 3:04 P.M., RN 4 indicated she usually only worked one night a week in the facility. She worked night shift on 12/30/21. When she received shift report from the off going nurse, she was told that two of her residents were going to be getting PICC lines placed later that evening. She could not remember exactly, but she thought the nurse told her the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She entered an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/24/22 at 10:00 A.M., the DON provided daily Nurse Report Sheets for 12/30/21 and 12/31/21. The first page of each document listed the following headings, .NEW MD ORDERS .LABS/X-RAY ., ATB .FALLS AND NEW INTERVENTIONS .Family Notification .MD Notification . Additional pages listed residents' names and room numbers with space to document pertinent resident information for the day and evening shifts. There was no documentation that related to Residents B, F, or H regarding PICC lines or antibiotics. During an interview on 02/24/22 at 10:58 A.M., the DON indicated Nurse Report Sheets should be utilized for new orders and anything that would need to be communicated to the staff about the residents. Staff document things like vital signs, blood sugar readings and new orders and use these sheets when they give report to the oncoming nurses. There was not a policy in place for using the Nurse Report Sheets. 2. The clinical record for Resident B was reviewed on 02/24/22 at 10:12 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 12/10/21, indicated the resident was cognitively sound. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for placement of a PICC line for IV antibiotic therapy related to a respiratory infection. On 02/23/22 at 2:58 P.M., the DON provided a document titled PICC/MIDLINE INSERTION DOCUMENTATION. The document indicated a double lumen PICC line was inserted into Resident B's right arm and the VAN and RN 4 confirmed the current patient, correct site, and correct procedure was performed. An NP visit progress note, dated 12/31/2021 at 12:25 P.M., indicated a nurse called to report that Resident B received a PICC line placement by accident. The nurse put an order in on Resident B when it should have been in on another resident. The NP gave an order to discontinue the PICC. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to discontinue the PICC line for the resident. During an interview on 02/24/22 at 2:15 P.M., LPN 2 indicated she removed Resident B's PICC line in the late morning or early afternoon of 12/31/21. She measured for the length and made sure the tip was intact. She monitored the insertion site and secured it with a dressing. She did not document the PICC removal procedure or assessment. The current undated Medication Administration policy was provided by the Administrator on 02/24/22 at 11:36 A.M. The policy indicated, .resident medications are to be administered in a timely manner and documentation is completed to substantiate administration . The current undated PICC Catheter Removal policy was provided by the Administrator on 02/24/22 at 11:36 A.M. The policy indicated, .Vasoconstriction ([MEDICATION(S)] of the vein) and venospasm (contractions of the vein as a protective mechanism) may occur during PICC catheter removal .Slowly remove catheter 1 - 2 inches at a time until the catheter is fully removed .Measure catheter and examine catheter tip to assure that entire catheter was removed .Document date, procedure and any abnormal findings. The CATHETER REMOVAL RECORD was provided by the administrator on 02/24/22 at 11:36 A.M. The form required the following criteria be addressed: Date PICC Line Removed .Complications at Site . No Complications .Red .Tender .Swollen . Serious [sic] drainage (clear or pale-yellow fluid slightly thicker than water) .Purulent drainage (white, yellow, or brown fluid slightly thick in texture) .Bleeding at insertion site .Reason for removal .Comments . The Immediate Jeopardy that began on 12/31/21 was removed on 2/25/22 when the facility audited all residents' records to ensure that residents had medications in their medication supply that had been ordered specifically for them. Further, a 60 day look back audit was done to validate that any ordered IVs to include peripheral and PICC lines, had orders for these, with required documentation to validate that the medications were administered. All licensed nursing staff were inserviced related to IV orders, medication administration, and documentation. A verification process was implemented to ensure two licensed nurses would validate that the specific resident is the resident who has the order and who is to have the IV or PICC line placed. The facility implemented a process to monitor medication administration and PICC line placement. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to complaint IN 037. 3.1-37(a)

Based on record review and interview, the facility failed to provide medically related social services for one resident who did not receive an antidepressant medication dose increase or psychosocial interventions as recommended by the consulting Psychologist (Resident B). This deficient practice resulted in harm in that Resident B experienced a decline in mood since admission and attempted suicide. Findings include: Resident B's closed clinical record was reviewed on 3/1/2016 at 12:40 p.m. [DIAGNOSES REDACTED]. Resident B was admitted to the facility on [DATE], following a hospital admission for urinary tract infection and intractable (uncontrollable) vomiting. Resident B's admission Minimum Data Set (MDS) assessment, dated 1/24/2016, indicated a Brief Interview for Mental Status (BIMS) score of 9; indicating the resident was moderately cognitively impaired. Resident B's Mood score was 4; indicating no depression. The resident required staff assistance for all activities of daily living (ADL's) and self-propelled in his wheelchair for mobility. Resident B's change of (occupational) therapy MDS assessment, dated 2/21/2016, indicated a BIMS of 12; indicating the resident was moderately cognitively impaired. Resident B's Mood score was 9; indicating mild depression (5-9). physician's orders [REDACTED]. Give 10 mg by mouth one time a day for Depression. Start Date: 1/18/2016 .Lorazepam (antianxiety medication) Tablet 0.5 mg. Give 0.5 mg by mouth every 8 hours as needed for Anxiety. Start Date: 1/17/2016 Resident B's Medication Administration Record (MAR) for January and February, 2016, indicated the resident received Celexa 10 mg one time daily from January 18, 2016, until his discharge 2/24/2016. Resident B's Medication Administration Record (MAR) for January and February, 2016 indicated the resident received Lorazepam 0.5 mg 10 times from 1/20/2016 through 2/23/2016. A care plan for Resident B indicated, Focus: At risk for decline in mood r/t (related to) dx (diagnosis): deprssion (sic) and on antidepressant. Date Initiated: 1/20/2016. Makes negative statements about self and has unrealistic expectations about wanting to live alone in house .wanting to drive. PHQ-9 (MDS Mood score) shows mild depression. Date Initiated: 2/12/2016. Revision on 3/1/2016. Goal: Will have no decline in mood daily TNR (until next review). Date Initiated: 1/20/2016. Interventions (all initiated 1/20/2016): Antidepressant per order. Encourage family involvement .Monitor for effectiveness of meds and interventions. Notify MD, Family and IDT (interdisciplinary team) of any changes. Observe for adverse reaction to antidepressant such as but not limited to: (blank). Psych (psychiatry/psychology) consult as needed. A care plan for Resident B indicated, Focus: At risk for increased anxiousness r/t dx: with need for anxiolytic (antianxiety). Date Initiated: 1/20/2016. Becomes agitated when talking about past events and money. Yells and screams at staff. Date Initiated: 1/20/2016. Revision on: 3/1/2016. Goal: Will have no adverse reaction r/t Anxiolytic use TNR. Date Initiated: 1/20/2016. Interventions (all initiated 1/20/2016): .Anxiolytic per order .Encourage family involvement .Encourage to vent feelings .Monitor for effectiveness of meds and interventions. Notify md (sic), family and IDT of changes. Observe for adverse reactions to anxiolytic such as but not limited to: (blank). Validate and assist. Resident B's Psychological Consultation note, related to a referral by the facility, dated 2/11/16, indicated, the patient .just yesterday made a statement that if he had a gun he would probably shoot himself with it. The patient denies any active suicidal ideation in today's clinical contact, though notes that he feels at times as if his circumstances are so bleak that this becomes a consideration .he simply indicates that he is very frustrated with his life circumstances .(Resident B) notes that after he left the facility last year, he (went to) the home of his brother .that his brother in fact was helping himself to a great deal of the patient's money .there is little doubt that there is significantly increased depression ongoing with the patient .Recommendations (with attending Physician Discretion): 1. Please consider Celexa dosing increase to 20 mgs (milligrams) po (by mouth) qd (once daily). 2. Continued follow up as appropriate, the patient seems to value from the opportunity to talk about his circumstances and the painful difficulties with which he continues to struggle at this juncture. 3.two strangers who essentially posed in his life as caretakers who he indicates took a lot of his money .This may be the case concurrently for brother, which I think in the long run is even sadder for the patient Resident B's Occupational Therapy Treatment Encounter Note, dated 2/13/2016, indicated, .Comments: .Resident expressed financial concerns to OTP (Occupational Therapist). OTP reported to social services. Resident B's Occupational Therapy Recertification & Updated Plan of Treatment, dated 2/15/2016, indicated, Progress: .(Resident B) has made disparaging comments about himself and has stated that he wishes to die. Consult with SSD regarding sttements (sic) Physician's Progress Notes for Resident B, dated 2/15/2016, indicated, .Is sad about overall physical condition .(9) Depression: stable. Describes himself as not necessarily happy There was no documentation in Resident B's clinical record to indicate Resident B received an increase of Celexa to 20 mg once daily, care plans were updated, or the physician was notified related to Resident B's increased depression scores, suicidal ideations, or psychology referral and recommendations. A Nurses Note, dated 2/24/2016 at 4:09 p.m., indicated, Went into res (resident) room to do accu check (blood sugar test) and found res in w/c (wheelchair) with clear garbage bag over res head with black elecric (sic) cord, appears as charger for phone, around res neck. removed bag and cord. res stated just let me kill myself res crying and distraught, wanting to die. LPN #4 was interviewed on 3/1/2016 at 3:40 p.m. She indicated she entered Resident B's room to check his blood sugar and find him in his wheelchair with a plastic trash bag over his head and what appeared to be a cell phone cord wrapped around his neck with his hands holding the cord fisted under his chin and around his neck. She indicated she immediately tore the plastic bag open and assessed the resident. LPN # 4 indicated his color and vital signs remained good (within normal limits) and he never lost consciousness. Documented vital signs indicated the same. LPN # 4 indicated Resident B was crying and indicated he wished to die. A Social Services Note for Resident B, dated 2/25/2016 at 10:27 a.m., and signed by the SSD, indicated, Res was sent to (hospital) for psych (psychiatric) evaluation and treatment for [REDACTED]. After visit no recommendation for inpatient psych treatment. Med (medication) adjustment recommendations in place. See psych notes in chart. The previous Social Services Note was dated 1/29/2016, and was related to a change in Power of Attorney (POA). The Social Services Director (SSD) was interviewed on 3/1/2016 at 12:41 p.m. She indicated Resident B had concerns related to family dynamics, possible misappropriation of funds by his POA, and unrealistic expectations about returning home to live independently. She indicated she assisted the resident with a change in POA and alerted Adult Protective Services (APS) regarding the possible misappropriation of funds by family and/or caretakers. She indicated she did not notify or enlist the help of the Ombudsman. The SSD indicated she obtained an order for [REDACTED]. The SSD indicated, When I did all my PHQ-9 (MDS mood) assessments, they showed he fell in the mild range, which is five to nine. His last assessment was on 2/21(2016), after making the negative statements. On 3/1/2016 at 2:40 p.m., the SSD indicated she was responsible for psychology consults and forwarding recommendations to nursing and the attending physician. She indicated she received Resident B's Psychological Consultation, dated 2/11/16, via fax on 2/16/16, reviewed it, and faxed it to Physician C (who was covering for Resident B's physician, Physician D, while she was on maternity leave) that day. The SSD indicated she normally advises nursing staff of any medication recommendations, but could not provide any documentation that she had done so, and nothing was indicated in the clinical record that anyone was notified of the recommendations. The SSD indicated that she did not change Resident B's care plan, interventions, or frequency of interaction related to the psychologist's second recommendation (above). The Director of Nursing (DON) was interviewed on 3/1/2016 at 2:45 p.m. The The DON indicated Resident B's recommended increased Celexa dose was never started. The DON indicated she learned Physician C was no longer covering for Physician D, but Resident B's psychology consult note and recommendations were not faxed/forwarded to Physician D. On 3/1/2016 at 3:33 p.m. the SSD was interviewed regarding the 2/25/2016 Social Services Note (above). She indicated, Honestly, it was an assumption that it (medication increase) was in place. On 3/1/2016 at 3:50 p.m., the Administrator indicated the facility did not have a policy or procedure related to consults/referrals or consult/referral recommendations. A copy of the current Director of Social Services Job Description was provided by the Administrator on 3/1/2016 at 3:50 p.m. The document indicated, .C. Role Responsibilities .5. Maintains significant social service progress notes on the resident's medical chart on a timely basis .6. Maintains a current social service plan On 3/1/2016 at 4:45 p.m., the DON indicated the SSD was responsible for following up on consults/referrals and recommendations. This Federal tag relates to Complaint IN 421. 3.1-34(a)

Based on record review and interview, the facility failed to ensure the attending physician was made aware of an antidepressant medication dose increase as recommended by the consulting Psychologist, update the plan of care, and provide appropriate and recommended interventions for a resident with increased depression and suicidal ideation (Resident B). This deficient practice caused harm in that Resident B experienced a decline in mood since admission and attempted suicide. Findings include: Resident B's closed clinical record was reviewed on 3/1/2016 at 12:40 p.m. [DIAGNOSES REDACTED]. Resident B was admitted to the facility on [DATE], following a hospital admission for urinary tract infection and intractable (uncontrollable) vomiting. Resident B's admission Minimum Data Set (MDS) assessment, dated 1/24/2016, indicated a Brief Interview for Mental Status (BIMS) score of 9; indicating the resident was moderately cognitively impaired. Resident B's Mood score was 4; indicating no depression. The resident required staff assistance for all activities of daily living (ADL's) and self-propelled in his wheelchair for mobility. Resident B's change of (occupational) therapy MDS assessment, dated 2/21/2016, indicated a BIMS of 12; indicating the resident was moderately cognitively impaired. Resident B's Mood score was 9; indicating mild depression (5-9). physician's orders [REDACTED]. Give 10 mg by mouth one time a day for Depression. Start Date: 1/18/2016 .[MEDICATION NAME] (antianxiety medication) Tablet 0.5 mg. Give 0.5 mg by mouth every 8 hours as needed for Anxiety. Start Date: 1/17/2016 Resident B's Medication Administration Record [REDACTED]. Resident B's Medication Administration Record [REDACTED]. A care plan for Resident B indicated, Focus: At risk for decline in mood r/t (related to) dx (diagnosis): deprssion (sic) and on antidepressant. Date Initiated: 1/20/2016. Makes negative statements about self and has unrealistic expectations about wanting to live alone in house .wanting to drive. PHQ-9 (MDS Mood score) shows mild depression. Date Initiated: 2/12/2016. Revision on 3/1/2016. Goal: Will have no decline in mood daily TNR (until next review). Date Initiated: 1/20/2016. Interventions (all initiated 1/20/2016): Antidepressant per order. Encourage family involvement .Monitor for effectiveness of meds and interventions. Notify MD, Family and IDT (interdisciplinary team) of any changes. Observe for adverse reaction to antidepressant such as but not limited to: (blank). Psych (psychiatry/psychology) consult as needed. A care plan for Resident B indicated, Focus: At risk for increased anxiousness r/t dx: with need for anxiolytic (antianxiety). Date Initiated: 1/20/2016. Becomes agitated when talking about past events and money. Yells and screams at staff. Date Initiated: 1/20/2016. Revision on: 3/1/2016. Goal: Will have no adverse reaction r/t Anxiolytic use TNR. Date Initiated: 1/20/2016. Interventions (all initiated 1/20/2016): .Anxiolytic per order .Encourage family involvement .Encourage to vent feelings .Monitor for effectiveness of meds and interventions. Notify md (sic), family and IDT of changes. Observe for adverse reactions to anxiolytic such as but not limited to: (blank). Validate and assist. Resident B's Psychological Consultation note, related to a referral by the facility, dated 2/11/16, indicated, the patient .just yesterday made a statement that if he had a gun he would probably shoot himself with it. The patient denies any active suicidal ideation in today's clinical contact, though notes that he feels at times as if his circumstances are so bleak that this becomes a consideration .he simply indicates that he is very frustrated with his life circumstances .(Resident B) notes that after he left the facility last year, he (went to) the home of his brother .that his brother in fact was helping himself to a great deal of the patient's money .there is little doubt that there is significantly increased depression ongoing with the patient .Recommendations (with attending Physician Discretion): 1. Please consider [MEDICATION NAME] dosing increase to 20 mgs (milligrams) po (by mouth) qd (once daily). 2. Continued follow up as appropriate, the patient seems to value from the opportunity to talk about his circumstances and the painful difficulties with which he continues to struggle at this juncture. 3.two strangers who essentially posed in his life as caretakers who he indicates took a lot of his money .This may be the case concurrently for brother, which I think in the long run is even sadder for the patient Resident B's Occupational Therapy Treatment Encounter Note, dated 2/13/2016, indicated, .Comments: .Resident expressed financial concerns to OTP (Occupational Therapist). OTP reported to social services. Resident B's Occupational Therapy Recertification & Updated Plan of Treatment, dated 2/15/2016, indicated, Progress: .(Resident B) has made disparaging comments about himself and has stated that he wishes to die. Consult with SSD regarding sttements (sic) Physician's Progress Notes for Resident B, dated 2/15/2016, indicated, .Is sad about overall physical condition .(9) Depression: stable. Describes himself as not necessarily happy There was no documentation in Resident B's clinical record to indicate Resident B received an increase of [MEDICATION NAME] to 20 mg once daily, care plans were updated, or the physician was notified related to Resident B's increased depression scores, [MEDICAL CONDITION], or psychology referral and recommendations. A Nurses Note, dated 2/24/2016 at 4:09 p.m., indicated, Went into res (resident) room to do accu check (blood sugar test) and found res in w/c (wheelchair) with clear garbage bag over res head with black elecric (sic) cord, appears as charger for phone, around res neck. removed bag and cord. res stated just let me kill myself res crying and distraught, wanting to die. LPN #4 was interviewed on 3/1/2016 at 3:40 p.m. She indicated she entered Resident B's room to check his blood sugar and find him in his wheelchair with a plastic trash bag over his head and what appeared to be a cell phone cord wrapped around his neck with his hands holding the cord fisted under his chin and around his neck. She indicated she immediately tore the plastic bag open and assessed the resident. LPN # 4 indicated his color and vital signs remained good (within normal limits) and he never lost consciousness. Documented vital signs indicated the same. LPN # 4 indicated Resident B was crying and indicated he wished to die. A Social Services Note for Resident B, dated 2/25/2016 at 10:27 a.m., and signed by the SSD, indicated, Res was sent to (hospital) for psych (psychiatric) evaluation and treatment for [REDACTED]. After visit no recommendation for inpatient psych treatment. Med (medication) adjustment recommendations in place. See psych notes in chart. The previous Social Services Note was dated 1/29/2016 and was related to a change in Power of Attorney (POA). The Social Services Director (SSD) was interviewed on 3/1/2016 at 12:41 p.m. She indicated Resident B had concerns related to family dynamics, possible misappropriation of funds by his POA, and unrealistic expectations about returning home to live independently. She indicated she assisted the resident with a change in POA and alerted Adult Protective Services (APS) regarding the possible misappropriation of funds by family and/or caretakers. She indicated she did not notify or enlist the help of the Ombudsman. The SSD indicated she obtained an order for [REDACTED]. His last assessment was on 2/21(2016), after making the negative statements. On 3/1/2016 at 2:40 p.m., the SSD indicated she was responsible for psychology consults and forwarding recommendations to nursing and the attending physician. She indicated she received Resident B's Psychological Consultation, dated 2/11/16, via fax on 2/16/16, reviewed it, and faxed it to Physician C (who was covering for Resident B's physician, Physician D, while she was on maternity leave) that day. The SSD indicated she normally advises nursing staff of any medication recommendations, but could not provide any documentation that she had done so, and nothing was indicated in the clinical record that anyone was notified of the recommendations. The SSD indicated that she did not change Resident B's care plan, interventions, or frequency of interaction related to the psychologist's second recommendation (above). The Director of Nursing (DON) was interviewed on 3/1/2016 at 2:45 p.m. The The DON indicated Resident B's recommended increased [MEDICATION NAME] dose was never started. The DON indicated she learned Physician C was no longer covering for Physician D, but Resident B's psychology consult note and recommendations were not faxed/forwarded to Physician D. On 3/1/2016 at 3:33 p.m. the SSD was interviewed regarding the 2/25/2016 Social Services Note (above). She indicated, Honestly, it was an assumption that it (medication increase) was in place. On 3/1/2016 at 3:50 p.m., the Administrator indicated the facility did not have a policy or procedure related to consults/referrals or consult/referral recommendations. A copy of the current Director of Social Services Job Description was provided by the Administrator on 3/1/2016 at 3:50 p.m. The document indicated, .C. Role Responsibilities .5. Maintains significant social service progress notes on the resident's medical chart on a timely basis .6. Maintains a current social service plan On 3/1/2016 at 4:45 p.m., the DON indicated the SSD was responsible for following up on consults/referrals and recommendations. This Federal tag relates to Complaint IN 421. 3.1-43(a)(1)

Based on record review, observation, and interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents in that one resident sustained [REDACTED]. This affected 1 of 4 residents reviewed for potential for accidents related to burns in a sample of 16. (Resident #37) Findings include: Resident # 37's record was reviewed on 9/1/11 at 2:45 p.m. The record indicated Resident #37 was admitted with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated Resident #37 was severely cognitively impaired, has continuous behavior of delirium and disorganized thinking, was independent with eating after set up, had no impairment in range of motion in upper or lower extremities, and used a wheelchair for mobility. Nurse's notes indicated: - 8/18/11 at 3:10 p.m.: "...CNA reported res (resident) spilt hot tea on self. res took to RM (room) & skin checked, tea on clothing protector & blue jeans. Skin normal color, no raised or O/A (open areas)...." - 8/18/11 at 5:00 p.m.: "...nurse reported to writer res spilt hot coffee on self removed lid of travel mug res was sitting at table in main dining room. Cool compress applied, area reddened. (no) O/A or raised area...dietary notified of N.O. Kennedy cup for hot liquids res clothes (changed) and returned to dining room for supper." - 8/18/11 at 5:50 p.m.: "res in room, writer went to check on reddness (sic)...Res noted to have small blisters on left lower abd. (abdomen)...." - 8/19/11 at 11:30 a.m.: "Resident observed to self remove lid from hot beverage container & has (increased) aggitation (sic) during attempts to assist (with) carrying of hot beverages when he wants to leave table (with) beverage. Resident is grossly demented & HOH (hard of hearing) - has poor ability to recognize safety needs & interventions. Will have therapy eval & will use heat protectant apron when resident insistant (sic) on traving (sic) (with) hot Beverage...." - 8/19/11 at 11:40 a.m.: "Res. refused cold compress to burn area, states "I don't want it." Res. in MDR (main dining room) (with) apron on. Noted to take lid off of Kennedy cup, filling it (with) cold water past fill line. Stated "the tea is always too hot so I add cold water." Explained to res. not to take lid off and importance of fill line. Res. (not) cooperative." - 8/19/11 at 12:20 p.m.: "Res was given hot tea in Kennedy cup per res request, staff had made tea & added sweeter & removed tea bag. Res was observed removing Kennedy cup lid res. had a used tea bag he had kept & he added that to his cup...." - 8/19/11 at 2:00 p.m.: "New order rec'd - cleanse blistered area to (L) (lower) abd (with) NS (normal saline), apply Silvadene cream then non adherent drsg (dressing), (change) bid (twice a day) & prn (as needed) until healed...." - 8/20/11 at 4:00 p.m. "8A late entry - At breakfast Res. removed lid from Kennedy cup containing coffee that was prepared for him by staff, he stated he wanted cold water added to it, cold water was added & Res. reminded not to remove lid on cup for safety (sic), 2-3 min after reminder Res. removed lid once again...." - 8/27/11 at 1:00 a.m.: "(L) lower abdomen & upper thigh (with) open area following burn on 8/18 from spilling hot beverage on self. Drsg (change) as per order. Res denies pain." Care plans dated 8/19/11 indicated the care plans were updated as follows: "Problem/Need: HAS PREFERENCE TO CARRYING HOT BEVERAGES WHILE UP IN W/C WITH HX (history) OF SELF REMOVAL OF LIDS, RECURRENT COFFEE SPILL WITH BURN, RES HAS POOR ABILITY TO RECOGNIZE SAFETY WITH HOT BEVERAGES AEB (as evidenced by) SELF REMOVAL OF LIDS" "Goal & Target Date: WILL HAVE NO FURTHER SPILLS OF HOT BEVERAGES WHICH RESULT IN INJURY TNR (through next review)" "Approaches: KENNEDY CUP FOR HOT LIQUIDS, ENCOURAGE TO SIT AT TABLE WHEN DRINKING HOT BEVERAGES, ENC (encourage) TO PERMIT STAFF TO CARRY HOT BEVERAGE FOR HIM, ENC TO WEAR HEAT PROTECTANT APRON WHEN CARRYING HOT BEVERAGES HIMSELF, THERAPY ADVISED AND WILL SCREEN 8/19/11, NOTIFY SS (Social Services) PRN, FOLLOW UP WITH DR/FAMILY PRN, SKIN TREATMENT PRN AS ORDERED, SKIN ASSESSMENT IMMEDIATELY AFTER SPILL EVENT." "Problem/Need: SELF REMOVES LIDS TO REUSE TEA BAG EVEN THOUGH BEVERAGE IS ALREADY MADE, NONCOMPLIANT WITH USING KENNEDY CUP/APRON AEB RES NOTED TO UNSCREW THE LID, TAKE A DRINK, AND SCREW THE LID BACK ON" "Goal & Target Date: WILL NOT REMOVE LIDS TNR, RES TO REMAIN SAFE IN HIS OWN ENVIRONMENT TNR" "Approaches: ENC RES TO USE KENNEDY CUP/APRON, STAFF TO MAKE RESIDENT'S TEA WITH 2 TEA BAGS AND REMOVE THE BAGS BEFORE SERVING, ENC RESIDENT TO ALLOW STAFF TO ADD SWEETNER TO HIS BEVERAGES, NOTIFY SS PRN." An "INCIDENT DOCUMENTATION AND INVESTIGATION TOOL" dated 8/18/11 at 3:00 p.m. indicated Resident #14 was propelling self in his wheelchair in the hallway and spilt hot tea on himself. The first intervention after this incident was to have the resident not hold tea and propel himself in the wheelchair. An "INCIDENT DOCUMENTATION AND INVESTIGATION TOOL" dated 8/18/11 at 4:50 p.m. indicated this resident was sitting in the dining room and had spilt the coffee he was drinking while awaiting supper. The first interventions after this incident was to encourage resident to allow them to prepare his hot beverage by adding sweetener, and to encourage to use the heat protectant apron. A care plan dated 8/31/11 indicated a Problem/Need/Concern for: "Resident has demonstrated poor safety awareness AEB removing secured lids from warm beverages. Goal: Resident will continue to enjoy warm beverages without injury TNR. Nursing: 1. Resident to be provided with warm beverages with meals and supervised activities. 2. Staff to supervise resident with all warm beverages. 3. Staff to ask resident if all warm beverages are at temperature resident enjoys. 4. Resident to wear water resistant clothing protection and use Kennedy cup when drinking warm beverages." On 8/31/11 at 12:25 p.m., with the Director of Nursing, Resident #14 was observed in the main dining room. He was seated in a wheelchair at a table by himself with a heat protectant apron on the front of his clothes from chin to knees. Resident #14 then removed the apron, folded it and placed it on the table. Social Services poured hot water from the insulated carafe into a Kennedy cup, added sugar, put the tea bag in and dunked it a few times, then snapped the lid on and gave to Resident #14. The heat protectant apron was placed back on the resident. The Activity Director was observed to sit at the table with the resident after the resident was given the Kennedy cup. The burns on Resident #14's left abdomen and left upper thigh were observed on 9/1/11 at 12:25 p.m. with LPN #2. Resident #14 was reclined in a recliner in his room. The burned area on the lower left abdomen was open, moist looking, tan in color, and approximately 3 inches by 2 inches in size. The burned area on the upper left thigh was also tan in color, moist, and approximately 4 inches by 2 inches in size. During an interview on 9/1/11 at 12:18 p.m., the Director of Nursing indicated, on a written document, further corrective actions to ensure no other residents are affected by hot liquid burns. These include: "1.) Have contacted vendor for evaluation/adjustment of coffee machine. 2.) Temperature taken of Carafes liquids prior to serving Res. for appropriate warmth for 3 months. 3.) Re-assess all res. receiving hot liquids for safety. 4.) (Resident's name) will receive liq.'s (liquids) only (with) meals & activities. Staff member will be 1 on 1 til (sic) cup is empty. 5.) Heating Device removed from kitchen. Coffee/Hot Water will go directly from Coffee Pot to Carafes. 6.) Each res. identified as a risk for burns will have the appropriate assistive decides in place, i.e. Kennedy cup; traveler's mug; water resistant clothing protector." A Policy and Procedure for "INCIDENT DOCUMENTATION AND INVESTIGATION" was provided by the Administrator on 8/29/11 at 12:45 p.m. The policy indicated, but was not limited to: "POLICY: All incidents involving resident care will be investigated and documented on the Incident Documentation and Investigation Tool to enable the facility to evaluate the care given to residents, to assist in prevention of incidents, and evaluate intervention given in the event of an incident. An "incident" is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents....." A Policy and Procedure for "Serving Food and Beverages" was provided by the Administrator on 8/31/11 at 12:54 p.m. The policy indicated, but was not limited to: "Guideline: Staff shall follow the guidelines below when preparing and serving hot beverages and food. Procedure: 1. Foods shall be served at the following temperatures to ensure a safe and appetizing dining experience...Hot Beverages 130 (degrees) F (Fahrenheit) to 165 (degrees) F...." On 9/1/11 at 9:05 a.m., the Corporate Nurse Consultant indicated they had a coffee maker that maintained the coffee at the high temperature and they removed it from dietary. Staff are now to use water from the insulated carafe and check the temperature at the dietary window before serving it to Resident #14 at each meal. On 9/1/11 at 3:54 p.m., the Corporate Nurse Consultant indicated staff began sitting with Resident #14 with each meal until he is finished with his coffee or tea, they will do a hot liquid assessment with each resident to identify potential residents who could be affected by hot liquids, and they will serve hot liquids at no higher than 130 degrees for dementia residents. The Corporate Nurse Consultant also indicated the facility "will forever have the staff sit with" Resident #14. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident remained free of injury from hot coffee, resulting in a second degree burn. This affected 1 of 3 residents reviewed for hot beverage precautions in a sample of 6. (Resident A) Findings include: On 6/27/2011 at 1:00 p.m., review of Resident A's clinical record indicated she was admitted with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) dated 3/11/11, indicated the resident was moderately impaired in cognitive status with a BIMS (brief interview for mental status) score of 6. A nurse's note dated 6/5/11 at 6:25 p.m. indicated, "This nurse was in MDR (main dining room) and resident was noted to be saying 'ow' 'ow.' I asked resident what is wrong? She stated, 'I burned myself with coffee this morning.' I looked at resident's shirt she was noted to have a coffee stain on her shirt which was dried. I looked @ resident's skin and noted it was reddened. This nurse took resident out of MDR and checked skin. It was noted to have a small open blister that was on skin and area around blister was noted to be reddened and blanchable." This same nurse's note indicated the nurse called the POA (resident's Power of Attorney), the on-call doctor and received a new order for "Polysporin ointment to be applied topically to area on chest BID (two times daily) then apply telfa and cover until healed." The nurse indicated she notified the DON of the incident and sent a dietary slip to the dietary department for "Kennedy cup (a light weight spill proof drinking cup. Once the lid is screwed on the liquid will not spill out even if the cup is turned completely upside down) with all hot beverages." The resident's care plan indicated she has a history of spilling coffee on herself, with a problem onset date of 4/02/2008, with approaches: * enc (encourage) resident to ask for assistance in carrying hot coffee to where she is sitting 7/14/08 *coffee cup with lid for all hot liquids, on 3/31/11 "Be sure cup has lid for all hot liquids esp (especially) c (with) transport", 6/5/11 "Put all hot liquids in Kennedy cup." On 6/27/2011 at 4:05 p.m., in an interview with Employee #1/CNA she indicated the resident wouldn't be able to tell much until she gets her blood sugar back up. "She's okay when her blood sugars are within her normal range." During an interview with Resident A on 6/28/2011 at 8:15 a.m., she indicated that she spilled about a half cup of hot coffee down the front of her shirt when she was burned. "The coffee was very hot; it's usually not that hot." "I told staff that I spilled my coffee on me and it was very hot." "I told them at breakfast, but they didn't do anything." She indicated that coffee was all down the front of her shirt, "but nobody noticed it until at supper and I told the nurse and she put medicine on it." "No, there was no lid on my cup of coffee that day." "Now, my burn is all better, doesn't hurt any more." On 6/28/2011 at 1:50 p.m., in interview with the ADON (Assistant Director of Nursing), she indicated the department heads serve residents at breakfast and they serve coffee, so they would be responsible for putting lids on cups for residents with "hot beverage precautions," "but I couldn't tell you if I put a lid on her coffee cup or not." During telephone interview with Resident A's daughter/POA on 6/29/11 at 2:12 p.m., she indicated the resident only has coffee at breakfast and, "I can only come for lunch or supper, so I don't know if she had a lid on her coffee cup or not...Mom is reliable if blood sugar is stable." 3.1-45(a)(2)