Every finding on record at Waters of Castleton Skilled Nursing Facility, The

Based on observation and record review, the facility failed to ensure a resident's right to privacy and dignity during 1 of 1 care observations in which 1 of 3 residents reviewed for care and services did not have the door or privacy curtain closed in a manner to provide privacy and dignity during the process of transferring the resident from the wheelchair into their bed. (Resident C) Findings include:During an interview with a family member of Resident C on 6-2-26 at 4:15 p.m., Resident C was sitting in her wheelchair and indicated she wanted to lay down. During an observation on 6/2/26 at 4:15 p.m., CNA 3 and CNA 4 entered Resident C's room and transferred the resident from the wheelchair to the bed. The resident's privacy curtain was not pulled closed and the resident's door was not shut during this observation. Resident C's transfer was visible from the hallway of the facility. A review of Resident C's clinical record on 6-3-26 at 1:50 p.m., indicated her diagnoses included, but were not limited to, unspecified dementia and a cerebral infarction (stroke) causing paralysis to the left side of her body. Her most recent Minimum Data Set analysis, dated 5-8-26, indicated she was severely cognitively impaired.On 6-3-26 at 3:19 p.m., the Executive Director provided an undated copy of a policy entitled, Your Rights and Protections as a Nursing Home Resident. This policy indicated, [You have the] right to be treated with dignity and respect .get proper privacy .The Indiana Department of Health's Nurse Aide Curriculum (revised 3-21-14) indicated, avoid unnecessary exposure.410 IAC (Indiana Administrative Code) 3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure the use of a gait belt (device used to enhance safety during movement while assisting another person) during the transfer of 1 of 3 residents reviewed for care and services during 1 of 1 care observations. (Resident C) Findings include: During an interview with CNA 3 on 6-2-26 at 4:05 p.m., she indicated she was aware Resident C was a big fall risk, and had a history of falls. During an interview with a family member of Resident C on 6-2-26 at 4:15 p.m., Resident C was sitting in her wheelchair and indicated she wanted to lay down. During an observation on 6-2-26 at 4:15 p.m., CNA 3 and CNA 4 entered Resident C's room they were observed to don gloves, prior to beginning the care to transfer the resident from the wheelchair to her bed. CNA 3 and CNA 4 were observed to explain each step of the transfer from the wheelchair to the bed with Resident C. The staff members were observed to instruct Resident C to stand up with assistance of both CNA's, while placing their arms under her arms, towards her back. Resident C was observed to stand and pivot one to two steps to sit down onto the mattress of her bed. The staff members were observed to assist the resident by placing her legs onto the bed and position her onto her back. CNA 3 and 4 did not utilize a gait belt during the transfer. During an interview with CNA 3 on 6-2-26 at 4:15 p.m., she indicated normally she would use a gait belt with Resident C's transfers, but unable to find a gait belt to use during the transfer. A review of Resident C's clinical record on 6-3-26 at 1:50 p.m., indicated her diagnoses included, but were not limited to, unspecified dementia, a history of repeated falls and a cerebral infarction (stroke) causing paralysis to the left side of her body. Her most recent Minimum Data Set analysis, dated 5-8-26, indicated she was severely cognitively impaired, did not walk or ambulate, had a history of falls and fractures prior to admission on [DATE], and had sustained two or more falls without injury since her admission.On 6-3-26 at 11:39 a.m., the Executive Director provided an undated copy of a procedure entitled, Transfer Belts/Gait Belts. This procedure indicated, It is the intent of the facility to promote safety in transferring and ambulating residents, a gait belt [sic] .A gait belt was used as indicated for safety by the person qualified to transfer the Resident .to provide stability and balance during movement.410 IAC (Indiana Administrative Code) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to prevent a urinary catheter bag or its tubing from coming in contact with the floor during 1 of 1 care observations for 1 of 3 residents reviewed for care and services. (Resident C) Findings include:During an observation for Resident C on 6-2-26 at 4:15 p.m., CNA 3 and CNA 4, were observed to assist the resident to transfer from her wheelchair and into her bed. The staff were observed to have the bed at a level of comfort and ease for her to move from the wheelchair to her bed. The staff were observed to place her urinary catheter bag onto the right side of the bed frame and the bag and tubing were not in contact with the floor. Upon completion of the care, the staff were observed to lower Resident C's bed into its lowest position. The urinary catheter bag and its tubing were in contact with the floor. The staff were observed to to clean up the area and exit the room. During an interview with CNA 4 on 6-2-26 at 4:20 p.m., indicated Resident C's catheter bag and tubing should not be touching the floor. CNA 4 found a wash basin under Resident C's bed and took the catheter bag and tubing from the floor and placed them in a wash basin. During an interview with the Corporate Nurse on 6-3-26 at 11:36 a.m., she indicated the facility did not have any policies or procedures that specifically address not allowing the urinary catheter bags or tubing to not touch the floor. She indicated staff education addressed the urinary collection bag and tubing should not come in contact with the floor.The clinical record for Resident C was reviewed on 6-3-26 at 1:50 p.m. Her diagnoses included but were not limited to unspecified dementia, neuromuscular dysfunction of the bladder (disruption that impairs the ability to store and empty urine) and urinary retention. The admission Minimum Data Set assessment for Resident C, dated 5-8-26, indicated she had an indwelling catheter.On 6-3-26 at 11:39 a.m., the Executive Director provided a copy of an undated policy entitled, Catheters. This policy indicated, It is the policy of the facility to ensure .appropriate treatment and services to prevent urinary tract infections .Insertion, ongoing care and catheter .protocols that adhere to professional standards of practice and facility policy and procedure with adherence to infection prevention and control techniques. 410 IAC (Indiana Administrative Code) 3.1-41(a)(2)

Based on interview and record review the facility failed to have complete and accurate documentation for a resident's follow- up physician appointments for 1 of 3 residents reviewed for physician appointments. (Resident C). Finding include:The clinical record of Resident B was reviewed on 6-2-26 at 2:42 p.m. Her diagnoses included, but were not limited to unspecified dementia (mental decline), low back pain, unspecified disease of the spinal cord, spinal stenosis of the lumbar region with neurogenic claudication (narrowing of the spine causing pain in the legs and buttocks) and a history of falls. The Minimum Data Set assessment for Resident C, dated 3-26-26, indicated she was cognitively impaired and was unable to walk or ambulate independently, required the use of a wheelchair for mobility. A review of her clinical record indicated she was sent out to the hospital on [DATE], related to an altered mental status. Upon her discharge from the hospital, she returned to the facility. Her hospital discharge medical orders, received on 10-29-25, included for the facility to schedule a follow-up appointment with a neurologist. A review of the clinical record failed to identify if any appointments had been scheduled for her to see a neurologist. In an interview with the Corporate Nurse on 6-3-26 at 11:45 a.m., she indicated she did locate information of appointments scheduled in the facility's electronic calendar in which Resident B was identified to have appointments scheduled for her to be transported by the facility to neurology appointments on 11-14-25, 1-13-26 and 2-14-26. The Corporate Nurse clarified she was unable to locate any documentation on/around those dates to support if Resident B had attended any of those appointments or any associated documentation from the specialist. The Corporate Nurse was unable to locate any information to suggest any further attempts had been made to reschedule the previously requested referral made for Resident B with a neurologist.On 6-3-26 at 3:00 p.m., the Executive Director provided a copy of an undated policy entitled, Guidelines for Electronic Health Record Documentation. This policy indicated its purpose as, A medical record is maintained for each resident to provide a permanent record of the care provided .The following medical records are being maintained .physician orders .progress notes .miscellaneous documents .Documentation guidelines include but may not be limited to: changes in condition .behaviors .documentation required by each discipline--timely and accurate.This Federal tag relates to Intake 3026020.410 IAC (Indiana Administrative Code) 3.1-50(a)(1)410 IAC (Indiana Administrative Code) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure sufficient nursing staff to provide administer medications for 15 of 28 residents reviewed who received medication from the second-floor west hall medication cart. (Resident E, Resident F, Resident G, Resident H, Resident K, Resident M, Resident N, Resident P, Resident R, Resident S, Resident V, Resident W, Resident X, Resident Y, Resident Z) Findings include:During an interview on 4/21/26 at 9:12 a.m., Resident E indicated he didn't have a nurse this past Sunday, on 4/19/26, during the day shift. Resident E did not get his day shift medications.During an interview on 4/21/26 at 2:49 p.m., the Director of Nursing (DON) indicated on 4/19/26, a nurse called off of work and the other nurse that worked that unit did not administer medications to all the residents that were to receive medication from the second floor west hall medication cart.During an interview on 4/22/26 at 10:28 a.m., Licensed Practical Nurse (LPN) 1 indicated, on 4/19/26 at approximately 9:00 a.m., she called the DON because a nurse called off work and she could not give medications to all the residents on the unit.1. The clinical record for Resident E was reviewed on 4/22/26 at 8:48 a.m. The diagnoses included, but were not limited to, phantom limb syndrome, obesity, and depression.The current physician's orders included, but were not limited to: - Amlodipine (medication used to treat high blood pressure) 10 milligrams (mg) administer one tablet orally once daily, initiated 3/6/26.- Hydrochlorothiazide (medication used to treat fluid retention) 25 mg administer one tablet orally once daily, initiated 1/30/26.- Lisinopril (medication used to treat hypertension) 40 mg administer one tablet orally once daily, initiated 3/28/26.- Spironolactone (medication used to treat hypertension) 25 mg administer half (12.5 mg) tablet orally daily, initiated 4/9/26.- Acetaminophen (medication used to treat pain) 500 mg administer two tablets orally twice daily, initiated 1/29/26.- Naproxen (medication used to treat pain/swelling) 500 mg administer one tablet orally for pain, take with breakfast and evening meals, initiated 1/29/26. - Nortriptyline (medication used to treat depression) 25 mg administer once capsule orally twice daily, initiated 1/29/26.- Pantoprazole (medication used to treat acid reflux) 20 mg administer one tablet orally twice daily, initiated 3/9/26.- Buspirone (medication used to treat anxiety) 5 mg administer one tablet orally three times daily, initiated 4/16/26 and discontinued 4/20/26. - Oxycodone (controlled medication used to treat pain) 5 mg administer once tablet orally three times daily, initiated 3/1/26. - Pregabalin (medication used to treat nerve pain) 75 mg administer one capsule orally every 8 hours, initiated 3/4/26. The Medication Administration Record (MAR), dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated, on 4/19/26, Resident E did not receive the following medications on day shift: Amlodipine 10 mg tablet; Hydrochlorothiazide 25 mg tablet; Lisinopril 40 mg tablet; Spironolactone 12.5 mg tablet; Acetaminophen 500 mg tablets; Naproxen 500 mg tablet; Nortriptyline 25 mg tablet; Pantoprazole 20 mg tablet; Buspirone 5 mg tablet; Oxycodone 5 mg tablet; Pregabalin 75 mg capsule.2. The clinical record for Resident F was reviewed on 4/22/26 at 8:53 a.m. The diagnoses included, but were not limited to, bipolar disorder, anxiety disorder, and asthma.The current physician's orders included, but were not limited to:- Amlodipine 10 mg administer one tablet orally once daily, initiated 10/18/25.- Ascorbic acid (oral supplement) 500 mg administer one tablet orally once daily, initiated 10/18/25.- Aspirin (medication used to prevent blood clots) 81 mg administer one tablet orally once daily, initiated 10/21/26. - Latanoprost (eye drop used to treat eye pressure) 0.005% instill one drop in each eye once daily, initiated 10/18/25.- Lisinopril 40 mg administer one tablet orally daily, initiated 4/9/26.- Montelukast (medication used to treat airway swelling/inflammation) 10 mg administer one tablet orally daily, initiated 10/21/25.- Omeprazole (medication used to treat acid reflux) 20 mg administer one tablet orally once daily, initiated 10/18/25.- Multivitamin (oral supplement) administer one tablet orally once daily, initiated 10/18/25. - Trintellix (medication used to treat major depression) 5 mg administer one tablet orally once daily, initiated 4/17/26. - Buspirone 5 mg administer two tablets orally twice daily, initiated 11/20/25.- Ferrous sulfate (oral supplement) 325 mg administer one tablet orally once daily, initiated 10/18/25. - Oxcarbazepine (medication used to treat seizures/mental illness) 150 mg administer three tablets orally twice daily, initiated 4/2/26.- Pregabalin 75 mg administer one capsule orally twice daily, initiated 10/18/25.- Sennosides (medication used to treat constipation) 8.6 mg administer two capsules orally twice daily, initiated 10/18/25.- Cyclobenzaprine (medication used to treat muscle pain) 10 mg administer one tablet orally three times daily, initiated 4/18/26.- Administer Lidoderm patch (medicated patch used to treat pain) 5% apply to the right hip every 24 hours for pain. Remove the previous patch. Initiated 2/14/26.The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated, on 4/19/26, Resident F did not receive the following medications on day shift: Amlodipine 10 mg tablet; Ascorbic acid 500 mg tablet; Aspirin 81 mg tablet; Cholecalciferol 50,000 units capsule; Latanoprost 0.005% eye drop; Lisinopril 40 mg tablet; Montelukast 10 mg tablet; Omeprazole 20 mg tablet; Multivitamin tablet; Trintellix 5 mg tablet; Buspirone 5 mg tablet; Ferrous sulfate 325 mg tablet; Oxcarbazepine 150 mg tablet; Pregabalin 75 mg capsule; Sennosides 8.6 mg capsules; Cyclobenzaprine 10 mg tablet; Lidoderm 5% patch.3. The clinical record for Resident G was reviewed on 4/22/26 at 11:02 a.m. The diagnoses included, but were not limited to, borderline personality disorder, anxiety disorder, and cerebral infarct.The current physician's orders included, but were not limited to:- Allopurinol (medication used to treat gout) 300 mg tablet administer one tablet orally once daily, initiated 2/26/26- Aspirin 81 mg administer one tablet orally daily, initiated 2/26/26.- Deutetrabenazine (medication used to treat uncontrolled movements) 36 mg tablet administer one tablet orally once daily, initiated 3/24/26.- Escitalopram (medication used to treat depression) 15 mg tablet administer one tablet orally once daily, initiated 3/27/26.- Lisinopril 10 mg tablet administer one tablet orally once daily, initiated 2/26/26.- Montelukast 10 mg tablet administer one tablet orally once daily, initiated 2/26/26.- Divalproex (medication used to treat seizures/mental illness) 250 mg tablet administer one tablet orally twice daily, initiated 3/26/26.- Eliquis (medication used to treat blood clots) 5 mg tablet administer one tablet orally twice daily, initiated 2/25/26.- Hydroxyzine (medication used to treat anxiety) 25 mg tablet administer one tablet orally twice daily, initiated 4/16/26.- Oxcarbazepine 300 mg tablet administer one tablet orally twice daily, initiated 3/5/26. The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident G did not receive the following medications on day shift: Allopurinol 300 mg tablet; Aspirin 81 mg tablet; Deutetrabenazine 36 mg tablet; Escitalopram 15 mg tablet; Lisinopril 10 mg tablet; Montelukast 10 mg tablet; Divalproex 250 mg tablet; Eliquis 5 mg tablet; Hydroxyzine 25 mg tablet; Oxcarbazepine 300 mg tablet. 4. The clinical record for Resident H was reviewed on 4/22/26 at 11:17 a.m. The diagnoses included, but were not limited to, neuropathy, panic disorder, and chronic obstructive pulmonary disorder.The current physician's order included, but were not limited to:- Benzonatate (medication used to treat cough) 100 mg capsule administer one capsule orally three times daily, initiated 3/24/26.- Gabapentin (medication used to treat nerve pain) 800 mg tablet administer one tablet orally three times daily, initiated 2/23/26.- Acetaminophen 500 mg tablet administer two tablets orally three times daily, initiated 10/18/24. The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident H did not receive the afternoon dose of the following medications: Benzonatate 100 mg capsule; Gabapentin 800 mg tablet; Acetaminophen 500 mg tablets.5. The clinical record for Resident K was reviewed on 4/22/26 at 11:40 a.m. The diagnoses included, but were not limited to, dementia, heart failure, and atrial fibrillation.The current physician's orders included, but were not limited to:- Fluoxetine (medication used to treat depression) 20 mg tablet administer one tablet orally once daily, initiated 2/9/23.- Metoprolol succinate (long acting medication used to treat hypertension) 25 mg tablet administer one tablet orally once daily, initiated 5/26/23. - Pantoprazole 20 mg tablet administer one tablet orally once daily, initiated 1/10/24.- Apixaban (medication used to prevent blood clots) 2.5 mg tablet administer one tablet orally once twice daily, initiated 3/28/20. - Acetaminophen 500 mg tablet administer two tablets orally twice daily, initiated 11/18/21. The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident K did not receive the following medications on day shift: Fluoxetine 20 mg tablet; Metoprolol succinate 25 mg tablet; Pantoprazole 20 mg tablet; Apixaban 2.5 mg tablet; Acetaminophen 500 mg tablet.6. The clinical record for Resident M was reviewed on 4/22/26 at 11:50 a.m. The diagnoses included, but were not limited to, diabetes, liver cancer, and atrial fibrillation.The current physician's orders included, but were not limited to:- Folic acid (daily supplement) tablet administer one tablet orally daily, initiated 2/18/26. - Amlodipine 5 mg tablet administer one tablet orally once daily, initiated 2/18/26.- Amiodarone (medication used for the heart) 200 mg tablet administer one tablet orally once daily, initiated 2/24/26. - Pantoprazole 40 mg tablet administer one tablet orally once daily, initiated 2/24/26.- Apixaban 5 mg tablet administer one tablet orally twice daily, initiated 2/17/26.- Metformin (medication used to treat diabetes) 750 mg tablet administer one tablet orally twice daily, initiated 2/18/26.The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident M did not receive the following medications on day shift: Folic acid tablet; Amlodipine 5 mg tablet; Amiodarone 200 mg tablet; Pantoprazole 40 mg tablet; Apixaban 5 mg tablet; Metformin 750mg tablet.7. The clinical record for Resident N was reviewed on 4/22/26 at 12:00 p.m. The diagnoses included, but were not limited to, heart failure, low back pain, and atrial fibrillation.The current physician's orders included, but were not limited to:- Aspirin 81 mg tablet administer one tablet orally once daily, initiated 11/5/25.- Cholecalciferol (daily supplement) 50 micrograms (mcg) tablet administer one tablet orally once daily, initiated 10/30/25.- Empagliflozin (medication used to treat diabetes) 10 mg tablet administer one tablet orally once daily, initiated 11/5/25.- Levothyroxine (medication used to treat hypothyroidism) 100 mcg tablet administer one tablet orally once daily for, initiated 2/26/26.- Metoprolol succinate 100 mg tablet administer one tablet orally once daily, initiated 4/9/26. - Torsemide (medication used to treat fluid retention) 10 mg tablet administer one tablet orally once daily, initiated 10/30/25.- Acetaminophen 500 mg tablet administer two tablets orally twice daily, initiated 10/30/25.The MAR, dated 4/1/26 at 12:00 a.m.until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident N did not receive the following medications on day shift: Aspirin 81 mg tablet; Cholecalciferol 50 mcg tablet; Empagliflozin 10 mg tablet; Levothyroxine 100 mcg tablet; Metoprolol succinate 100 mg tablet; Torsemide 10 mg tablet; Acetaminophen 500 mg tablet.8. The clinical record for Resident P was reviewed on 4/22/26 at 12:09 p.m. The diagnoses included, but were not limited to, hypertension, ataxia, and contracture of elbow.The current physician's orders included, but were not limited to:- Aspirin 81 mg tablet administer one tablet orally once daily, initiated 12/20/19.- Cholecalciferol 50 mcg capsule administer one capsule orally once daily, initiated 12/20/19. - Citalopram (medication used to treat depression) 10 mg administer half tablet (5mg) orally once daily, initiated 3/27/26.- Clopidogrel (medication used to prevent blood clots) 75 mg tablet administer one tablet orally once daily, initiated 12/20/19. - Ferrous sulfate 325 mg tablet administer one tablet orally once daily, initiated 3/10/26.- Florastor (probiotic supplement) 250 mg capsule administer one capsule orally once daily, initiated 3/4/26.- Lisinopril 40 mg tablet administer one tablet orally once daily, initiated 10/17/24.- Amlodipine 10 mg tablet administer one tablet orally once daily, initiated 10/17/24.- Acetaminophen 325 mg tablet administer two tablets orally three times daily, initiated 12/29/25. The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident P did not receive the following medications on day shift: Aspirin 81mg tablet; Cholecalciferol 50 mcg capsule; Citalopram 10 mg tablet; Clopidogrel 75mg tablet; Ferrous sulfate 325 mg tablet; Florastor 250 mg capsule; Lisinopril 40 mg tablet; Amlodipine 10 mg tablet; Acetaminophen 325 mg tablets.9. The clinical record for Resident R was reviewed on 4/22/26 at 12:25 p.m. The diagnoses include, but were not limited to, delusional disorder, aortic aneurysm, and muscle weakness.The current physician's orders included, but were not limited to:- Bupropion (medication used to treat depression) 75 mg tablet administer three tablets orally once daily, initated 3/27/26.- Furosemide (medication used to treat fluid retention) 20 mg tablet administer one tablet orally once daily, initiated 9/16/25.- Potassium chloride (supplement) 10 milliequivalent (mEq) tablet administer two tablets orally once daily, initiated 9/29/25.- Pimavanserin (medication used to treat hallucinations and delusions) 34 mg capsule administer one capsule orally once daily, initiated 2/27/26.- Acetaminophen 650 mg tablet administer one tablet orally twice daily, initiated 9/15/25. - Apixaban 5 mg tablet administer one tablet orally twice daily, initiated 12/8/25. - Pantoprazole 40 mg tablet administer one tablet orally twice daily, initiated 9/27/25.- Carbidopa-levodopa 25-100 mg tablet administer half tablet orally three times daily, initiated 9/15/25. The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident R did not receive the following medications on day shift: Bupropion 75 mg tablet; Furosemide 20 mg tablet; Potassium chloride 10 mEq tablet; Pimavanserin 34 mg capsule; Acetaminophen 650 mg tablet; Apixaban 5 mg tablet; Pantoprazole 40 mg tablet; Carbidopa-levodopa 25-100mg tablet.10. The clinical record for Resident S was reviewed on 4/22/26 at 12:55 p.m. The diagnoses included, but were not limited to, mood disorder, muscle weakness, and cognitive communication deficit.The current physician's orders included, but were not limited to:- Lisinopril 20 mg tablet administer one tablet orally once daily, initiated 10/16/25.- Loratadine (medication used to treat allergies) 10 mg tablet administer one tablet orally once daily, initiated 10/16/25. - Sertraline (medication used to treat depression) 25 mg tablet administer one tablet orally once daily, initiated 4/17/26.- Tiotropium bromide (a medication used to treat chronic obstructive pulmonary disorder) 18 mcg capsule inhale one application orally once daily, initiated 10/16/25.- Divalproex 125 mg tablet administer one tablet orally twice daily, initiated 1/29/26.- Divalproex 250 mg tablet administer one tablet twice daily, initiated 12/17/25. - Olanzapine (medication used to treat mental illness) 10 mg tablet administer 7.5 mg orally twice daily, initiated 4/8/26. The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident S did not receive the following medications on day shift: Lisinopril 20 mg tablet; Loratadine 10 mg tablet; Sertraline 25 mg tablet; Tiotropium bromide 18 mcg capsule; Divalproex 125 mg tablet; Divalproex 250mg tablet; Olanzapine 10 mg tablet.11. The clinical record for Resident V was reviewed on 4/22/26 at 1:30 p.m. The diagnoses included, but were not limited to, paraplegia, scoliosis, and personality disorder.The current physician's orders included, but were not limited to:- Aspirin 81 mg tablet administer one tablet orally once daily, initiated 2/20/26.- Polyethylene glycol (a medication used to treat constipation) 17 grams (gm) administer 17 gm orally once daily for, initiated 2/8/26.- Multivitamin tablet administer one tablet orally once daily, initiated 2/8/26.- Sennosides 8.6 mg tablet administer one tablet orally once daily, initiated 2/8/26.- Metoprolol tartrate (fast acting medication for hypertension) 50 mg tablet administer one tablet orally twice daily, initiated 2/8/26.The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident V did not receive the following medications on day shift: Aspirin 81 mg tablet; Polyethylene glycol 17 gm; Multivitamin tablet; Sennosides 8.6 mg tablet; Metoprolol tartrate 50 mg tablet.12. The clinical record for Resident W was reviewed on 4/22/26 at 1:40 p.m. The diagnoses included, but were not limited to, muscle weakness, depression, and quadriplegia.The current physician's orders included, but were not limited to:- Amaryl (medication used to treat diabetes) 2 mg tablet administer one tablet orally once daily, initiated 3/18/26.- Empagliflozin (medication used to treat diabetes) 10 mg tablet administer one tablet orally once daily, initiated 3/19/26.- Metoprolol succinate 25 mg tablet administer one tablet orally once daily, initiated 4/9/26.- Tamsulosin (medication used to treat difficulty urinating) 0.4 mg capsule administer two capsules orally once daily, initiated 3/19/26. - Cyanocobalamin (daily supplement) tablet administer one tablet orally once daily, initiated 3/19/26.- Apixaban 5 mg tablet administer one tablet orally twice daily, initiated 3/18/26.- Bupropion 150 mg tablet administer one tablet orally twice daily, initiated 3/18/26The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident W did not receive the following medications on day shift: Amaryl 2 mg tablet; Empagliflozin 10 mg tablet; Metoprolol succinate 25 mg tablet; Tamsulosin 0.4 mg capsule; Cyanocobalamin tablet; Apixaban 5 mg tablet; Bupropion 150 mg tablet.13. The clinical record for Resident X was reviewed on 4/22/26 at 1:46 p.m. The diagnoses included, but were not limited to, autistic disorder, down syndrome, and depression.The current physician's orders included, but were not limited to:- Cholecalciferol 400 unit capsule administer once capsule orally once daily, initiated 2/24/26. - Cyanocobalamin 250 mcg tablet administer one tablet orally once daily, initiated 2/25/26- Levothyroxine 50 mcg tablet administer one tablet orally once daily, initiated 2/25/26.The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident X did not receive the following medications on day shift: Cholecalciferol 400 unit capsule; Cyanocobalamin 250 mcg tablet; Levothyroxine 50 mcg tablet.14. The clinical record for Resident Y was reviewed on 4/22/26 at 1:55 p.m. The diagnoses included, but were not limited to, delusional disorder, muscle weakness, and anxiety disorder.The current physician's orders included, but were not limited to:- Aspirin 81 mg tablet administer one tablet orally once daily, initiated 10/26/23. - Multivitamin tablet administer one tablet orally once daily, initiated 2/16/24.- Clopidogrel 75 mg tablet administer one tablet orally once daily, initiated 10/26/23. - Hydroxyzine (medication used to treat anxiety) 50 mg tablet administer one tablet orally once daily, initiated 10/30/25. The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident Y did not receive the following medications on day shift: Aspirin 81 mg tablet; Multivitamin tablet; Clopidogrel 75 mg tablet; Hydroxyzine 50 mg tablet.15. The clinical record for Resident Z was reviewed on 4/22/26 at 2:06 p.m. The diagnoses include, but were not limited to, syncope and collapse, fatty liver, and retention of urine.The current physician's orders included, but were not limited to:- Amlodipine 10 mg tablet administer one tablet orally once daily, initiated 4/4/26. - Aspirin 81 mg tablet administer one tablet orally once daily, initiated 4/4/26.- Cyanocobalamin 500 mcg tablet administer one tablet orally once daily, initiated 4/4/26. - Sennosides-docusate 8.6/50 mg tablet administer one tablet orally twice daily, initiated 4/4/26.The MAR, dated 4/1/26 at 12:00 a.m. until 4/22/26 at 12:00 p.m., indicated on 4/19/26, Resident Z did not receive the following medications on day shift: Amlodipine 10 mg tablet; Aspirin 81 mg tablet; Cyanocobalamin 500 mcg tablet; Sennosides-docusate 8.6/50 mg tablet.On 4/22/26 at 5:00 p.m., the facility was unable to provide a policy regarding sufficient nurse staffing by end of survey.This citation relates to Intake 2980834410 IAC (Indiana Administrative Code) 16.2-3.1-17(a)

Based on interview and record review, the facility failed to implement procedures that assured the accurate accounting of controlled substance medications for 1 of 3 medication carts reviewed for controlled medication records. (West Hall second floor medication cart) Findings include:On 4/21/26 at 9:15 a.m., the change of shift-controlled medication count sheet, dated 4/1/26 through 4/21/26, for the second-floor west hall medication cart was reviewed. A review of the sheet indicated:- On 4/1/26 on first shift, the total items in cart box and the on-coming nurse signature box were left blank.- On 4/1/26 on second shift, the off-going nurse signature box was left blank, total items in cart box was left blank, and on-coming nurse box was left blank.- On 4/1/26 on third shift, the off-going nurse signature box was left blank and the total items in cart box was left blank.- On 4/2/26 on second and third shifts, the total items in cart box was left blank.- On 4/3/26 on first shift, the total items in cart box was left blank.- On 4/7/26 on first and third shifts, the total items in cart box was left blank. - On 4/8/26 on first and second shifts, the total items in the cart box was left blank.- On 4/9/26 on third shift, the total items in cart box and the on-coming nurse signature box were left blank.- On 4/10/26 on first shift, the off-going nurse signature box and the total items in cart box were left blank. - On 4/12/26 on third shift, the total items in cart box was left blank.- On 4/13/26 on third shift, the total items in cart box was left blank.- On 4/14/26 on all shifts, the total items in cart box was left blank.- On 4/15/26 on first and second shifts, the total items in cart box was left blank.- On 4/15/26 on third shift, the off-going nurse signature box was left blank.- On 4/16/26 on all shifts, the total items in cart box was left blank.- On 4/17/26 on all shifts, the total items in cart box was left blank.- On 4/17/26 on third shift, the on-coming nurse signature box was left blank.- On 4/18/26 on first shift, the off-going nurse signature box and the total items in cart box were left blank.- On 4/18/26 on second shift, the off-going nurse signature box and the total items in cart box were left blank.- On 4/18/26 on second and third shifts, the total items in cart box was left blank.- On 4/19/26 on second and third shifts, the total items in cart box was left blank.- On 4/20/26 on all shifts, the total items in cart box was left blank.- On 4/21/26 on second and third shifts, the total items in cart box was left blank.During an interview on 4/21/26 at 9:17 a.m., the Assistant Director of Nursing (ADON) indicated the controlled medication count sheet should have been filled in completely at every shift change. The off going nurse should have signed in the off going nurse signature box, should have filled in the number of medication packets added box if any were delivered, filled in the number of medication cards removed box if any medication packets were removed for any reason, and filled in the total items box. Then, once the medications were reconciled the on-coming nurse should have signed the on-coming nurse signature box. On 4/22/26 at 1:00 p.m., the Regional Nurse provided a copy of a facility policy, titled Controlled Substances, dated 7/2024, and indicated this was the current policy used by the facility. A review of the policy indicated both nurses will sign all controlled substances will be counted each shift or whenever there is an exchange of keys. The two nurses will inspect the medication packets, count the number of packets in the cart, document on the shift change controlled substance count sheet, and each sign the appropriate boxes on the shift change controlled substances count sheet acknowledging that the actual count of controlled substances and count sheets match.This citation relates to Intake 2974658.410 IAC (Indiana Administrative Code) 16.2-3.1-25(e)(2)

Based on interview and record review the facility failed to protect a resident's right to be free from physical abuse by another resident for 2 of 3 residents reviewed for abuse. A resident punched another resident repeatedly. (Resident B, Resident C) Finding includes:During an interview on 4/21/26 at 2:38 p.m., RN 1 indicated she worked, on 3/18/26, when Resident B had been sitting in the common area and all of the sudden, RN 1 heard someone yell. When she looked over, RN 1 saw Resident C standing over Resident B and punching Resident B in the head with a closed fist multiple times. Resident B was sent to the hospital because he had been punched in the head. The police came and took Resident C to be seen by psychiatric services.The clinical record for Resident B was reviewed on 4/20/26 at 10:07 a.m. The diagnoses included, but were not limited to, down syndrome, pseudobulbar affect, and muscle weakness.An annual Minimum Data Set (MDS) assessment, dated 1/5/26, indicated Resident B was severely cognitively impaired.A progress note, dated 3/18/26 at 9:39 p.m., indicated Resident B was seated in the common area when Resident C approached and punched Resident B on the forehead. Resident B had a raised knot noted to the forehead. Resident B was sent to the hospital for further evaluation.The clinical record for Resident C was reviewed on 4/20/26 at 10:51 a.m. The diagnoses included, but were not limited to, anxiety disorder, schizophrenia, and antisocial personality disorder.A quarterly MDS assessment, dated 3/18/26, indicated Resident C was severely cognitively impaired.A care plan, dated 12/1/25, indicated Resident B had a history of conflicts and altercations with other residents including verbal and physical aggression. Interventions included, but were not limited to, keep Resident C in line of sight and do not enter Resident C's personal space when he is agitated.A progress note, dated 3/18/26 at 5:55 p.m., indicated Resident C punched Resident B in the face and back of the head multiple times. On 4/20/26 at 10:14 a.m., the Administrator provided an undated copy of a facility policy, titled Abuse Prevention Policy, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to prevent physical abuse.This citation relates to Intake 2973951410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(1)

Based on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of property for 1 of 3 residents reviewed for misappropriation of property. A resident's controlled narcotic pain medication was signed out while the resident was in the hospital. (Resident D) Finding includes:During an interview on 4/21/26 at 9:01 a.m., the Director of Nursing (DON) indicated, on 3/22/26, he had been made aware that there were three tablets of Resident D's oxycodone/acetaminophen (narcotic pain medication) 10-325 mg (milligrams) missing from the cart. A staff member initialed that a tablet was removed on 3/18/26, and two tablets had been removed on 3/19/26. At the time those tablets were removed, Resident D was at the hospital. The facility was unable to identify to whom the initials belonged. The clinical record for Resident D was reviewed on 4/20/26 at 11:14 a.m. The diagnoses included, but were not limited to, heart failure, morbid obesity, and adjustment disorder.A physician's order, initiated on 2/1/26, indicated give one oxycodone/acetaminophen 10-325 mg orally every six hours as needed for pain.A Controlled Drug Record, dated 2/27/26, indicated Resident D had 30 tablets of oxycodone/acetaminophen 10-325 mg. On 3/18/26, one tablet was removed which left 18 tablets in the medication cart. Then, on 3/19/26, two tablets were removed from the medication cart.A progress note, dated 3/25/26 at 3:04 p.m., indicated the Director of Nursing (DON) contacted the pharmacy to refill three tablets of Resident D's oxycodone/acetaminophen 10-325 mg. The pharmacy was unable to refill medication until the resident had been readmitted .During an interview on 4/22/26 at 10:47 a.m., Qualified Medication Aide (QMA) 1 indicated, on 3/22/26, when reconciling the narcotic counts, a discrepancy had been noted. Three of Resident D's oxycodone/acetaminophen 10-325 mg had been signed out when he was not in the facility. When QMA 1 last worked, there were 18 of Resident D's oxycodone/acetaminophen 10-325mg tablets in the cart. One tablet was signed out on 3/8/26, then two tablets were signed out on 3/19/26. Resident D had been at the hospital since approximately 3/9/26 and had not been readmitted .On 4/20/26 at 10:14 a.m., the Administrator provided an undated copy of a facility policy, titled Abuse Prevention Policy, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to prevent misappropriation of property.This citation relates to Intake 2974658.410 IAC (Indiana Administrative Code) 16.2-3.1-28(a)

Based on observation, interview and record review, the facility failed to timely have the interdisciplinary team (IDT) determine and document that self-administration of medications and treatments were clinically appropriate for 2 of 16 residents reviewed. (Resident B and Resident N)Findings include: 1.The clinical record for Resident B was reviewed on 3/10/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, personality disorder (behavior that deviates markedly from cultural expectations). A Quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated Resident B was cognitively intact. A current physician's order, with a start date of 1/21/21, indicated Resident B was prescribed 81 milligrams of aspirin daily.A current physician's order, with a start date of 11/16/23, indicated Resident B was prescribed 2 capsules of 100 milligrams o docusate sodium twice a day. A current physician's order, with a start date of 10/18/24, indicated Resident B was prescribed 1000 milligrams of acetaminophen three times a day.A current physician's order, with a start date of 3/28/25, indicated Resident B was prescribed vitamin b-12 daily before breakfast.A current physician's order, with a start date of 2/23/26, indicated Resident B was prescribed 800 milligrams of gabapentin three times a day.A current physician's order, with a start date of 2/24/26, indicated Resident B was prescribed 0.3/1.5 milligrams prempro daily.A current physician's order, with a start date of 2/28/26, indicated Resident B was prescribed 25 milligrams of hydroxyzine daily.A current physician's order, with a start date of 3/10/26, indicated Resident B was prescribed 2 tablets of 10 milligrams of lisinopril daily. An observation and interview, on 3/11/26 at 10:37 a.m., of Resident B's room, the resident was in bed with a bedside table next to her. There was a cup observed with multiple medications sitting on the bedside table. No staff were present in the resident's room. Resident B indicated the cup of medications were her morning medications. She had heartburn and she was going to take her medications later. At 10:40 a.m., the resident indicated she was able to take her own medications. While in the resident's room Licensed Practical Nurse (LPN) 3 had entered the resident's room to administer another medication to the resident. The LPN indicated the medication she brought in was the resident's lisinopril. The resident spoke with the LPN and LPN 3 placed the second medication cup with the pill inside the cup on the resident's bedside table next to the other medication cup with pills inside of it and left the resident's room. Resident B's clinical record lacked a current self-administration assessment or a physician's order for the resident to self-administer her medications.2. The clinical record for Resident N was reviewed on 3/10/26 at 2:30 p.m. The resident's diagnosis included, but was not limited to Schizophrenia (a chronic severe mental disorder characterized by disruptions in thought processes and perceptions). An admission MDS Assessment, dated 1/19/26, indicated Resident N was cognitively intact. A current physician's order, with a start date of 1/7/26, indicated Resident N was prescribed 1 tablet of tums every 6 hours as needed and 10 milligrams of Buspar three times a day. An observation was made of Resident N on 3/10/26 at 2:35 p.m. The resident was observed sitting on her bed. There was a bedside table sitting by her and the bed with a medication cup observed to have 1 (greenish) pill and 1 (pinkish) pill in the cup. The resident indicated the pills were tums. Resident N's clinical record lacked a documented self-administration assessment or a physician's order to self administer her medicaitons. An interview was conducted with the Nurse Consultant on 3/11/26 at 9:15 a.m. She indicated she was unable to find current self-administration assessments for Resident B or Resident N. A self-medication assessment policy was provided by the Nurse Consultant on 3/11/26 at 9:17 a.m. The policy indicated .Self-administration medications will be encouraged if it is desired by the resident, safe for the resident and other residents of the facility, ordered by the attending physician, and approved by the Interdisciplinary Team. Procedure: 1. Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facility interdisciplinary team .5. A physician order is obtained to self-administer Medication if the above storage and self assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the MSR .11. Update the residents care plan quarterly or as indicated by the change in medication scheduling, dose or a change in resident's condition with a reassessment of the resident's knowledge and ability to self-administer medications. 410 IAC (Indiana Administrative Code) 16.3.1-11

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 5 residents reviewed for abuse (Resident E).Findings include: The clinical record for Resident E was reviewed on 3/10/26 at 11:15 a.m. The resident's diagnoses included, but were not limited to, dementia (mental decline) and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 1/8/26, indicated the resident had severely impaired cognition. The resident was able to make himself understood, understood others, and had no behaviors noted during the assessment period. A care plan, initiated on 1/19/26, indicated Resident E had impaired cognitive function or impaired thought process. The goals included, but were not limited to, the resident would remain oriented to person, place situation and time. Resident E's clinical record included a follow-up progress note, dated 2/26/26 at 12:27 p.m., that indicated the resident was being seen for a medication follow-up. Resident E had a resident-to-resident encounter during the past weekend. Resident E reported he was not bothered about the encounter, but staff reported that he appeared anxious since the incident. On 3/10/26 at 11:24 a.m., an interview was conducted with Resident E. The resident indicated there was a resident who had been mean to him and was messing with him. The other resident had hit him and the other resident sat behind Resident E in the dining room. Resident E tried to stay away from the other resident. On 3/10/26 at 11:55 a.m., a continuous observation was conducted in the second floor dining room. At 12:12 p.m., Resident D entered the dining room and went to sit at a table behind Resident E. On 3/11/26 at 10:58 a.m., the Nurse Consultant (NC) provided a copy of the investigation file for the incident between Resident D and Resident E. The investigation file included an incident report, dated 2/24/26 at 4:58 p.m., that indicated Resident D had made contact with the head of Resident E. Resident D used an open hand and there were no injuries noted to either resident. During an interview on 3/11/26 at 12:10 p.m., Licensed Practical Nurse (LPN) 12 indicated she had been the one to separate Resident D and Resident E on 2/24/26. The LPN had not witnessed the incident but had been informed by another resident who had seen it happen. LPN 12 had spoken with Resident D at the time of the incident. Resident D had not denied hitting Resident E. Resident D indicated that Resident E would not be quiet. On 3/10/26 at 11:27 a.m., the NC provided the Abuse Prevention Program policy, dated 10/22/22. The policy indicated .it is the policy of this facility to prevent resident abuse .For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain .Abuse: the willful infliction of injury .intimidation or punishment with resulting physical harm, pain, mental anguish .to attain or maintain physical, mental, and psychosocial well-being .Physical Abuse: Hitting, slapping .etc . 410 IAC (Indiana Administrative Code) 16.31-27(a)(1)

Based on interview and record review the facility failed to document thorough investigations for allegations of abuse for 1 of 5 residents investigated for abuse (Resident F).Finding include: The clinical record for Resident F was reviewed on 3/10/26 at 1:10 p.m. The resident's diagnosis included, but was not limited to, Down Syndrome (genetic condition resulting in distinct physical features, developmental delays, and mild-to-moderate intellectual disabilities). On 3/11/26 at 10:58 a.m., the Nurse Consultant (NC) provided a copy of the allegation of abuse investigation for Resident F for review. The investigation file contained an Incident Report, dated 12/27/25, that indicated Resident F had witnessed a verbal disagreement between Qualified Medication Aide (QMA) 10 and Certified Nursing Assistant (CNA) 11. The immediate action taken was to suspend QMA 10 and CNA 11 pending outcome of the investigation. The investigation file did not contain statements from QMA 10 or CNA 11 about the verbal disagreement. On 3/11/26 at 12:58 p.m., the NC provided a written statement from QMA 10, dated 12/27/25, that indicated QMA 10 and CNA 11 had gotten into an argument at the nurses' station about CNA 11 not assisting with passing out trays in the dining room. CNA 11 had made accusation against QMA 10 and accused QMA 10 of talking about CNA 11 with the residents. Resident F had been in her room at the time the argument began but had come into the hallway and witnessed the argument between QMA 10 and CNA 11. During an interview on 3/11/26 at 1:06 p.m., the Executive Director (ED) indicated there was not a written statement from CNA 11. The ED and the weekend supervisor had interviewed CNA 11 together but had not written the interview down. CNA 11 had rescinded the accusation against QMA 10. During an interview on 3/11/26 at 1:19 p.m., CNA 11 indicated she had written a statement about the incident on 12/27/25, and given it to the ED. The argument between QMA 10 and CNA 11 had started over CNA 11 refusing to serve trays with regular consistency food to residents who were on mechanically altered diets. During an interview on 3/11/26 at 1:27 p.m., the ED indicated CNA 11 had not provided a written statement. The ED indicated she would not recognize CNA 11 in person. The statement from CNA 11 had been taken over the phone. On 3/10/26 at 11:27 a.m., the NC provided the Abuse Prevention Program policy, dated 10/22/2022, that read . The Charge Nurse must complete an incident report and obtain a written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from the witnesses, if any, will be provided to the Administrator or individual in charge of the facility within twenty-four (24) hours of the occurrence of such incident . 410 IAC (Indiana Administrative Code) 16.3.1-28(d)

Based on observation, interview and record review, the facility failed to ensure a urinary catheter was available for resident use for 1 of 1 resident reviewed for urinary catheters. (Resident G)Findings include: The clinical record for Resident G was reviewed on 3/10/26 at 11:30 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body) and neuromuscular dysfunction of bladder (loss of bladder control). An admission Minimum Data Set (MDS Assessment, dated 2/18/26, indicated Resident G was cognitively intact. A care plan, dated 2/7/26, indicated the resident had the potential for infection due to the need for intermittent self-catheterization (resident will insert a tube to empty his bladder) related to neurogenic bladder. A physician's visit note, dated 2/13/26, indicated Resident G wanted to be seen due to urgent request regarding catheter supplies.patient reports he is running low on straight catheters and requires an order to prevent running out. He verbalizes concern that without appropriate supply he would be forced to reuse catheters, increasing risk of infection. Given his history of recurrent UTI [Urinary Tract Infections] with sepsis, we discussed the importance of sterile, single-use technique to reduce UTI risk.Nursing notified and order placed.16F [French] straight catheters for intermittent catheterization. The resident reports ongoing concerns regarding the management of his neurogenic bladder, specifically noting that he has not been consistently receiving straight catheterizations as previously instructed. Patient expresses frustration and anxiety regarding interruptions in his catheterization schedule, emphasizing concern about potential bladder overdistention and associated complications. Patient reports understanding that intermittent catheterization is recommended every 4-6 hours during the day to maintain bladder health and prevent complications such as urinary retention or infection. He notes difficulty adhering to this schedule due to limitations in catheter supply. Nursing staff report that the patient was provided with a box of catheters and that if the supply is exhausted prematurely, it may indicate overuse or improper scheduling. Patient demonstrates awareness of the plan to monitor bladder volumes, with target volumes of 400-500 mL [milliliters] to prevent overdistention and potential renal complications.Patient [Resident G] verbalizes clear understanding of the intermittent catheterization plan and expresses willingness to adhere to the prescribed schedule, pending adequate catheter supply. He is motivated to participate in self-care and demonstrates appropriate insight into the importance of bladder management to prevent complications. A physician's order, dated 2/13/26, indicated staff were to provide Resident G 16 French straight urinary catheters (single-use, flexible tube with a straight tip, primarily used for intermittent catheterization to drain the bladder) for self-removal of urine from his bladder. An interview was conducted with Resident G on 3/10/26 at 11:33 a.m. He indicated he had been asking since 9:00 a.m. that morning for a supply of urinary catheters. He had just received 4 urinary catheters from the nursing staff for the day at approximately 11:15 a.m. He had not emptied his bladder since last night. It was difficult with long delays to receive the urinary catheter supply. The resident was told by the medical provider he would receive at least 5 urinary catheters for the day. He was unsure why he couldn't have the entire box but was agreeable with 5 catheters. The staff are only giving him 4 urinary catheters, which was not enough. Today, he just received 4 urinary catheters to use for the day. He was supposed to empty every 4 to 6 hours a day depending on how much he drinks. I know when I have to empty my bladder. It's ridiculous. During the evening and night shifts, he will ask the staff when he runs out of supply for more, but they report they don't know where the supply was located or the supply was gone. He needs at least one for the evening and one for the nighttime. He has had to reuse his urinary catheters at night due to not receiving enough supply. The resident's physician had educated the resident about not reusing catheters. He indicated he was aware of the risk of infection, but what do you do when you have to empty your bladder with no supplies? The resident at that time opened his drawer to his night table, and there were three packaged new urinary catheters observed. Resident G indicated that was all the supply he would receive for the day.An interview was conducted with the Nurse Practitioner 2 on 3/10/26 at 3:00 p.m. She indicated she had spoken to nursing regarding the resident's concerns with receiving supply of urinary catheters to empty his bladder. He should be receiving enough urinary catheters to have the ability to empty his bladder at least every 4 to 6 hours and as needed. The frequency does depend on how much he drinks, so he could have to empty his bladder more frequently. An interview was conducted with Qualified Medication Aide (QMA) 1 on 3/10/26 at 3:14 p.m. She indicated she ordered the urinary catheters for Resident G. She was at one time giving him several urinary catheters, but he was going through them quickly. She had given him 20 urinary catheters almost an entire box over a weekend. He had gone through all of them before the weekend was up. She was unaware Resident G was emptying his bladder every 4 to 6 hours. She thought he was supposed to be emptying his bladder every 8 hours. Nursing staff had not updated her Resident G's order had changed with the increased frequency of emptying his bladder. The urinary catheter supply was stored in the medical supply storage room. At that time, an observation was made of the medical supply room. There was one box that contained nineteen 16F urinary catheters for Resident G. QMA 1 indicated she had ordered another supply for Resident G and should be there that day. The evening and night staff had access to the medical supply room. An observation was made of Resident G's room on 3/12/26 at 3:14 a.m. Resident G opened his bedside table and there were two new packaged urinary catheters observed.An interview was conducted with the Nurse Consultant on 3/10/26 at 3:41 p.m. She indicated Resident G will receive more than four urinary catheters going forward. The facility does not have a policy for self-catheterization that addresses the availability of supplies.410 IAC (Indiana Administrative Code) 16.3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure new behaviors were documented in the clinical record and to ensure staff were monitoring and tracking behaviors for 1 of 5 residents reviewed for abuse and 1 of 5 residents reviewed for call light response (Resident B and Resident D).Findings include:1. The clinical record for Resident D was reviewed on 3/10/26 at 11:20 a.m. The resident's diagnoses included, but were not limited to, dementia (mental decline) and bipolar disorder (a chronic mental health condition causing extreme shifts in mood, energy, and activity levels). A physician's order, dated 4/24/25, indicated Resident D's behavior was to be monitored each shift for delusions/hallucinations, tearfulness, crying, verbal expressions of sadness, anger, yelling, cursing, insomnia, anxiety, skin picking, and physical aggression. A Quarterly MDS Assessment, dated 1/9/26, indicated the resident had moderately impaired cognition and had not displayed behaviors during the assessment period. A care plan, revised on 1/21/26, indicated Resident D had displayed behavioral symptoms related to delusions, hallucinations, tearfulness, crying, verbal expressions of sadness, anger, yelling, cursing, insomnia, anxiety, skin picking, and physical aggression. The goal was for him to comply with staff redirection and behave in a safe and respectful manner. The interventions included, but were not limited to, conduct an evaluation of my behavioral symptoms to determine what strengths or abilities and needs are communicated via the behavior, intervene when inappropriate behavior was observed. A follow-up progress noted, dated 2/26/26 at 10:51 a.m., indicated Resident D had a recent resident to resident bodily contact incident. The February 2026 Medication Administration Record indicated Resident D had not displayed any behaviors during the month. Resident D's clinical record did not contain a behavior note addressing his behavior of hitting another resident. On 3/10/26 at 11:20 a.m., the Nurse Consultant (NC) provided the investigation file for the resident-to-resident incident that Resident D had been involved in on 2/24/26. The file contained an incident report that indicated Resident D had made contact with the head of another resident, using an open hand. There were no injuries to either resident. During an interview on 3/10/26 at 3:48 p.m., the Social Services Director (SSD) indicated Resident D was not normally aggressive to other residents. When a resident had new behaviors, the nurse should have documented the behavior in the clinical record using a behavior progress note and the new behavior would be reviewed in the morning meeting. The Interdisciplinary (IDT) Team had discussed Resident D striking another resident after it occurred. The IDT team had been unable to come up with a root cause for the behavior. There had been no new care plan started, and no new interventions added to Resident D's behavior care plan since the incident on 2/24/26. During an interview on 3/11/26 at 12:10 p.m., Licensed Practical Nurse (LPN) 12 indicated she had been the one to separate Resident D and the other resident on 2/24/26. LPN 12 had not witnessed the incident but had been informed by another resident who had seen it happen. LPN 12 had spoken with Resident D at the time of the incident. Resident D had not denied hitting the other resident. Resident D had indicated that the other resident would not be quiet. LPN 12 had assumed that was why Resident D had hit the other resident. The intervention was for there to be a Certified Nursing Assistant (CNA) in the dining room at all times when there are residents in the dining room. 2. The clinical record for Resident B was reviewed on 3/10/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, personality disorder (behavior that deviates markedly from cultural expectations). A Quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated Resident B was cognitively intact. A physician's order, dated 8/12/25, indicated the staff were to monitor Resident B's behaviors. The following behaviors were to be monitored and tracked, calling emergency services, false accusations/beliefs, anxiety, tearfulness, insomnia, refusal of care, verbal aggression, throwing objects, OCD (obsessive-compulsive disorder) behaviors, crying, verbal expressions of sadness, racial slurs, self-isolation, anger, yelling, and cursing. The staff were to implement the following interventions to address the resident's behaviors: attempt redirection; snack; fluid offered; Activity for diversion; toileting; change of environment; pain assessment; offer nap/rest period; and provide comfort. The March 2026 Medication/Treatment Record (MAR/TAR) indicated Resident B had not exhibited any behaviors as of 3/11/26. During an interview with Resident B on 3/11/26 at 10:37 a.m., License Practical Nurse (LPN) 3 arrived in the resident's room to administer a medication. The resident was curt in tone with LPN 3 about the delivery of the type of medication she had brought in the room. The LPN responded politely and left the room. An interview was conducted with LPN 3 on 3/11/26 at 11:33 a.m. She indicated she had returned to Resident B's room a little while ago. As soon as she entered the room, the resident started screaming and yelling at her about the medication she had delivered earlier that morning. LPN 3 was unsure why the resident was upset. Resident B's clinical record lacked documented behaviors for the behavior observed on 3/11/26 with LPN 3. The resident's clinical record lacked any implemented interventions provided for Resident B related to the behavior exhibited with LPN 3 at that time. During an interview on 3/12/26 at 12:23 p.m., the NC indicated the nurses should document behaviors on the Medication Administration Record (MAR) which triggered the nurse to enter a progress note. On 3/10/26 at 2:16 p.m., the NC provided the Guidelines for Behavior Management Meetings Psychotropic Medication policy, dated 8/18/23, that read .These meetings are held monthly or more often as needed. The purpose is to review residents who have behaviors and who are being monitored for these behaviors. Further, to discuss and review residents who have newly developed behaviors to ensure that all appropriate interventions are in place to manage the behaviors . Nursing .Monitors for presence of target behaviors on a daily basis and documenting same . 410 IAC (Indiana Administrative Code) 16.3.1-37

Based on observation, interview, and record review, the facility failed to ensure outdated items were discarded from the refrigerator timely, items were not open to air in the refrigerator, and the kitchen and kitchen equipment were clean with the potential to affect 50 of 51 residents residing at the facility.Findings include: On 12/9/25 at 9:45 a.m., the facility kitchen was observed with the Dietary Manager (DM). The walk-in refrigerator contained a silver pan of gelatin, dated 11/30/25, and a package of sliced cheese that was not sealed. The DM indicated the gelatin should be discarded and the cheese should have been wrapped completely and would be discarded. The kitchen floor had a film and did not appear to be clean. On 12/11/25 at 10:27 a.m., the facility kitchen was observed to have a dirty film and did not appear to have been mopped. On 12/11/25 at 12:35 p.m., the second-floor kitchenette was observed. The inside of the double-door refrigerator had dried food substances at the sides of the floor and a piece of fuzz stuck to the floor on the bottom of the interior refrigerator door. The bottom shelf of the steam table had a white film and dark, rust looking spots were present on the shelf. The prep table at the back of the kitchenette had a tray of white souffle cups on the bottom shelf. One of the souffle cups had dried on food stuck to the inside of the cup. During an interview on 12/11/25 at 12:50 p.m., Dietary [NAME] 23 indicated the white souffle cup needed to be washed again. On 12/11/25 at 2:15 p.m., the facility kitchen and second floor kitchenette were observed with the DM. The DM indicated the kitchen floor needed to be mopped and should be mopped daily. The second-floor kitchenette refrigerator floor needed to be cleaned. The DM was unsure what caused the white film on the bottom shelf of the steam table. He indicated the steam table was older and needed to be cleaned. On 12/11/25 at 2:30 p.m., the DM provided the Food Storage policy, last reviewed 8/12/23, that read .Food storage areas will be clean, dry and maintained at temperatures as required to ensure food safety .5. All open products [as able] will be sealed [rolled closed, wrapped closed, with lid closed, etc ] to ensure quality and prevent contamination against pests or rodents . 7. Good that have been opened with no date, left on the floor, or not properly sealed will be discarded. 8. All outdated goods will [sic] discarded the day after expiration . 3.1-21(l)(3)

Based on interview and record review, the facility failed to timely discontinue an anti-psychotic medication as recommended by pharmacy and medial provider for 1 of 6 residents reviewed for unnecessary medications. (Resident 7) Findings include: The clinical record for Resident 7 was reviewed on 12/9/25 at 3:00 p.m. The resident's diagnoses included, but were not limited to, dementia. A physician order, dated 9/15/25, indicated Resident 7 was to receive 0.25 milligrams of risperidone at night for agitation. A November 2025 pharmacy recommendation for Resident 7 indicated the medical provider needed to provide justification for the usage of the 0.25 milligrams of risperidone at bedtime for agitation. The medical provider responded with discontinuation of the 0.25 milligrams of risperidone at bedtime for Resident 7 as of 12/4/25. The staff was to monitor the resident for worsening symptoms. A medical provider note, dated 12/4/25, indicated the pharmacy had reviewed Resident 7's medications. The recommendation indicated that the resident does not have appropriate diagnosis to support the use of risperidone 0.25 mg (milligrams) at hs [night]. It is appropriate to discontinue medication at this time. A December 2025 Medication Administration Record (MAR) indicated the following days Resident 7 had received the 0.25 milligrams of risperidone nightly after the medical provider indicated to discontinue the risperidone medication: 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, and 12/10/25. An interview was conducted with the Nurse Consultant on 12/11/25 at 11:50 a.m. She indicated Resident 7's 0.25 milligrams of risperidone she received nightly should have been stopped. It was missed.

Based on interview and record review, the facility failed to ensure a transfer form was sent with a resident who was transferred to an acute care hospital for 1 of 2 residents reviewed for hospitalization (Resident 2)Findings include: The clinical record for Resident 2 was reviewed on 12/10/25 at 11:00 a.m. The resident's diagnoses included, but were not limited to, Alzheimer's Disease and history of falling. An interview was conducted with Resident 2's Representative on 12/10/25 at 11:37 a.m. She indicated Resident 2 had been hospitalized for low blood sugar at the beginning of October. Resident 2's medical record did not include a transfer form for the resident being discharged to the hospital. Hospital records for Resident 2 were provided by the Nurse Consultant on 12/16/25 at 1:32 p.m. It indicated Resident 2 was brought in by Emergency Medical Services (EMS) and admitted to the hospital on [DATE]. The chief complaint was altered mental status. An interview was conducted with the Director of Nursing on 12/15/25 at 3:17 p.m. He indicated Resident 2 was discharged to the hospital by EMS on 9/25/25. He was unable to locate discharge transfer form staff had completed for that resident. A transfer and discharge policy was provided by the Nurse Consultant on 12/12/25 at 10:03 a.m. It indicated, .Emergency Transfer:.7. Complete the Resident Transfer form make 2 copies of any portion of the health record necessary for care of resident. (E.g. Physician orders, History and Physical, chest x-ray, immunization information, any pertinent lab work etc.) 8. Send original of transfer form and portions of health record that was copied with the resident, attach the second copy of the portions of the health record to the facility copy of the transfer form. Give the third copy of the transfer form to the DON.

Based on interview and record review, the facility failed to ensure a care plan accurately reflected resident wishes regarding discharge and to ensure care plan meetings were held timely for 2 of 3 residents reviewed for discharge care plans, 1 of 1 resident reviewed for notification of change, and 1 of 3 residents reviewed for care plans (Resident 4, Resident 37, Resident 36, and Resident 20)1. The clinical record for Resident 4 was reviewed 12/12/2025 at 1:30 p.m. The medical diagnoses included, but were not limited to, diabetes and polyneuropathy. A Quarterly Minimum Data Set Assessment, dated 9/4/2025, indicated Resident 4 was cognitively intact, had no active discharge planning, and did not want to speak to someone about returning to the community. A discharge care plan, dated 8/31/2023 and revised on 11/8/2025, indicated Resident 4 wanted to discharge home. The interventions included, but were not limited to, for staff to offer support and encouragement as needed. A progress note, dated 6/19/2025, indicated Resident 4 wished to stay in the facility and not discharge to the community. 2. The clinical record for Resident 37 was reviewed on 12/11/2025 at 3:15 p.m. The medical diagnoses included, but were not limited to, malnutrition and hypertension. A Quarterly Minimum Data Set Assessment, dated 10/9/2025, indicated Resident 37 was not cognitively intact, had no active discharge planning, and did not want to speak to someone about returning to the community. A discharge care plan, dated 2/25/2025 and revised 10/2/2025, indicated Resident 37 would stay in the facility long term. The interventions, indicated social services to schedule discharge needs as needed. During an interview with Family Member 11, on 12/10/2025 at 11:56 a.m., she indicated she wanted Resident 37 to discharge to an assisted living. She has been working with someone about Resident 37's insurance and discharge, but they stopped responding. A progress note, dated 6/26/2025, indicated Resident 37's family would like to know if he qualified for assisted living and would like to reapproach after Medicaid waiver was approved. A census log for Resident 37 indicated Medicaid as the payor source starting 6/1/2025. During an interview, on 12/12/2025 at 3:05 PM, the Administration indicated it was the responsibility of the Social Service Designee to revise and update the discharge planning care plans. 3. The clinical record for Resident 36 was reviewed on 12/9/25 at 2:20 p.m. The resident's diagnosis included, but were not limited to, dementia and dysphagia (inability to swallow). A Quarterly Minimum Data (MDS) Assessment, completed 11/13/25, indicated she was severely cognitively impaired. During an interview on 12/9/25 at 2:20 p.m., Family Member (FM) 10 indicated she had not attended a care plan meeting for Resident 36 since July 2025. On 12/10/25 at 2:50 p.m., the Nurse Consultant (NC) provided care plan meeting notes for Resident 36. The last care plan meeting for Resident 36 was held 7/3/25. 4. The clinical record for Resident 20 was reviewed on 12/9/25 at 2:44 p.m. The resident's diagnosis included, but was not limited to, hypertension and diabetes. A Quarterly MDS Assessment, completed 9/24/25, indicated he was cognitively intact. During an interview on 12/9/25 at 2:44 p.m., Resident 20 indicated he did not recall ever having a care plan meeting. On 12/10/25 at 2:50 p.m., the NC provided the care plan meeting notes for Resident 20. The last care plan was held on 6/24/25. During an interview on 12/10/25 at 2:50 p.m., the NC indicated families should be invited to care plan meetings. Care plan meetings are held quarterly. On 12/12/25 at 1:30 p.m., the Director of Nursing provided the Baseline Care Plan Assessment/ Comprehensive Care Plans Policy, last revised 3/23/21, that read As the resident remains in the Nursing Home, additional changes will be made to the comprehensive care plan based on the assessed need of the resident . 5. The facility Social Services Director or designee will notify the resident's responsible party either by letter or a phone call to inform them of the scheduled Care Plan Conference to include the date and time . 9. The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum . 3.1-45(b)(1)

Based on observation, interview, and record review, the facility failed to ensure the optometry plan of care was implemented for a resident with glaucoma for 1 of 1 resident reviewed for vision services ( Resident 17).Finding include: The clinical record for Resident 17 was reviewed on 12/9/25 at 11:45 a.m. The resident's diagnosis included, but was not limited to, glaucoma.An Eye Care Chart Note, dated 4/11/25, indicated Resident 17 had blurred vision in the right and left eyes. The assessment and plan was to treat her open-angle glaucoma in both eyes with brimonidine 0.1% dorzolamide 2% (medication to treat high eye pressure) eye drops 1 drop into each eye twice daily and latanoprost 0.0005% eye drop (medication to treat open-angle glaucoma) one drop in both eyes at bedtime.A physician's order, dated 4/26/25, indicated she was to receive brimonidine tartrate ophthalmic solution 0.2 % 1 drop into both eyes two times a day for glaucoma.The clinical record did not contain an order for latanoprost eye drops. A Quarterly Minimum Data Set (MDS) Assessment, completed 11/28/25, indicated Resident 17 had moderately impaired cognition and severely impaired vision. During an interview on 12/09/25 at 11:45 a.m., Resident 17 indicated she had not received eye drops in a very long time. She had glaucoma and did not know why she was not receiving eye drops. On 12/10/25 at 9:45 a.m., Resident 17 was observed receiving her morning medications. Resident 17 did not receive eye drops from the nurse administering the medications. Resident 17 indicated she had not received eye drops in a long time. The November and December Medication Administration Record (MAR) indicated that the brimonidine tartrate ophthalmic solution 0.2 % had been given daily. During an interview on 12/11/25 at 11:05 a.m., Pharmacy Technician 21 indicated Resident 17 had not had a refill of the brimonidine tartrate ophthalmic solution 0.2 % sent to the facility since April 2025. During an interview on 12/11/25 at 11:45 a.m., the Director of Nursing indicated the latanoprost eye drops for Resident 17 had not been transcribed from the Eye Care Visit Note in April. Resident 17 should have received her eye drops as ordered by the Optometrist. 3.1-39(a)

Based on interview, observation, and record review, the facility failed to address a resident's (Resident 26) pain by ensuring availability of pain medications and implementing other pain relief interventions for 1 of 1 resident reviewed for pain management. Findings include:The clinical record for Resident 26 was reviewed on 12/12/2025 at 1:30 p.m. The medical diagnoses included, but were not limited to, cancer and pneumonia.An admission minimum data set (MDS) assessment, dated 11/13/2025, indicated Resident 26 was cognitively intact, frequently had pain, utilized as needed pain medication, and the severity raised to a 9/10.A pain care plan, dated 11/23/2025, indicated that Resident 26 was at risk for pain and discomfort. The interventions included for staff to administer pain medications as ordered and the use of non-pharmacological relief of pain. During an observation and interview, on 12/09/2025 11:53 AM, Resident 26 was laying in bed. He was observed to be rubbing his right thigh frequently and having facial grimacing. Resident 26 indicated he was having pain at 8/10 and could not get pain medicine because the facility had run out of it. When asked the last dose of pain medicine, he said that evening and that he had asked for his narcotic pain medicine about 5:30 a.m. this morning for a pain of 7.5/10. Resident 26 stated] he hadn't had . anything to help with the pain but would try anything to take the edge off. During an interview and observation, on 12/9/2025 at 11:53 AM, LPN 8 confirmed that Resident 26 was out of pain medicine and stated, it is coming from pharmacy today. She administered Tylenol to Resident 26 for pain.A physician's order, dated 11/14/2025, indicated for Resident 26 to have narcotic pain medicine every four hours as needed for pain.Review of the Medication Administration Record for December 2025, indicated resident 26 utilized narcotic pain medicine as needed. He received a dose of narcotic pain medicine on 12/8/2025 at 10:20 PM.An Electronic Transmission Report, dated 12/11/2025, indicated that Resident 26's pain medicine was requested as reordered on 12/9/2025 at 12:00 PM.An email corresponded with Pharmacist 12 at Pharmacy 11, indicated the script was received electronically on 12/9/2025 at 4:04 PM.During an interview, on 12/12/2025 at 2:34 PM, the DON indicated staff should be reordering narcotics before residents run out, but at least when residents have at least a day of narcotics left.A policy entitled, Guidelines for Pain Management, was provided by the Executive Director on 12/10/2025 at 2:40 PM. The purpose of the policy to [provide residents the means to receive necessary comfort, exercise greater independence, and enhance their overall well-being. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure the availability of a resident's seizure medication for 1 of 6 unnecessary medications reviewed. (Resident 58)Findings include: The clinical record for Resident 58 was reviewed on 12/10/25 at 1:00 p.m. The resident's diagnoses included, but were not limited to, anoxic brain injury (brain deprived of oxygen), tracheostomy (airway in neck) and epilepsy. The resident was admitted to the facility on [DATE]. A physician's order, dated 12/9/25, indicated the resident was to receive 100 milligrams of lacosamide for seizures twice a day. The December 2025 Medication Administration Record (MAR) for Resident 58 indicated the following days and times the administration of 100 milligrams of lacosamide: -On 12/10/25 at 9:00 a.m. and 9:00 p.m., the medication was not available to be administered.-On 12/11/25 at 9:00 a.m. and 9:00 p.m., the medication was not available to be administered. -On 12/12/25 at 9:00 a.m., administered medication as ordered and at 9:00 p.m., the medication was not available to be administered.-On 12/13/25 at 9:00 a.m. and at 9:00 p.m., the medication was not available to be administered. -On 12/14/25 at 9:00 a.m., the medication was not available to be administered and at 9:00 p.m., the medication was administered as ordered.-On 12/15/25 at 9:00 a.m., the medication was not available to be administered and at 9:00 p.m., the medication was administered as ordered. -On 12/16/25 at 9:00 a.m., the medication was not available to be administered. A nursing progress note, dated 12/10/25 at 9:17 p.m., indicated the pharmacy needed a prescription for 100 milligrams of lacosamide. A nursing progress note, dated 12/11/25 at 10:56 a.m., indicated the medical provider and pharmacy were contacted. A prescription was needed and was sent in by the medical provider for 100 milligrams of lacosamide. A nursing progress note, dated 12/13/25 at 2:06 p.m., indicated the medical provider was notified for a prescription that was needed for 100 milligrams of lacosamide. The prescription was sent to the pharmacy and will be arriving STAT [As soon as possible]. A nursing progress note dated 12/14/25 at 2:41 a.m., Resident 58 has an order for 100 milligrams of lacosamide. Unfortunately, the medication has not arrived from pharmacy. The pharmacy was contacted by nursing asking why medication has not arrived; pharmacist states that they do not have a prescription for medication. At that time MD [medical doctor] was contacted and asked to send in script to pharmacy. MD stated that he did send the script, however when writer called pharmacy back, there was no sign of the prescription being sent on their end. Pharmacy states that they will not be able to send the medication until they receive a full correct prescription. Res [Resident] will be continually monitored and IS STABLE AT THIS TIME.Also res has no s/s [signs or symptoms] of distress. A nursing progress note, dated 12/14/25 at 12:25 p.m., indicated the pharmacy required the medical provider to send a prescription for the medication. The medical provider was contacted twice. An observation was made of the first-floor medication cart with the Director of Nursing (DON) on 12/16/25 at 9:13 a.m. Resident 58's 100 milligrams of lacosamide medication supply was not located in the medication cart. An interview was conducted with the DON on 12/16/25 at 9:20 a.m. He indicated Resident 58 was admitted on [DATE]. The facility's pharmacy was based out of Chicago, so STAT does not necessarily mean in a few hours the facility would receive medications that were coming STAT. He was unsure why the facility was not receiving the 100 milligrams of lacosamide for Resident 58. An interview was conducted with the DON on 12/16/25 at 12:40 p.m. He indicated Resident 58's MAR was incorrectly documented. Resident 58 has not received any dosages of 100 milligrams of lacosamide twice a day since ordered on admission, 12/9/25. He had contacted pharmacy that day. The pharmacy reported they still needed a prescription for the 100 milligrams of lacosamide medication. The DON had also contacted the medical provider. The medical provider reported the prescription had been sent over to the pharmacy multiple times. Resident 58's lacosamide medication was currently placed on hold by the provider until the arrival of the medication from the pharmacy. The staff were to monitor Resident 58 for seizures. 3.1-25(g)(1)(2)(3)

Based on interview and record review, the facility failed to ensure residents were free from abuse, resulting in crying and emotional distress for 3 of 5 residents reviewed for abuse. (Residents' 20, 37, 40) Findings include: 1. The clinical record for Resident 37 was reviewed on [DATE] at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until [DATE]. The [DATE] Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The [DATE], 7:18 p.m. nurses note, recorded as a late entry on [DATE], read, Writer notified sister [name of sister] and provider about the incident that occurred same day. Sister appreciative of the call and thanked us for taking care of [name of Resident 37.] On [DATE] at 11:17 a.m., the ED (Executive Director) provided the investigative file into the [DATE] incident referenced in the above note. It included a [DATE] follow up incident report. The incident report indicated on [DATE], the ED was notified at 5:15 p.m. that another employee overheard a CNA (Certified Nursing Assistant) [CNA 3] state to Resident 37 that you are disgusting, and I'm going to puke after having an accident in which the aide would have to clean up. The [DATE] follow up section of the incident report indicated after the investigation was completed, the statement of the staff member, CNA 3, in question was noted to be in the hallway, and no residents were in the area when said comment was made. Psychosocial assessments were completed for 72 hours and Resident 37 had shown no ill effects from the situation. Customer Service and Abuse inservices were completed facility wide. The [DATE] Confidential Witness Statement of LA (Laundry Aide) 5 was included in the file. It was conducted as an interview by the ED. It read, I was passing 1st level, putting linen in room (name of Resident 37) when I overheard [name of CNA 3] say 'You are disgusting. This is nasty. You should be ashamed of yourself. I'm going to throw up. There was a [DATE] handwritten statement from LA 5 included in the file. It read, I overheard an aide, [name of CNA 3,] speaking bad to a resident. She told [name of Resident 37] that she was disgusting, nasty, and that she was going [sic] puke. [Name of CNA 3] was cleaning her up after a bathroom accident. An interview was conducted with LA 5 on [DATE] at 2:59 p.m. She indicated, earlier in the day, she knocked on the door to Resident 37's room, but no one answered, so she went in to deliver laundry. LA 5 did not realize CNA 3 and Resident 37 were in the restroom until LA 5 was already in the room. While hanging up clothing, she heard CNA 3 say to Resident 37 that Resident 37 was nasty, should be ashamed of herself, and it was going to make her [CNA 3] sick. CNA 3 then began making gagging noises. Resident 37 was pretty much nonverbal and doesn't speak, more like repeats. LA 5 did not see them come out of the restroom, as LA 5 just tried to get in and out of the room quickly. LA 5 informed the BOM (Business Office Manager) the following day of what she heard. LA 5's supervisor was not working that day, so she told the BOM. It was bothering me overnight. CNA 3 always had an attitude anyway and always talked nasty towards people. LA 5 never saw CNA 3 again after that. The [DATE] Confidential Witness Statement of QMA 4 was included in the file. It was conducted as an interview by a previous Director of Nursing. It read, [Name of Resident 37] had a bowel movement and heard CNA ask her why she does that. She told her that if she does it again she will make resident clean herself up. Resident began laughing and she heard the aide say this isn't funny. An interview was conducted with QMA 4 on [DATE] at 2:30 p.m. She indicated she was assisting Resident 37's roommate in the room after a meal, while CNA 3 and Resident 37 were in the restroom. Resident 37 had a mess, trail coming from the dining room. QMA 4 heard CNA 3 say something like the next time you go on yourself, I'm going to make you change yourself. The way CNA 3 was talking to Resident 37 in the restroom did not sound abusive to her, because it was in such a calm voice. Resident 37 began laughing. CNA 3 was like, It's not funny [name of Resident 37.] After QMA 4 finished assisting Resident 37's roommate with incontinent care, QMA 4 left the room. The next thing QMA 4 knew, she was getting asked questions. QMA 4 knew telling a resident they were going to have to clean themselves up and it wasn't funny was not okay. The [DATE] Confidential Witness Statement of CNA 6 was included in the file. It was conducted as an interview by a previous DON. It read, Was on Boulevard [previous memory care unit of the facility] and noted a horrible smell. I was in hallway with [name of CNA 3 and QMA 4.] You were informed that above resident was in the bathroom. Staff member made statement that it was so bad it made me want to throw up. The [DATE] Confidential Witness Statement of CNA 3 was included in the file. It was conducted as an interview by a previous Director of Nursing. It read, Took [name of Resident 37] to restroom and she cleaned resident up D/T [due to] bowel movement. States QMA [Qualified Medication Aide] [name of QMA 4] was in the room with her. States she did make the statement that resident bowel movement about made her puke in the hallway but not directly in front of resident. CNA 3 was unavailable for interview as she no longer worked at the facility. An interview was conducted with the ED on [DATE] at 2:06 p.m. and 3:10 p.m. He indicated they did not substantiate the allegation of abuse because of the tone. The occurrence happened on [DATE], but it was not reported to him until the following day by LA 5. The late reporting didn't help, muddied the [NAME] a bit, and there was some he said, she said. CNA 3's last day of work was [DATE], the date of the incident, as she was let go over customer service. The file included a [DATE] Employee Teachable Moment Form for QMA 4 and a [DATE] Employee Teachable Moment Form for LA 5, both regarding reporting of potential abuse immediately. 2. The clinical record for Resident 20 was reviewed on [DATE] at 2:37 p.m. Her diagnoses included, but were not limited to, heart failure and chronic kidney disease. She resided on the memory care unit of the facility until [DATE] The [DATE] Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 00, indicating she was severely cognitively impaired. The clinical record for Resident 37 was reviewed on [DATE] at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until [DATE]. The [DATE] Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The investigative file into an allegation of abuse involving Resident 37, Resident 20, and CNA (Certified Nursing Assistant) 7 was provided by the ED (Executive Director) on [DATE] at 11:17 a.m. The file included the [DATE] follow up incident report. The report indicated on [DATE] the ED was notified at 12:00 p.m. that an aide transferred a resident and the resident appeared upset afterwards and then spoke in an upset tone. The [DATE] follow up section of the report indicated the investigation was completed and the resident had no adverse effects noted related to the alleged incident. Psychosocial follow ups were completed for 72 hours. Staff interviews were completed, and it was determined that no fault was found, and CNA 7 returned to schedule. The [DATE] follow up incident report did not indicate Resident 20 was involved, only Resident 37. The file included a [DATE] written statement by the MDSC (Minimum Data Set Coordinator.) It read, Writer returned to unit from break to witness [name of CNA 7] transferring [initials of Resident 37] to recliner. The resident sat down in recliner hard and started crying. The CNA was yelling at the resident telling her that she was not allowed into her room and that she wasn't going to be laid down, that she never lays down at this time of day. Writer saw CNA leave resident to complete another task, at that time a member of laundry and a member of activities approached writer about another resident [initials of Resident 20.] Activities stated that the [sic] took [initials of Resident 20] to her room to have CNA lay her down as she was requesting, they told writer that CNA then pushed resident back out of her room and then blocked the doorway so she couldn't wheel herself into her room. It was reported that CNA was yelling at [initials of Resident 20] prior to writer re-entering unit. Writer asked both residents what happened. Both residents were crying at this time. [Initials of Resident 20] stated she wouldn't let me lay down and I'm tired. [Initials of Resident 37] unable to report what happened. VS [vital signs] and head to toe completed on both [Initials of Resident 20] stated her left shoulder and arm was hurting upon palpation. [Initials of Resident 37] c/o [complained of] left hip pain on assessment. NP [Nurse Practitioner] was notified and orders for xrays for both residents obtained. Administrator notified and CNA was sent home, where she started yelling and cussing at writer and the other 2 staff members while getting close to their faces while pointing fingers. CNA finally left building. An interview was conducted with the MDSC on [DATE] at 3:42 p.m. She indicated she took a 10 minute break and when she came back to the unit, she caught the tail end of what was going on. CNA 7 was transferring Resident 37 from her wheel chair into the recliner in the television area of the unit. It looked like it could have been a hard transfer, like she landed hard into the recliner. Resident 37 also had a tendency to drop weight. Then CNA 7 started yelling at Resident 37, saying she couldn't go into her room. The MDSC immediately separated them and informed the ED. Then AA (Activity Assistant) 9 and LA (Laundry Aide) 8 came to her and said they heard CNA 7 yelling at both Resident 37 and Resident 20, and was physically blocking both of them from going in their room. The MDSC had AA 9 and LA 8 write statements. The MDSC indicated she considered what she saw abuse, like confining them from their room. An x-ray was done on Resident 37's left hip, because of how hard she landed in the recliner, and an x-ray was done on Resident 20's left arm and shoulder due to her complaints of arm pain. Neither residents had fractures, came back clean. She indicated she thought both residents were crying because they both wanted to lay down after bingo, but weren't allowed to do so. She thought Resident 37 was crying more out of anger than pain, and Resident 20 was crying, because she was mad. The file included a [DATE] written statement from LA 8 that read, I was in the activities room with residents when I heard [name of Resident 20] yelling. Me being curious I went to see what was happening The aide with [name of Resident 20] was yelling at her saying she wasn't allowed to take a nap and stopping [name of Resident 20] from getting to bed. She was causing [name of Resident 20] to cry from it. After getting told she was getting sent home, she yelled at me and [name of AA 9] saying that we don't know what we're talking about. An interview was conducted with LA 8 on [DATE] at 2:13 p.m. She indicated she was locked out of the laundry room, so she was helping AA 9 in the activity room. Resident 20 wanted to go back to her room, so AA 9 wheeled her to her room, while LA 8 remained in the activity room. After a couple minutes, she heard Resident 20 yell, so she knew she was agitated, because Resident 20 doesn't really yell. Resident 20 was yelling at CNA 7, saying she wanted to go back to bed, wanted to lay down, and didn't feel well. CNA 7 was yelling back at Resident 20, saying, You're not going back to bed. It wasn't time, because CNA 7 was not going to get her up later. CNA 7 pushed Resident 20 into the television area of the unit. Resident 20 was crying. Resident 20 was usually only out of bed short amounts of time and rested a lot during the day. If she was up, it was because she was having a good day. Resident 20 was crying, upset, and kept asking anyone to take her to bed. Resident 20 asked AA 9 if she would take her to bed, and CNA 7 said no. Both LA 8 and AA 9 informed the MDSC about what happened, so the MDSC went to talk to CNA 7. CNA 7 then came to her and AA 9, pointing her finger in their faces, saying to the other CNA, CNA 35, saying she had to go home. CNA 35 was upset that she would have to do the floor alone, saying this shouldn't be happening. CNA 7 was very mad. The [DATE] Confidential Witness Statement of CNA 35 was included in the file. It was conducted as an interview by a previous DON (Director of Nursing.) It read, Staff member states that she knew that an activity aide had told above CNA that resident wanted to lay down. This was close to 12:00 and lunch was being served in 30 minutes. CNA in question told resident we aren't laying down right now, lunch is soon. She then did place resident in recliner until lunch. She heard no yelling. The file included a [DATE] written statement from AA 9. It read, I took [name of Resident 20] into her room because that's where she wanted to go. [Name of CNA 7] the aide took [name of Resident 20] back out of her room and started yelling at [name of Resident 20,] saying she wasn't allowed to take a nap yet and blocked [name of Resident 37] from going into their room and yelled and told her that she would put her in the recliner to be more comfortable. Me and [name of LA 8] walked back to the activities room to clean when we heard [name of Resident 37] start to cry so we walked back out and [name of CNA 7] was still yelling at [names of Residents 20 and 37.] After we told [name of MDSC] all of it and she talked to [name of CNA 7] and she came out and started yelling at me and [name of LA 8] saying we don't know what we are talking about. AA 9 was unavailable for interview. The file included a [DATE] Confidential Witness Statement of CNA 7, conducted as an interview by a previous DON. It read, Both residents requested to lay them down. The residents made request to activities aide and the activities aide told her [name of CNA 7] this request. Told resident no you are going to stay up, put both in recliners D/T [due to] lunch being served @ 12:30. CNA 7 was unavailable for interview. 34850 3a. The clinical record for Resident 45 was reviewed on [DATE] at 2:17 p.m. The resident's diagnoses included, but were not limited to, opioid dependence with intoxication, major depressive disorder, bipolar disorder, psychoactive substance abuse, personality disorder, and stroke. The resident was admitted to the facility on [DATE]. An Admissions MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was cognitively impaired. 3b. The clinical record for Resident 40 was reviewed on [DATE] at 2:00 p.m. The resident's diagnosis included, but was not limited to, major depressive disorder. A Significant change of condition MDS assessment dated [DATE] indicated Resident 40 was cognitively intact. Resident 40's care plans did not indicate she makes false allegations. A reportable incident dated [DATE] indicated .Brief Description of Incident XXX[DATE] At approximately 5:30 p.m. [Resident 40] notified nursing staff that there was an alleged physical altercation with [Resident 45] Action taken .[Resident 45] placed on 1:1 supervision, and room change completed .Follow up added - [DATE] .[Resident 40] stated that the incident occurred during the nighttime hours, as she was asleep in bed, clothed, with a blanket over her. She awoke to find [Resident 45] standing over her bedside, touching her upper thigh on the outer side. [Resident 40] then pushed her away and told her to go back to her side of the room, in which she did. [Resident 45] stated that she couldn't tell if she was sleeping walking or dreaming, but when she 'snapped back into it', she realized she was standing at [Resident 40]'s bedside. She also denies that she touched [Resident 40]. After being pushed away, [Resident 45] returned to her bed, and went to sleep. [Resident 40] had psychosocial monitoring by Social Services completed through out the week, with initially being upset on the initial day about the incident but progressed to no concerns any further . An observation was made of Resident 45 on [DATE] at 10:30 a.m. The resident was observed propelling self in wheelchair down hallway with staff person presence. Resident 45 indicated to staff person she was not trying to get in bed with another resident. An interview was conducted with SSD on [DATE] at 9:46 a.m. She indicated Resident 45's behaviors has increased for approximately a week in half. Psych NP 31 was notified of the incident between Resident 40 and Resident 45 this past weekend. Resident 40 had awoken to Resident 45 at her bedside. Resident 40 had pushed Resident 45 in the chest at that time. Resident 45 then returned back to her bed. Resident 45 reported to SSD that she had awoken standing next to Resident 40's bed. Resident 40 then pushed her. Resident 45 at that time, realized she was at the wrong bed. She then returned back to her own bed. Resident 45 can not recall why she was standing at Resident 40's bedside. Resident 40 had reported she no longer wanted to be roommates with Resident 45. Psych NP 31 will be out [DATE] to evaluate Resident 45. Resident 45 was currently 1 on 1 staff supervision. An interview was conducted with Qualified Medication Aide (QMA) 4 and Certified Nursing Assistant (CNA) 30 on [DATE] at 10:09 a.m. QMA 4 indicated she was Resident 45's sitter that day. CNA 30 and QMA 4 indicated Resident 45 has had lots of outbursts. She does not sleep. Resident 45 had inappropriately touched Resident 40 over the weekend, so she was moved to another room. An interview was conducted with License Practical Nurse (LPN) 42 on [DATE] at 10:39 a.m. She indicated she had work over the weekend. Resident 40 had reported to her in the evening of [DATE], Resident 45 had touched her inappropriately early morning of [DATE]. Resident 40 was sleeping in her bed and was awoken by Resident 45 standing over her rubbing her left thigh. Resident 40 was startled and kicked Resident 45 in the chest. Resident 45 did not fall after her roommate kicked her. Resident 45 then returned back to her bed. Resident 40 was embarrassed about the incident. Resident 45 was removed out of the room she shared with Resident 40 and placed on 1 on 1 supervision. An interview was conducted with Resident 40 on [DATE] at 11:02 a.m. She indicated she was Resident 45's roommate. The staff recently moved Resident 45 to another room, because Resident 45 had inappropriately touched her early morning of [DATE]. Resident 40 had just gotten to sleep, because Resident 45 had been yelling very loudly all day into the night wanting her drugs. She then was startled awake by Resident 45 standing over her with her hand under her covers rubbing on her thigh. She then kicked Resident 45 in the chest. Resident 45 did not say anything and walked back to her own bed. It was scary. She reported the incident to the nurse later that evening. Resident 45 was moved to another room. She had not had any contact with her roommate since the move, until Bingo today. She was sitting at the table waiting for Bingo to start, and Resident 45 had propelled right up at the table next to her. At that time, she had told Resident 45 to move to another place at the table. Resident 45 did not respond just moved to another place at the table. This is the 2nd incident the resident inappropriately touched her. The fist time, was shortly after Resident 45 was admitted . She had woke up and Resident 40 was standing over her with her hand under the covers rubbing her thigh. Resident 40 yelled what are you doing? Resident 40 returned back to her bed at that time. She had reported to a staff person, and the staff person had thought it was her imagination possibly dreaming. Resident 40 agreed with the staff person maybe she was dreaming, and it didn't happened. After this past weekend, and Resident 40 did it again. She knows now she was not dreaming; it really happened. Resident 40 indicated she felt sexually abused. A statement by Resident 45 dated [DATE] indicated .[Resident 45] stated she was sleeping and felt like there was a lot going on in her head and couldn't tell if she was sleepwalking, dreaming or quote 'living reality.' [Resident 45] stated by the time she quote 'snapped back into it' she realized she was standing at [Resident 40]'s bedside. [Resident 45] stated she did not have any physical touch with [Resident 40]. [Resident 45] stated quote 'I did not touch [Resident 40] and I never got into bed with Resident 40.' [Resident 45] stated when she realized she was bedside at [Resident 40]'s bed, [Resident 40] pushed her in the chest. [Resident 45] stated she didn't fall she said quote 'she just pushed me in the chest.' [Resident 45] said she remembers [Resident 40] asking her 'what are you doing?' [Resident 45] said when she was asking her what she was doing, [Resident 45] was already walking back towards her bed. [Resident 45] stated she got back into bed to go back to sleep and woke up later that morning . An interview was conducted with Activities Assistant (AA) 35 on [DATE] at 8:56 a.m. She indicated she had assisted with conducting the Bingo activity on [DATE]. Resident 40 and Resident 45 did attend the activity. When she entered the room, the room was full of residents. Resident 40 and Resident 45 was not sitting next to one another. She had heard about the incident over the weekend between Resident 40 and Resident 45 with the inappropriate touching. At first, Resident 40 and Resident 45 got along as roommates, but Resident 40 started complaining about her as time went on. Resident 45 was loud and up most of the night yelling out; pacing up and down the hallways. AA 35 indicated it was not the first time, Resident 45 had inappropriately touched Resident 40. The incident had occurred a few weeks ago. AA 35 had taken Resident 40 to an appointment approximately a little over a week ago. Resident 40 had indicated she had reported to the nurse staff that night, Resident 45 had inappropriately touched her. Resident 40 had woke up and Resident 45 was standing over her touching her in a sexual manner. Resident 40 stated she said What are you doing? Resident 45 then returned to her bed. Resident 40 had indicated she was embarrassed about the incident. Resident 45 does not know any better due to her state of mind. AA 35 had not reported the incident due to Resident 40 had indicated she had reported to the nurse on the night of the incident. An interview was conducted with Activities Assistant (AA) 35 on [DATE] at 8:56 a.m. She indicated she had heard about the incident over the weekend between Resident 40 and Resident 45 with the inappropriate touching. She indicated it was not the first time. A 2nd incident had occurred a few weeks ago. AA 35 had taken Resident 40 to an appointment approximately a little over a week ago. Resident 40 had indicated she had reported to the nurse staff that day, Resident 45 had inappropriately touched her. Resident 40 had woke up and Resident 45 was standing over her touching her in a sexual manner. Resident 40 stated she said What are you doing? Resident 45 then returned to her bed. Resident 40 had indicated she was embarrassed about the incident. Resident 45 does not know any better due to her state of mind. AA 35 had not reported the incident due to Resident 40 had indicated she had reported to the nurse on the night of the incident. The Abuse Prevention Program policy was provided by the ED on [DATE] at 9:00 a.m. It read, The facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: 1. Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm. pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. 2. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless off their age, ability to comprehend or disability. 3. Sexual Abuse: Including but not limited to, sexual harassment, sexual coercion or sexual assault 5. Involuntary Seclusion: Separation of the resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal guardian or representative 6. Mental Abuse: Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate resident(s), harassment, threats of punishment, humiliation, or withholding of treatment or services 8 Neglect/Mistreatment: means the failure to provide, or willful withholding of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident. 3XXX,d+[DATE](a)(1)

Based on record review and interview, the facility failed to ensure residents were provided care and services to prevent the development of pressure ulcers in the facility. One resident, who developed pressure ulcers to the bilateral heels after admission, developed infection and required hospitalization and emergency surgery, ultimately resulting in an above the knee amputation (Resident B), and another resident developed unstageable pressure ulcers to the heels after admission and required ongoing treatment (Resident C), for 2 of 5 residents reviewed for pressure ulcers. The Immediate Jeopardy began on 12/09/20, when the facility failed to implement pressure relief interventions to prevent pressure ulcers to the heels of Resident B, who was admitted without pressure ulcers. The Regional Vice President and Director of Nursing were notified of the Immediate Jeopardy on 3/22/21 at 4:16 p.m. The Immediate Jeopardy was removed on 3/23/21, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The record of Resident B was reviewed on 03/03/21 at 1:00 P.M. and again on 3/18/21 at 11:45 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (M.D.S.) assessment, dated 12/13/20, indicated Resident B had clear speech, was severely cognitively impaired, had significant limitations on bed mobility and transfers, did not ambulate, and was incontinent of bowel and bladder. Resident B was admitted to the facility on [DATE]. A care plan titled SKIN RISK, dated 12/9/2020, indicated the following, .I [Resident B] am at risk for further skin breakdown. Dementia, Incontinence, Fracture, Chronic renal disease, Chronic heart disease, Dementia, Incontinence [sic], dm [diabetes mellitus] with [CONDITION(S)], hx [history of] dehydration, hx [history of] CVA [cerebrovascular accident] with dysphagia, Alzheimer's, decreased mobility d/t [due to] right femur fx [fracture] repair, lack of motivation The interventions listed with this care plan included the following: Assess food likes and dislikes, Assist to toilet &/or check and change frequently, Encourage meal/fluid intake and record, Monitor labs as available, Monitor skin daily during care, Notify physician and family of any change in skin integrity, Provide pericare (perineal care) as needed, Provide pressure reducing device to bed, Provide pressure reducing device to chair, Remind or assist to turn at least every 2 hours, See nutritional plan of care, Serve diet as ordered & Skin assessment at least weekly by nurse. A care plan titled Late loss ADL [activities of daily living], dated 12/9/2020, indicated the following, .I [Resident B] need limited to extensive/dependent assist [assistance] with toileting, bed mobility, and eating d/t [due to] right hip fx [fracture] repair, alzheimer's [sic], dementia, hx [history of] stroke with deysphagia [sic], DM [diabetes mellitus] with [CONDITION(S)]; level of assistance can vary throughout the day and day to day A care plan, dated 12/9/2020, indicated the following, .I [Resident B] am at risk for complications r/t [related to] healing from my fracture: right femur fx [fracture] repair after having a fall. Preferred to stay in the bed Upon review of Resident B's care plans, there were no interventions specifically related to the pressure relief of Resident B's lower extremities, prior to 1/10/21, due to the increased risk identified related to recent right femur fracture repair. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1/10/21 3:00 P.M.: Float bilateral heels off bed. 1/13/21 3:00 P.M.: Boots on at all times except for hygiene. There were no previous physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility documents related to Resident B's skin and wound care were reviewed in their entirety. They included, but were not limited to, the following: A Nursing-Assess Skilled (skilled nursing assessment) dated 1/09/21 at 10:41 P.M., indicated: Instructions: This assessment is all inclusive .Do not need to open separate .skin alteration . 8. Skin: 1. Currently receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Currently has wound/incision receiving tx [treatment] but not infected was marked None of the above. New Skin Issues Noted During This Assessment: 3. New Wound [potentially related to pressure, vascular insuff [insufficiency] or diabetic [CONDITION(S)]-need further assessment by wound nurse] This box was unchecked, and the comment field was blank. Skilled nursing assessments as above were also documented with the same information on 1/10/21 at 12:56 P.M. and 1/12/21 at 3:56 P.M. A Nursing-New Skin Alteration Assessment (non-occurrence) form, dated 1/10/21 at 2:42 P.M., indicated: Description: New Skin Alteration. A. New Skin Alteration Findings: 1. New Wound- Potentially related to pressures, vascular insufficiency or diabetic [CONDITION(S)]- need further assessment by wound nurse B. Description of New Skin Alterations: 3 cm x 3 cm blister to Right outer heel Notifications of new areas noted: MD [Medical Director] notifeid [sic] orders to apply skin prep every shift. Daughter inlaw [sic] notified A Nursing-New Skin Alteration Assessment (non-occurrence) form, dated 1/13/21 at 11:18 A.M., indicated: Description: New Skin Alteration. A. New Skin Alteration Findings: 1. New Wound- Potentially related to pressure, vascular insufficiency or diabetic [CONDITION(S)]- need further assessment by wound nurse B. Description of New Skin Alterations: Left heel red, nonblancable [sic]; [not blanchable] area 5.1 x 4.7 [cm] and within red area there is a dti [deep tissue injury] 1.4 x 2.6 [cm]. Notifications of new areas noted: NP [Nurse Practitioner] notified and new order for skin prep and boots. [Family member] notified A Wound: Pressure Injury Assess (assessment) w/ (with) Braden indicated: Description: Foot-heel-right Date: 1/20/21 2:55 P.M. A. Pressure injury assessment 1. Date originally noted: 1/10/21 2. Location on body: right heel 3 Type of wound: Stage 2 (shallow open injury with a moist red/pink wound bed - includes intact skin or open/ruptured serum-filled blister) 4. Current Status: Healing 5. PUSH (Pressure Ulcer Scale for Healing - a tool used to measure the status of pressure ulcers over time) score: 14 (Total score ranges from 0 to 17 [0 = healed].) 6. Length: 3.8 (cm) 7. Width: 5.8 (cm) 8. Depth: 0.1 9. Shape: Round 10. Edges: Attached; Unattached; Irregular 11. Describe the wound bed characteristics: (granulation tissue present, epithelialization present; moist/dry): Wound is ruptured blister dark in color 12. Exudate type: Serous Wound: Pressure Injury Assess (assessment) w/Braden indicated: Description: Foot-heel-right Date: 1/27/21 2:18 P.M. A. Pressure injury assessment 1. Date originally noted: 1/10/21 2. Location on body: right heel 3. Type of wound: Stage 2 4. Current Status: Healing 5. PUSH score: 14 6. Length: 3.8 (cm) 7. Width: 5.5 (cm) 8. Depth: 0.1 9. Shape: Round 10. Edges: Attached; Unattached; Irregular 11. Describe the wound bed characteristics: (granulation tissue present, epithelialization present; moist/dry): dry black eschar wound is unattached at 12pm 12. Exudate type: Serous Although dry, black eschar was noted on this assessment, the pressure ulcer continued to be documented as a stage 2. Wound: Pressure Injury Assess (assessment) w/Braden indicated: Description: Foot-heel-right Date: 2/03/21 6:29 P.M. A. Pressure injury assessment 1. Date originally noted: 1/10/21 2. Location on body: right heel 3 Type of wound: Unstageable (Full thickness skin and tissue loss in which the base of the injury is obscured by slough and/or eschar) 4. Current Status: Non-healing 5. PUSH score: 15 6. Length: 16.1 (cm) 7. Width: 14.6 (cm) 8. Depth: 0 9. Shape: Irregular 10. Edges: Attached; Unattached; Irregular 11. Describe the wound bed characteristics: (granulation tissue present, epithelialization present; moist/dry): Moist black eschar surrounded by dark and clear fluid filled blisters. 12. Exudate type: Seropurulent 17. Necrosis: Yes Progress notes for Resident B were reviewed in their entirety, from admission through discharge, with particular attention to skin and wound care issues. They included, but were not limited to: 12/11/20 11:48 A.M.: General Note .Review of systems .All other systems reviewed and are negative. 12/23/20 9:30 A.M.: General Note .Skin negative .Skin warm and dry . 01/08/21 11:29 A.M.: A Physician Services note, including a comprehensive evaluation, did not contain any mention of skin concerns, and contained the note, All other systems reviewed and are negative. 01/10/21 2:48 P.M.: General Note .Apply skin prep to bilateral heels. Ensure both heels are elevated off bed every shift. Daughter in law notified new skin and new orders. 1/13/21 2:21 P.M.: Pressure Injury Note: Pressure injury: Stage 1 [persistent non-blanchable redness]; Current status: New-inhouse. Original date: 01/13/2021 Location: left lateral heel. PUSH score: 9. Length: 5.1 (cm); Width: 4.7 (cm); Depth : 0. 1/13/21 2:42 P.M.: Pressure Injury Note: Pressure injury: Stage 2; Current status: New-inhouse. Original date: 01/10/2021 Location: right heel. PUSH score: 10. Length: 4.4 (cm); Width: 5.5 (cm); Depth : 0.1. 1/20/21 2:50 P.M.: Pressure Injury Note: Pressure injury: Stage 1; Current status: New-inhouse. Original date: 01/13/2021 Location: left lateral heel. PUSH score: 9. Length: 4.0 (cm); Width: 4.2 (cm); Depth : 0. 1/20/21 2:55 P.M.: Pressure Injury Note: Pressure injury: Stage 2; Current status: Healing. Original date: 01/10/2021 Location: right heel. PUSH score: 14. Length: 3.8 (cm); Width: 5.8 (cm); Depth : 0.1 1/27/21 2:18 P.M.: Pressure Injury Note: Pressure injury: Stage 2; Current status: Healing. Original date: 01/10/2021 Location: Right heel. PUSH score: 14. Length: 3.8 (cm); Width: 5.5 (cm); Depth : 0.1 1/27/21 2:22 P.M.: Pressure Injury Note: Pressure injury: Stage 1; Current status: Non-healing. Original date: 01/13/2021 Location: left lateral heel. PUSH score: 9. Length: 3.8 (cm); Width: 4.5 (cm); Depth : 0. 2/03/21 6:29 P.M.: Pressure Injury Note: Pressure injury: Unstageable; Current status: Non-healing. Original date: 01/10/2021 Location: right heel. PUSH score: 15. Length: 16.1 (cm); Width: 14.6 (cm); Depth : 0. 2/03/21 6:35 P.M.: Pressure Injury Note: Pressure injury: Unstageable; Current status: Non-healing. Original date: 01/13/2021 Location: left lateral heel. PUSH score: 9. Length: 3.0 (cm); Width: 4.1 (cm); Depth : 0. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1/10/21 Apply skin prep to right outer heel every shift for blister 1/13/21 Rt [right] heel- cleanse with NS [normal saline] and pat dry. Apply hydrogel on wound bed and cover with 2 x 2 calcium alginate and abd [abdominal] pad and wrap with kerlix Treatment was daily. 1/13/21 Apply skin prep to left outer heel and wrapped [sic] with kerlix every day and night shift for blister 1/27/21 Apply skin prep to left outer heel three times a day for eschar cap 1/27/21 Rt [right] heel- cleanse with NS and pat dry. Cover with 2x2 calcium alginate and abd pad and wrap with kerlix Treatment was daily. 2/4/21 Rt heel- cleanse with NS and pat dry. Apply [MEDICATION(S)] over eschar and blistered area and allow to dry. Apply abd pad and wrap with kerlix Treatment was daily. There were no other physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's acting medical representative was interviewed on 03/03/21 at 2:40 P.M. They stated that Resident B had been admitted to the facility after a hospital stay for surgery and recovery from a broken hip, and that hospital records indicated Resident B did not have any pressure sores at the time of transfer. The representative stated that on 1/11/21, they received a phone call from a facility nurse indicating Resident B had a small blister on her left heel, and a stage 3 pressure sore on her right heel. On 02/03/21, the representative received a phone message that the resident was not eating or drinking, and her wounds were not improving. They called back to the facility, and the nurse they spoke with told them the resident was doing fine and had just asked for some iced tea. On 02/04/21, at 4:55 P.M., the representative received a phone call from Resident B's treating physician. They described his demeanor as hysterical. The doctor stated the resident needed to go to the hospital immediately, as the resident's wounds were such that they could not treat them in the facility. On 02/04/21, at approximately 9:00 P.M., the representative stated they received a call from the hospital admitting nurse. The nurse described the resident's heels as completely necrotic; the right heel was draining puss and blood. A wound nurse was called to document the wounds with pictures. The Nurse Practitioner who had followed Resident B was interviewed on 03/03/21 at 3:25 P.M. She indicated she was aware of Resident B's heel wounds, and her discharge to the hospital, but had nothing to add that wasn't in the record. Resident B's treating physician was interviewed on 03/04/21 at 10:10 A.M. He indicated that on 02/03/21, he received a call from a facility nurse informing him Resident B had developed a sudden onset petechiae rash on her hands and upper arms. He stated he received lab results on 02/04/21 indicating Resident B had an elevated white blood cell count, possibly indicating an infection. He stated that based on these two issues, he decided to come into the facility to assess the resident, though it was not his normal day to come to the facility. He said that following examination of the resident, he noted the right foot was cooler than the left, and the right heel was in a condition requiring extensive surgical debridement, which could not be done in the facility. He called the resident's medical power of attorney and got permission to send the resident to the hospital. The facility wound nurse who treated Resident B was interviewed on 3/04/21 at 11:05 A.M. She indicated she did not know Resident B well, as she had worked on a different unit for most of the resident's stay. She noted she began following her on 1/10/21 when she was alerted to the resident's skin issues. She stated that as wound nurse it was her job to assess and measure the wounds, document that, and let nursing and the treating physician know. She stated, At that point, I'm out of it. Facility progress notes, as reviewed 03/03/21, contained no documentation Resident B had been transferred to the hospital on 02/04/21 for emergent treatment, including, but not limited to, the resident's condition at discharge, a discharge assessment, or the reason for the transfer. Hospital records documented the resident's condition on admission, including the necessity for extensive emergency surgery on the right foot, in an attempt to save it. This was unsuccessful, and the resident subsequently underwent an above the knee amputation on her right leg. Hospital records also documented the presence of a pressure sore wound to the resident's coccyx, recorded with measurements and a picture. Facility records as reviewed contained no assessment, diagnosis, or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A hospital Progress Note for Resident B, dated 02/04/21, included New Complaint-swelling and pain in the right foot .Assessment: Abscess of right foot .Plan .Will continue IV antibiotics .Will request an immediate transfer of the patient to ED [emergency department] for incision and drainage of the right foot abscess A hospital ED (emergency department) to Hosp (hospital) Admission, dated 02/04/21, indicated: Radiology: CT [computerized tomography scan] Right foot with IV contrast: There is soft tissue swelling along the foot .there is significant plantar surface soft tissue swelling. Several soft tissue ulcers are noted .There are several enhancing bands along the plantar surface of the foot which could reflect phlegmonous [acute inflammation] change or even early abscess formation The hospital wound nurse documented skin concerns for Resident B on 2/05/21, based on her assessment of Resident B after admission on 02/04/21. Each wound description was accompanied by a picture. They included: Type of Wound: Ulcer Heel Left Placement Date: 02/05/21. Wound types: Ulcer. Wound Origination: Present on admission. Location: Heel. Orientation: Left. Pressure Injury Stage: Unstageable. Wound Length: 3 cm Wound Width: 5 cm Type of Wound: Ulcer Heel Right; Medial Placement Date: 02/05/21 Wound Types: Ulcer. Wound Origin: Present on Admission. Location: Heel. Orientation: Right; Medial. Pressure Injury Stage: Unstageable. Wound Length: 10 cm Wound Width: 5 cm Type of Wound: Ulcer Heel Right; Lateral Placement Date: 02/05/21 Wound Types: Ulcer. Location: Heel. Orientation: Right; Lateral. Pressure Injury Stage: Unstageable. Wound Length: 9 cm Wound Width: 4 cm Drainage: Serosanguious (Sic; Serosanguinous; blood and serum). A hospital OR [operating room] Procedure and Wound Class document dated, 2/05/21, indicated: Pre-op Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] of the right foot . Post-op Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Procedure: I and D [incision and drainage] of the right foot, deep, below fascia. Anesthesia type: General. Description of each procedure finding: Extensive abscess of the right foot with 50 cc [cubic centimeter] of purulence drained from the posterior right foot. Extensive necrosis of the lateral and plantar heel skin and to a lesser extent the medial and posterior heel. Extensive necrosis of the lateral muscle compartment and plantar fascia. Purulence tunnels deep to the calcaneus [heel bone] through the central muscle compartment deep to the plantar fascia A hospital Operative/Procedure note, dated 02/05/21, indicated: Procedure: Incision and drainage of the right foot, deep, below fascia. Brief History and Indications: The patient was found to have developed decubitus ulcers bilaterally with the right side developing a [CONDITION(S)]. This was extremely painful . Procedure in detail: Attention was directed towards the posterior heel and the lateral heel where large amounts of sloughing skin was present .Having removed all sloughing skin, large areas of soft tissue necrosis were evident to the plantar heel and lateral heel as well as smaller areas to the medial heel .Incision was made into the plantar heel with copious amounts of purulence coming out. The entirety of the posterior heel necrosis was excised at this time with copious amounts of purulence drained. This was done to the lateral heel, excising all of the necrosis down to the posterior eschar [scab]. Copious amounts of purulence were drained at this time .There were also found to probe a small area of necrosis on the medial side of the foot. This was well incised and excised with copious amounts of draining evident. At this time attention was directed deep to the skin where it was noted to have extensive necrosis of the muscles and tendons of the plantar foot extending deep into the central and lateral compartments of the foot .The central compartment as well had extensive necrosis including the plantar fascia, which was excised at this time with copious amounts of purulence drained .Attention was then directed to the small skin bridge connecting the posterior and anterior portions of the foot and separating the lateral and plantar areas of necrosis. This was excised and it was easily visualized that extensive necrosis had occurred throughout the entirety of the skin bridge deep. This was removed from the field. Purulence at this time was also taken and sent for culture .The entirety of the ulcerated area measures 11cm [centimeters] by 6cm by 3cm The patient was discussed with the power of attorney, who would like a vascular consult to consider potential BKA [below knee amputation]. Right lower extremity is likely nonsalvagable [sic] and will not be amenable to closure with wound healing A hospital Operative Report for Resident B indicated: Date of Procedure: 2/07/21 . Pre-operative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Post-operative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Procedure: Right above knee amputation (AKA) . Operative details: Using electrocautery, the subcutaneous tissue and muscle of the thigh compartments were dissected. The femoral vein and artery were dissected independently, and each was ligated using a silk ties. [sic] The femur was transected at the distal portion. Hemostasis [stopping blood flow] achieved .Muscle was re-approximated over bone. The flaps of anterior and posterior fascia were re-approximated over bone. The flaps of anterior and posterior fascia were re-approximated A hospital pathology report dated as collected 02/07/21, received 02/08, and reported 02/11/21, and noted to be the specimen from Resident B's AKA, indicated: .There is an ulcer on the plantar aspect, 8.1 x [by] 6.1 cm. The base is necrotic appearing with areas of leathery black mummification. The surrounding skin is purple and dusky A hospital Discharge Summary dated 2/11/21, indicated: The patient presented to the hospital emergency room with right foot pain and ulcer diagnosed with infection, had a CT scan of her right foot .soft tissue ulcers, and swelling along the plantar surface of the foot Hospital course: The patient was seen by podiatry and had I and D on 02/04/21. [Resident B] was seen by vascular surgery, diagnosed with gangrene, and underwent right AKA on 02/07/21 .Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .[Resident B] had atherosclerosis [blockage of an artery] and gangrene. She had incision and drainage by podiatry on 02/04 and right above-knee amputation by Vascular 02/07 2. The record of Resident C was reviewed on 03/04/21 at 1:00 P.M. and again on 3/18/21 at 11:55 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (M.D.S.) assessment, dated 02/03/21, indicated Resident C had clear speech and usually understands, has mild cognitive impairment, displayed no mood or behavior issues during the assessment period, required total assistance of two staff for bed mobility and transfers, did not ambulate, required total assistance for locomotion, dressing, and toileting, and functional range of motion was limited on one side, both upper and lower. There were no skin impairments marked for Resident C on the assessment. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2/19/21 9:15 P.M.: Skin Prep to bilateral heels. Three times a day. 2/19/21 4:15 P.M.: Prevalon Heel Protector boots while in wheelchair. Two times a day . 2/20/21 7:00 A.M.: Heels Up cushion while resident is in bed. Ensure heels are floated [Nothing touching heels at all] 3/4/21 9:15 P.M.: Skin prep to left heel. Three times a day. 3/4/21 9:15 P.M.: apply [MEDICATION(S)] to the right heel and leave open to air. Three times a day. Resident C was admitted to the facility on [DATE]. Resident C's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated 9/11/18, indicated the following, .SKIN RISK: I [Resident C] am at risk for skin breakdown/skin tears: hx [history of] CVA [cerebrovascular accident] right side [CONDITION(S)], dysphagia, chronic pain, decreased mobility, chronic cardiovascular disease, dementia, incontinence, [CONDITION(S)] The interventions listed with the care plan include the following: Administer vitamins and minerals as ordered, Assist to toilet &/or check and change frequently, Geri sleeves as tolerated, Monitor labs as available, Monitor skin daily during care, Notify physician and family of any change in skin integrity, Provide pressure reducing device to bed, Provide pressure reducing device to chair, See nutritional plan of care, Serve diet as ordered, and Skin assessment at least weekly by nurse. Upon review of Resident C's care plans, there were no interventions specifically related to the pressure relief of Resident C's lower extremities, prior to 2/19/21, due to the increased risk identified related to [CONDITION(S)] following cerebral infarction affecting the right dominant side. A care plan for Resident C, initiated on 2/19/21, indicated, I have skin alterations. Location: left and right heels, toes on right foot. Resident C's care plans contained no plans for actual skin alterations prior to 2/19/21. A Nursing-New Skin Alteration Assessment (non-occurrence) form, dated 2/18/21 at 2:18 P.M., indicated: Description: New Skin Alteration. A. New Skin Alteration Findings: 1. New Wound - Potentially related to pressure, vascular insufficiency or diabetic [CONDITION(S)]- need further assessment by wound nurse B. Description of New Skin Alterations: Right foot toes. Eschar on 3 right foot toes. No moisture or drainage noted. No pain noted. A Nursing-New Skin Alteration Assessment (non-occurrence) form dated 2/18/21, at 2:18 P.M., indicated: Description: New Skin Alteration. A. New Skin Alteration Findings: 1. New Wound - Potentially related to pressures, vascular insufficiency or diabetic [CONDITION(S)]- need further assessment by wound nurse B. Description of New Skin Alterations: R and L (right and left) heel pressure areas noted. No drainage or odor present. A Nursing-New Skin Alteration Assessment (non-occurrence) form dated 2/19/21, at 2:33 P.M., indicated: Description: New Skin Alteration. A. New Skin Alteration Findings: 1. New Wound - Potentially related to pressures, vascular insufficiency or diabetic [CONDITION(S)]- need further assessment by wound nurse B. Description of New Skin Alterations: R and L (right and left) outer heel pressure areas noted. No drainage or odor present. Wound: Pressure Injury Assess (assessment) w/Braden indicated: Description: Foot-heel-right Date: 2/24/21 5:38 P.M. A. Pressure injury assessment 1. Date originally noted: 2/19/21 2. Location on body: left heel 3 Type of wound: Unstageable 4. Current Status: New-in house 5. PUSH score: 7 6. Length: 3.1 (cm) 7. Width: 2.2 (cm) 8. Depth: 0 9. Shape: Round 10. Edges: Unmarked 11. Describe the wound bed characteristics: (granulation tissue present, epithelialization present; moist/dry): Closed dry blister. 12. Exudate type: None Wound: Pressure Injury Assess (assessment) w/Braden indicated: Description: Foot-heel-right Date: 2/24/21 5:39 P.M. A. Pressure injury assessment 1. Date originally noted: 2/19/21 2. Location on body: right heel 3 Type of wound: Unstageable 4. Current Status: New- in house 5. PUSH score: 7 (Length x width plus Exudate plus Tissue type) 6. Length: 2.0 (cm) 7. Width: 2.6 (cm) 8. Depth: 0 9. Shape: Round 10. Edges: Unmarked 11. Describe the wound bed characteristics: (granulation tissue present, epithelialization present; moist/dry): Closed hard blister red and purple in color. 12. Exudate type: None Wound: Pressure Injury Assess (assessment) w/Braden indicated: Description: Foot-heel-left Date: 3/03/21 4:25 P.M. A. Pressure injury assessment 1. Date originally noted: 2/19/21 2. Location on body: left heel 3 Type of wound: Unstageable 4. Current Status: Healing 5. PUSH score: 7 6. Length: 2.6 (cm) 7. Width: 2.1 (cm) 8. Depth: 0 9. Shape: Round 10. Edges: Unmarked 11. Describe the wound bed characteristics: (granulation tissue present, epithelialization present; moist/dry): Closed dark dry blister 12. Exudate type: None Wound: Pressure Injury Assess (assessment) w/Braden indicated: Description: Foot-heel-right Date: 3/03/21 4:31 P.M. A. Pressure injury assessment 1. Date originally noted: 2/19/21 2. Location on body: right heel 3 Type of wound: Unstageable 4. Current Status: Non-healing 5. PUSH score: 8 6. Length: 3.0 (cm) 7. Width: 2.8 (cm) 8. Depth: 0 9. Shape: Round 10. Edges: Unmarked 11. Describe the wound bed characteristics: (granulation tissue present, epithelialization present; moist/dry): Closed soft blister purple in color. 12. Exudate type: None The facility wound care nurse was interviewed by phone 03/05/21 at 12:10 P.M. She indicated she was aware Resident C had presented with pressure sores on 02/19/21 but had no other information to offer. The Director of Nursing was interviewed on 3/05/21 at 12:20 P.M. She reviewed Resident C's condition, noted that her condition had been declining, and indicated she was aware Resident C had been assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility policy titled Skin Management Program, dated 08/14/2014, indicated: It is our policy to assess for and reduce risk factors that may contribute to the development of pressure ulcers and other skin alterations unless the individual demonstrates that the development is clinically unavoidable The Immediate Jeopardy began on 12/09/20. The Immediate Jeopardy was removed on 3/23/21, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because the facility had not in-serviced all nursing staff on prevention strategies for pressure ulcers and continued on-going audits of all residents' relating to their skin integrity and interventions. This Federal tag relates to Complaint IN 388. 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a resident (Resident B) was protected from verbal abuse, when a staff member cursed at and threatened the resident, resulting in psychosocial harm, in the form of fear and intimidation. 1 of 3 residents reviewed for abuse. Findings include: The record of Resident B was reviewed on 4/21/17 at 3:15 P.M. Diagnoses, obtained from the most recent electronic medical record, included, but were not limited to, a history of cerebral infarct (stroke), [MEDICAL CONDITION], diabetes mellitus, hypertension, [MEDICAL CONDITION], depression, anxiety, and [MEDICAL CONDITION]. A Medicare 14 Day Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident B had no cognitive or communication deficits, required extensive staff assistance for bed mobility and transfers, did not ambulate, used a wheelchair for locomotion, and was dependent on staff assistance for locomotion off her unit, such as to dining, activities, and treatments. Resident B was interviewed by phone on 4/25/17 at 10:30 A.M. She was pleasant and cooperative, and recalled the incident of 11/07/16 involving CNA #1 in detail. She indicated she called for assistance to get off the bed pan, and when CNA #1 came in the room, he shut the door, leaned against it, and stated Contrary to what you think you do not own or run this nursing home. There are other people here who need help. We won't be back to help you until the morning. She indicated his language was rough. She stated she called her friend and asked her to come to the facility as she was afraid of CNA #1. She indicated she was afraid to use her call light as CNA #1 might come back. She indicated she remained afraid of CNA #1 to this day. Resident B's family member who is primarily involved in her care was interviewed by phone on 4/25/17 at 1:05 P.M. He indicated that on 11/08/17 he received a call from Resident B's friend advising him of the incident of the previous evening involving CNA #1. He indicated he called Resident B and she sounded scared. He indicated Resident B said she was worried CNA #1 would come back and hurt her. He indicated Resident B was crying during the conversation. He indicated he visited with Resident B a few days later and she remained afraid of CNA #1, noting he still has the codes to the building and he might come back and hurt me. He indicated Resident B remained afraid of CNA #1 even after she was discharged from the facility. An electronic report filed by the facility with the State Agency's Survey Report System on 11/08/16 indicated: Residents Involved: (Resident B) Staff Involved (CNA #1) Brief Description of Incident: 11/08/2016 Upon entering office this morning there was a note under Director of Nursing door from residents (sic) friend explaining that staff member had cursed in the resident room and was visibly angry about helping resident with her bed pan late last night . Follow Up: Follow up added -- 11/9/2016 After investigation and interviews with residents and staff it was determined that staff member (CNA #1) cursed in the residents room and spoke to the resident in a demeaning manner. The staff members employment has been terminated . An undated document, identified as the note placed under the door of the Director of Nursing on 11/08/16, signed by Resident B's friend who she called after the incident with CNA #1 and who then came to the facility at her request, indicated: An aide with (an identifiable hairstyle) cussed at (Resident B) .He scared her so much she called me at 10:30 PM to come because she was afraid he would come back to her room. Please keep him away from her. I sat with her for an hour until she calmed down and the nurse gave her a sleeping pill. I hope you can address this incident, as it doesn't help the healing process. A note signed by the Social Services Director dated 11/8/16, identified as relating to Resident B, indicated: SSD (Social Services Director) approached resident sitting in her room .Resident was asked about reported concern from the previous evening. Resident reports there was a problem with the male CNA with the red glasses .she reports that last evening the nurse assisted with putting her on the bed pan .she reports that about an hour and a half she needed to be toileted again and when no one responded to the call light she yelled out. She reports the male CNA came in her room and couldn't believe that she had to go to the bathroom again. She reported that he yelled, 'What the h l is wrong with you, you just went to the bathroom.' She reports she told him she could not help it. She reports he told her he has 60 other residents to take care of and that she is not number one. She reports he told her he will get to her when he can get to her. He (sic; she) reports that she is not special in this hospital. She reports he .stormed out of the room and slammed the door . A facility document dated 11/8/16 and indicated to be information from Resident B's friend indicated .Rec'ed (received) a call from (Resident B), in tears, and overly upset and agitated and asked (friend) to come to building .there in about 10-15 minutes. Door shut, light on, was in tears and 'scared to death' .Apparently she needed bed pan .When aide came, he 'berated her' and called her a 'b .h' and asked what she needed. (Friend) stayed with her for about an hour until calmed (sic) down . A facility Abuse Investigation Worksheet: Reasonable Suspicion of a Crime document, dated 11/07/16, indicated: Resident Involved: (Resident B), Date of Incident: 11/7/16, Staff: (CNA #1), Description of allegation: (Resident B) called friend to report that CNA had cursed at her when she put her light on for bed pan .Immediate action taken to protect resident: Staff member was suspended (symbol for and) the investigation started. Suspicion of Crime: Suspected crime committed? (The box for yes was checked.) Law enforcement notified? (The box for yes was checked). Name of Agency and Person contacted: Indiana State Police (name of detective) .Plan of Action: Staff member terminated. Final Reports: Staff member terminated for cursing (symbol for and) speaking to resident in a demeaning manner. A document from the facility's Nursing Policy and Procedure Manual titled Abuse Prohibition, Reporting, and Investigation dated 04/12/2017 received from the Administrator on 4/21/17 at 11:00 A.M., indicated: It is the policy of (name of parent company of facility) that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Definitions: 1. Abuse- Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful- as used in the definition of abuse means the individual must have acted deliberately, not that the individual intended to inflict injury or harm. C. Verbal Abuse-The use of oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents . D. Mental Abuse- Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological suffering. Examples: Humiliation, harassments, threats of punishment or deprivation, bullying . Residents will be protected from abuse through the provisions of this policy, the procedure. The Past Noncompliance began on 11/08/16 and was corrected on 11/09/16. The facility immediately initiated their investigation, reported to ISDH and law enforcement, and suspended the accused employee on 11/08/16 upon receiving the allegation of abuse/neglect. Other residents and employees were interviewed with no other concerns related to abuse and neglect. The facility followed their abuse prohibition, reporting and investigation policy and procedure, and continued monitoring and inservicing on abuse following the allegation dated 11/08/16. The facility completed the investigation and terminated the employee on 11/09/16. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal tag relates to Complaint IN 275. 3.1-28(b)

Based on interview and record review, the facility failed to ensure a resident (Resident B) was protected from neglect, when a staff member failed to ensure the resident had access to the call light and telephone, resulting in psychosocial harm, in the form of fear and intimidation. 1 of 3 residents reviewed for abuse. Findings include: The record of Resident B was reviewed on 4/21/17 at 3:15 P.M. Diagnoses, obtained from the most recent electronic medical record, included, but were not limited to, a history of cerebral infarct (stroke), [MEDICAL CONDITION], diabetes mellitus, hypertension, [MEDICAL CONDITION], depression, anxiety, and [MEDICAL CONDITION]. A Medicare 14 Day Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident B had no cognitive or communication deficits, required extensive staff assistance for bed mobility and transfers, did not ambulate, used a wheelchair for locomotion, and was dependent on staff assistance for locomotion off her unit, such as to dining, activities, and treatments. Resident B was interviewed by phone on 4/25/17 at 10:30 A.M. She was pleasant and cooperative, and recalled the incident of 11/07/16 involving CNA #1 in detail. She indicated she called for assistance to get off the bed pan, and when CNA #1 came in the room, he did help her get off the bed pan, but left her bedside table out of reach. She indicated she had to get up on her hands and knees in bed to reach the beside table with the call light and telephone. She stated she called her friend and asked her to come to the facility as she was afraid of CNA #1. She indicated she was afraid to use her call light as CNA #1 might come back. She indicated she remained afraid of CNA #1 to this day. Resident B's family member who is primarily involved in her care was interviewed by phone on 4/25/17 at 1:05 P.M. He indicated that on 11/08/17 he received a call from Resident B's friend advising him of the incident of the previous evening involving CNA #1. He indicated he called Resident B and she sounded scared. He indicated Resident B said she was worried CNA #1 would come back and hurt her. He indicated Resident B was crying during the conversation. He indicated he visited with Resident B a few days later and she remained afraid of CNA #1, noting he still has the codes to the building and he might come back and hurt me. He indicated Resident B remained afraid of CNA #1 even after she was discharged from the facility. An electronic report filed by the facility with the State Agency's Survey Report System on 11/08/16 indicated: Residents Involved: (Resident B), Staff Involved (CNA #1), Brief Description of Incident: 11/08/2016 Upon entering office this morning there was a note under Director of Nursing door from residents (sic) friend explaining that staff member .was visibly angry about helping resident with her bed pan late last night .Follow Up: Follow up added -- 11/9/2016 After investigation and interviews with residents and staff .The staff members (CNA #1) employment has been terminated . An undated document, identified as the note placed under the door of the Director of Nursing on 11/08/16, signed by Resident B's friend who she called after the incident with CNA #1 and who then came to the facility at her request, indicated: An aide with (an identifiable hairstyle) .He scared her so much she called me at 10:30 PM to come because she was afraid he would come back to her room. Please keep him away from her. I sat with her for an hour until she calmed down and the nurse gave her a sleeping pill. I hope you can address this incident, as it doesn't help the healing process. A note signed by the Social Services Director dated 11/8/16, identified as relating to Resident B, indicated: SSD (Social Services Director) approached resident sitting in her room .Resident was asked about reported concern from the previous evening. Resident reports there was a problem with the male CNA with the red glasses .she reports that last evening the nurse assisted with putting her on the bed pan .she reports that about an hour and a half she needed to be toileted again and when no one responded to the call light she yelled out. She reports the male CNA came in her room and couldn't believe that she had to go to the bathroom again .She reports she told him she could not help it. She reports he told her he has 60 other residents to take care of and that she is not number one. She reports he told her he will get to her when he can get to her. He (sic; she) reports that she is not special in this hospital. She reports he .stormed out of the room and slammed the door . A facility document dated 11/8/16 and indicated to be information from Resident B's friend indicated .Rec'ed (received) a call from (Resident B), in tears, and overly upset and agitated and asked (friend) to come to building .there in about 10-15 minutes. Door shut, light on, was in tears and 'scared to death' .Apparently she needed bed pan .(Friend) stayed with her for about an hour until calmed (sic) down . A facility Abuse Investigation Worksheet: Reasonable Suspicion of a Crime document, dated 11/07/16, indicated: Resident Involved: (Resident B), Date of Incident: 11/7/16, Staff: (CNA #1), Description of allegation: (Resident B) called friend to report (a problem) .when she put her light on for bed pan .Immediate action taken to protect resident: Staff member was suspended (symbol for and) the investigation started. Suspicion of Crime: Suspected crime committed? (The box for yes was checked.) Law enforcement notified? (The box for yes was checked). Name of Agency and Person contacted: Indiana State Police (name of detective) .Plan of Action: Staff member terminated. Final Reports: Staff member terminated . A document from the facility's Nursing Policy and Procedure Manual titled Abuse Prohibition, Reporting, and Investigation dated 04/12/2017 received from the Administrator on 4/21/17 at 11:00 A.M., indicated: It is the policy of (name of parent company of facility) that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Definitions: 3. Neglect- Failure of the facility, It's employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or mental illness . Examples: An action that actually harms a resident, such as: Placing call light out of reach resulting in anxiety or mental distress. Residents will be protected from abuse through the provisions of this policy, the procedure. The Past Noncompliance began on 11/08/16 and was corrected on 11/09/16. The facility immediately initiated their investigation, reported to ISDH and law enforcement, and suspended the accused employee on 11/08/16 upon receiving the allegation of abuse/neglect. Other residents and employees were interviewed with no other concerns related to abuse and neglect. The facility followed their abuse prohibition, reporting and investigation policy and procedure, and continued monitoring and inservicing on abuse following the allegation dated 11/08/16. The facility completed the investigation and terminated the employee on 11/09/16. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal tag relates to Complaint IN 275. 3.1-28(a)(3)

Based on record review and interview, the facility failed to ensure a resident who was admitted without identified skin conditions did not develop skin concerns in the form of incontinence associated [MEDICAL CONDITION], requiring intervention and treatment by a skin care specialist. Resident B; 1 resident of 3 reviewed for skin concerns. Findings include: The record of Resident B was reviewed on 5/31/16 at 1:00 P.M. Diagnoses, obtained from the current electronic medical [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident B was severely cognitively impaired, required use of a mechanical lift for transfers with 2 staff assisting, did not ambulate, required staff assistance for activities of daily living, and was incontinent of bowel and bladder. A Nursing Assessment form dated 2/01/16, the date of Resident B's admission to the facility, indicated a Braden pressure sore risk assessment score of 14, indicating she was at moderate risk for skin breakdown. Potential problems were identifies as shear and incontinence of bowel and bladder. A Nursing Admission/Return Assessment form dated 2/01/16 indicated several bruises to all extremities. Documentation for wounds, rashes, [MEDICAL CONDITION], and abrasions were unmarked, indicating they were not present. A physician's services progress note dated 2/02/16 at 10:18 P.M., indicated: Review of systems: Skin negative .Physical exam: Skin is warm and dry. A Nursing Weekly Assessment form dated 2/13/16 indicated Resident skin is very fragile . Areas to document treatment for [REDACTED]. A Nursing Weekly Assessment form dated 3/31/16 indicated skin assessed. Skin w/d (warm and dry). No skin issues/conditions were documented. A physician's orders [REDACTED].WCS (Wound Care Services) to eval (evaluate) (symbol for and) Tx (treat). Resident B's Care Plans included Skin Risk: Potential for skin breakdown initiated 2/2/16 and updated 2/22/16, and Wound: Actual skin breakdown initiated 4/18/16 and updated 6/01/16. Wound care specialist visit documentation was detailed in reports titled Progress Note Details; On 6/01/16 at 12:45 P.M. the Director of Nursing indicated the following represented all assessments and reports done for Resident B by the wound care specialist. Information in those reports included, but was not limited to: 4/19/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary: . Wound #3 Left, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Not Healed. Initial wound encounter measurements are 1.8cm length x 0.8cm width x 0.1cm depth . Wound #4 Right, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Not Healed. Initial wound encounter measurements are 1.0cm length x 0.7cm width x 0.1cm depth .Additional orders .Off-loading .Low air loss mattress . On 6/03/16 at 1:30 P.M., the Director of Nursing indicated that Resident B was currently on a low air loss mattress as ordered on [DATE], but she was unable to confirm on what date the low air loss mattress had been put into service for Resident B. 4/26/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #3 Left, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Not Healed. Subsequent wound encounter measurements are 0.6cm length x 0.4cm width x 0.1cm depth . Wound #4 Right, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Resolved . 5/03/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #3 Left, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Not Healed. Subsequent wound encounter measurements are 0.6cm length x 0.4cm width x 0.1cm depth . 5/10/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #3 Left, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Not Healed. Subsequent wound encounter measurements are 1.1cm length x 1cm width x 0.1cm depth .the wound is improving . 5/17/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (left and right buttock) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #3 Left, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Not Healed. Subsequent wound encounter measurements are 1.5cm length x 1cm width x 0.1cm depth .There is no change in the wound progression . 5/24/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (left and right buttock) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary Wound #3 Left, Inferior Buttock is a Full Thickness Dermatologic/Rash and has received a status of Not Healed. Subsequent wound encounter measurements are 0.9cm length x 1.2cm width x 0.2cm depth .There is no change in the wound progression . The wound care specialist assigned to see Resident B was interviewed by telephone on 6/01/16 at 3:40 P.M. He indicated he could not remember the exact date he first saw Resident B but thought it might be mid April. He indicated the causes of Resident B's skin issues, including pressure sores, were multifactoral and could be considered progressive. He indicated incontinence associated [MEDICAL CONDITION] as a contributing factor to the development of pressure sores, and indicated good incontinence care could prevent a lot of this. He did not identify or indicate [MEDICAL CONDITION] as a contributing factor. Weekly Skin Assessment Sheets for Resident B were obtained from the Director of Nursing on 6/02/16 at 9:10 A.M. She indicated what she provided were all the facility had. She also indicated a Skin Assessment Sheet should be filled out each time a CNA gave a resident a shower or bath, and any skin findings reported to the nurse. Skin Assessment Sheets were provided for the dates of 2/03/16, 2/10/16, 2/13/16, 2/17/16, 3/04/16, 3/12/16, 3/16/16, 3/23/16, 3/26/16, 4/02/16, and 4/06/16. None of the Skin Assessment Sheets indicated any skin issues or concerns; for the entry of Any Skin Issues Noted? all had the box no checked. The Administrator was interviewed on 6/01/16 at 12:45 P.M. She indicated the facility had arranged for an outside wound care group to consult on Resident B's skin concerns. She indicated the facility's attending physician deferred to the wound care specialist in matters of wound care. She also indicated the wound care specialist determined the appropriate frequency of visits and assessments for assigned residents. She indicate it was the wound care specialist's practice to visit the assigned residents, then write a report with findings and recommendations and email them to the facility at a later time. The Director of Nursing or other staff member would then enter these findings in the resident's record, typically the following day. She indicated the wound care specialist was currently on vacation, and that the wound care service had not assigned another wound care specialist while he was away. She indicated the facility's interim wound care nurse was assuming his duties until he returned. The Administrator also indicated it was the facility's practice to employee a nurse designated to be the facility's Wound Care Specialist, but that position was currently vacant, and was being filled on an interim basis by a member of the nursing staff. Resident B was observed on 6/03/16 at 2:50 P.M., and an attempt was made to interview her. She declined to answer questions and was unable to give permission for an observation of her wounds and skin condition. A facility document titled Skin Management Program dated 08/14/2014 obtained from the Director of Nursing on 6/02/16 at 1:40 P.M., indicated: Purpose: It is our policy to assess for and reduce risk factors that may contribute to the development of pressure ulcers and other skin conditions . Residents who receive assistance with bathing and/or peri-care will be observed daily by nursing staff and any notation of red areas, open areas, skin tears, bruises, rashes, abrasions, excoriations or other alterations will be reported to the licensed nurse for further assessment. Prevention and treatment will include but are not limited to the following major categories: Nutritional support, medication therapy, risk reducing products, assistance with mobility and hygiene; physical or occupational therapy, and physician consultation. This Federal tag relates to Complaint IN 048. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident who was admitted without identified pressure sores or other wounds did not develop pressure sores at Stage lll requiring treatment and wound consultation, or prevent them from reoccurring. Resident B; 1 resident of 3 reviewed for pressure sores. Findings include: The record of Resident B was reviewed on 5/31/16 at 1:00 P.M. Diagnoses, obtained from the current electronic medical [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident B was severely cognitively impaired, required use of a mechanical lift for transfers with 2 staff assisting, did not ambulate, required staff assistance for activities of daily living, and was incontinent of bowel and bladder. A Nursing Assessment form dated 2/01/16, the date of Resident B's admission to the facility, indicated a Braden pressure sore risk assessment score of 14, indicating she was at moderate risk for skin breakdown. Potential problems were identifies as shear and incontinence of bowel and bladder. Resident B's Care Plans included Skin Risk: Potential for skin breakdown initiated 2/2/16 and updated 2/22/16, and Wound: Actual skin breakdown initiated 4/18/16 and updated 6/01/16. A Nursing Admission/Return Assessment form dated 2/01/16 indicated several bruises to all extremities. Documentation for wounds, rashes, [MEDICAL CONDITION], and abrasions were unmarked, indicating they were not present. A physician's services progress note dated 2/02/16 at 10:18 P.M., indicated: Review of systems: Skin negative .Physical exam: Skin is warm and dry. A Nursing Weekly Assessment form dated 2/13/16 indicated Resident skin is very fragile . Areas to document treatment for [REDACTED]. A Nursing Occurrence: Initial Assessment form dated 2/22/16 indicated Type of incident: Open area to right cheek (buttocks) 2.2 x 1.5 CM (centimeters) . A physician's orders [REDACTED].M., indicated Thin duoderm to OA (open area) on right and left buttocks . A physician's orders [REDACTED].M., indicated DC (discontinue) duoderm treatment to buttocks. WCS (Wound Care Services) to treat and evaluate. A nursing New Skin Alteration Assessment dated 2/25/16 indicated New lesion(s): Skin area noted to left buttock 4 CM (length) x 2 CM (width) with excoriation to surrounding area . A Wound: Pressure Ulcer with Braden assessment form dated 3/01/16 indicated Date originally noted 2/22/16 Location on body left buttock. Type of wound Stage lll. Current status: closed over. A nurse's progress note dated 3/01/16 at 9:00 A.M., indicated Pressure ulcer note: Late entry .Pressure ulcer: Stage lll Current status: Closed/resurfaced. Original date: 2/22/16. Location: Left buttock . A nurse's progress note dated 3/01/16 at 3:59 P.M., indicated Pressure ulcer note: Late entry .Pressure ulcer: Stage lll Current status: New-Inhouse. Original date: 2/22/16. Location: Right buttock . A nurse's progress note dated 3/15/16 at 4:16 P.M., indicated Contacted (family member) notified .that WCS seen (sic) resident today (symbol for and) that wound is all resolved . Resident B's record contained no documentation of an evaluation by the wound care specialist on that date. A Nursing Weekly Assessment form dated 3/31/16 indicated skin assessed. Skin w/d (warm and dry). No skin issues/conditions were documented. A physician's orders [REDACTED].WCS (Wound Care Services) to eval (evaluate) (symbol for and) Tx (treat). A Nursing-New Skin Alteration Assessment (non-occurrence) form dated 4/18/16 indicated New Wound .Left buttocks 1cm x 0.2 cm open, edges attached, wound bed granulation tissue, serosanguinous (watery/bloody) drainage noted, no odor, no c/o (complaint of) pain. R (right) labia 0.5cm x 0.1cm open, edges attached, wound bed granulation tissue, no drainage, no odor, no c/o pain. R buttocks 2cm x 1.5cm open, edges attached, wound bed granulation tissue, no drainage, no odor, no c/o pain. R buttocks non blanchable area close (sic) 5.5 cm x 2.8cm. A nurse's progress note dated 4/19/16 at 7:44 P.M., indicated Pressure ulcer note: Late entry .Pressure ulcer: Stage lll. Current status: New-Inhouse. Original date: 4/17/16. Location: Right lateral knee .L 1.8, W 1.0, D 0.1 A Wound: Pressure Ulcer Assessment (symbol for with) Braden form dated 4/19/16 indicated Date originally noted: 4/17/16. Location: Right knee. Type of wound: Stage lll. Current status: new-inhouse. L (length) 1.8 W (width) 1.0 D (depth) 0.1 (measurements in centimeters). A nurse's progress note dated 5/03/16 at 11:12 A.M., indicated Pressure ulcer note: Late entry .Pressure ulcer: Stage lll Current status: New-Inhouse. Original date: 5/03/16. Location: Left superior buttocks .Length 0.9, width 0.6, depth 0.2. A nurse's progress note dated 5/10/16 at 1:55 P.M., indicated Pressure ulcer note: Late entry .Pressure ulcer: Stage lll Current status: New-Inhouse. Original date: 5/03/16. Location: Left superior buttocks .Length 1.8, width 1.0, depth 0.1. A nurse's progress note dated 5/17/16 at 2:52 P.M., indicated Pressure ulcer note: Late entry .Pressure ulcer: Stage lll Current status: Non-healing. Original date: 5/03/16. Location: Left superior buttocks .Length 1.5, width 1.0, depth 0.1. A Wound: Pressure Ulcer Assessment (symbol for with) Braden form dated 5/21/16 indicated Date originally noted: 5/14/16. Location: Right hip. Type of wound: Unstageable. Current status: new-inhouse. L (length) 2.0 W (width) 1.0 D (depth) 1.2 (measurements in centimeters). A nurse's progress note dated 5/21/16 at 6:13 A.M., indicated Pressure ulcer note: Pressure ulcer: Unstageable. Current status: New-Inhouse. Original date: 5/14/16. Location: Right hip .Length 0.9, width 0.6, depth 0.2. A physician's orders [REDACTED].M., indicated Order clarification: Cleanse right hip wound with NS (normal saline), pat dry. Apply skin prep or barrier cream to wound edges and santyl to open area. Cover with gauze and foam and secure. Change daily and PRN (as needed). Wound care specialist visit documentation was detailed in reports titled Progress Note Details; On 6/01/16 at 12:45 P.M. the Director of Nursing indicated the following represented all assessments and reports done for Resident B by the wound care specialist. Information in those reports included, but was not limited to: 4/19/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary: . Wound #2 Right lateral knee is a Stage lll Pressure Ulcer and has received a status of Not Healed .Additional Orders .Off-loading .Low air loss mattress . On 6/03/16 at 1:30 P.M., the Director of Nursing indicated that Resident B was currently on a low air loss mattress as ordered on [DATE], but she was unable to confirm on what date the low air loss mattress had been put into service for Resident B. 4/26/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #2 Right lateral knee is a Pressure Ulcer and has received an outcome of Resolved . 5/03/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #5 Left, Superior Buttock is a Stage 3 Pressure Ulcer and has received a status of Not Healed . 5/10/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (knee) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #5 Left, Superior Buttock is a Stage 3 Pressure Ulcer and has received a status of Not Healed .the wound is deteriorating . 5/17/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (left and right buttock) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #5 Left, Superior Buttock is a Stage 3 Pressure Ulcer and has received a status of Not Healed .the wound is improving . 5/24/16. Chief complaint .open area on buttock. Location: Right lateral knee (4/17/16) Left and right buttocks (4/17/16). Severity: Stage lll (left and right buttock) .Context: Wound occurred as a result of incontinence (buttocks) and pressure (knee) .Integumentary .Wound #5 Left, Superior Buttock is a Stage 3 Pressure Injury Ulcer and has received a status of Not Healed .the wound is improving .Wound #6 Lateral, Superior Lower Leg is a Stage 3 Pressure Injury Ulcer and has received a status of Not Healed .Wound #7 Left, Lateral, Inferior Lower Leg is a Stage 3 Pressure Injury Ulcer and has received a status of Not Healed .Wound #8 Left, Lateral Lower Leg is a Stage 3 Pressure Injury Ulcer and has received a status of Not Healed .Wound #9 Right Hip is an unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed . The wound care specialist assigned to see Resident B was interviewed by telephone on 6/01/16 at 3:40 P.M. He indicated he could not remember the exact date he first saw Resident B but thought it might be mid April. He indicated the causes of Resident B's skin issues, including pressure sores, were multifactoral and could be considered progressive. He indicated incontinence associated [MEDICAL CONDITION] as a contributing factor to the development of pressure sores, and indicated good incontinence care could prevent a lot of this. He did not identify or indicate [MEDICAL CONDITION] as a contributing factor. Weekly Skin Assessment Sheets for Resident B were obtained from the Director of Nursing on 6/02/16 at 9:10 A.M. She indicated what she provided were all the facility had. She also indicated a Skin Assessment Sheet should be filled out each time a CNA gave a resident a shower or bath, and any skin findings reported to the nurse. Skin Assessment Sheets were provided for the dates of 2/03/16, 2/10/16, 2/13/16, 2/17/16, 3/04/16, 3/12/16, 3/16/16, 3/23/16, 3/26/16, 4/02/16, and 4/06/16. None of the Skin Assessment Sheets indicated any skin issues or concerns; for the entry of Any Skin Issues Noted? all had the box no checked. The Administrator was interviewed on 6/01/16 at 12:45 P.M. She indicated the facility had arranged for an outside wound care group to consult on Resident B's skin concerns. She indicated the facility's attending physician deferred to the wound care specialist in matters of wound care. She also indicated the wound care specialist determined the appropriate frequency of visits and assessments for assigned residents. She indicate it was the wound care specialist's practice to visit the assigned residents, then write a report with findings and recommendations and email them to the facility at a later time. The Director of Nursing or other staff member would then enter these findings in the resident's record, typically the following day. She indicated the wound care specialist was currently on vacation, and that the wound care service had not assigned another wound care specialist while he was away. She indicated the facility's interim wound care nurse was assuming his duties until he returned. The Administrator also indicated it was the facility's practice to employee a nurse designated to be the facility's Wound Care Specialist, but that position was currently vacant, and was being filled on an interim basis by a member of the nursing staff. Resident B was observed on 6/03/16 at 2:50 P.M., and an attempt was made to interview her. She declined to answer questions and was unable to give permission for an observation of her wounds and skin condition. A facility document titled Skin Management Program dated 08/14/2014 obtained from the Director of Nursing on 6/02/16 at 1:40 P.M., indicated: Purpose: It is our policy to assess for and reduce risk factors that may contribute to the development of pressure ulcers and other skin conditions . Residents who receive assistance with bathing and/or peri-care will be observed daily by nursing staff and any notation of red areas, open areas, skin tears, bruises, rashes, abrasions, excoriations or other alterations will be reported to the licensed nurse for further assessment. Prevention and treatment will include but are not limited to the following major categories: Nutritional support, medication therapy, risk reducing products, assistance with mobility and hygiene; physical or occupational therapy, and physician consultation. This Federal tag relates to Complaint IN 048. 3.1-40(a)(1) 3.1-40 (a)(2)

Based on record review and interview, the facility failed to ensure a resident who required staff assistance for activities of daily living, did not ambulate, and required use of a mechanical lift for transfers, did not suffer an injury of unknown origin requiring physician intervention and ongoing treatment. Resident B; 1 of 3 residents reviewed for safety and injury. Findings include: The record of Resident B was reviewed on 5/31/16 at 1:00 P.M. Diagnoses, obtained from the current electronic medical [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident B was severely cognitively impaired, required use of a mechanical lift for transfers with 2 staff assisting, did not ambulate, required staff assistance for activities of daily living, and was incontinent of bowel and bladder. A Nursing-Occurrence Initial Assessment form dated 4/07/16 indicated Date and time: 4/07/16 1:00 P.M. Location: Resident's room. Type of incident-other. Description: 'CNA was check on (sic) resident and reported to this nurse and other staff nurse that blood was noted in the bed sheets upon pulling the sheets back CNA noticed trauma to the L (left) great toe and L 2nd toe, L great toe nail almost completely off of toe, bruising noted on L great toe APPX (approximately) 1cm (centimeter) x 1.1cm, bruising on L 2nd toe noted under toe nail, scant amount of red drainage noted . A physician's orders [REDACTED].M., indicated 1. Bacitracin thin layer apply QD (every day) to L great 1st toe 2. Apply nonstick adherent drsg (dressing) to L great toe x 5 days wrap loosely with Kerlex x 5days. A physician's orders [REDACTED].M., indicated Clarification: Cleanse L great toe with NS (normal saline)before applying bacitracin daily and PRN (as needed) for soilage/dislodgement. A Facility-Post Occurrence IDT (Interdisciplinary Team) (symbol for and) Fall Risk Assessment form dated 4/08/16 indicated Date and time: 4/07/16 1:00 P.M. Location: Resident's room. Type of incident-other. Description: 'CNA was check on (sic) resident and reported to this nurse and other staff nurse that blood was noted in the bed sheets upon pulling the sheets back CNA noticed trauma to the L (left) great toe and L 2nd toe, L great toe nail almost completely off of toe, bruising noted on L great toe APPX (approximately) 1cm (centimeter) x 1.1cm, bruising on L 2nd toe noted under toe nail, scant amount of red drainage noted .Type of injuries: Injuries to great and second toe. Root cause: Toes hit bed frame during transfer. Recommendations: Staff are to look at environment prior to transfer to ensure enough space is there to use mechanical lift . A nurse's progress note dated 4/08/16 at 4:02 P.M., indicated X-ray results to left foot received .Conclusion: No acute findings to the toes .suspicious for acute to subacute injury of the calcaneous and/or talus. Consider advanced imaging . A physician's orders [REDACTED].M., indicated Schedule MRI (magnetic resonance imaging) for left foot in a.m . A nurse's progress note dated 4/13/16 at 10:23 A.M., indicated MRI for left foot scheduled for Friday April 15 at 1:00 P.M . A nurse's progress note dated 4/14/16 at 4:48 P.M., indicated MRI for left foot Friday April 15th dx: (diagnosis) poss (possible) fracture . A Nursing-Outpatient/ER Services Return Assessment form dated 4/15/16 at 3:16 P.M., indicated Type of Appointment: Return fro outpatient procedure .Return from MRI appointment. Hospital was unable to complete procedure d/t (due to) resident has pacemaker. On 6/02/16 at 11:55 the Administrator indicated she could provide no documentation that the physician who had ordered the MRI of Resident B's left foot had been notified of the cancellation of the procedure, or that any follow up or alternative intervention had been done. On 6/01/16 at 12:45 P.M., the Administrator indicated that prior to Resident B's admission, her family had visited the facility, and provided specific instructions about how they wished Resident B's room to be arranged. They indicated they wanted her bed placed with the left side against the wall. The Administrator indicated the standard facility arrangement was for the headboard to be against the wall, allowing access to both sides of the bed, and that she had concerns the family's arrangement might present safety issues, based on the resident's required use of a mechanical lift for transfers. She indicated that she discussed this with the family, but they were insistent about this arrangement. She indicated there was no documentation of her discussions with the family about safety concerns, and that no safety evaluation had been done. On 6/02/16 at 11:55 the Administrator indicated that the determination that the root cause of the injury to Resident B's toes being identified as Toes hit bed frame during transfer as indicated in the Facility-Post Occurrence IDT (Interdisciplinary Team) (symbol for and) Fall Risk Assessment form dated 4/08/16 was based on observation and analysis of the incident. She indicated CNA #1, who reported the injury, was interviewed, but did not provide any description or information about how the injury occurred, and there were no other witnesses to the incident. On 6/01/16 at 4:05 P.M., the Director of Nursing (D.O.N.) indicated that after lunch on 4/07/16 CNA #1 was transferring Resident B back to bed using a mechanical lift. The D.O.N. indicated CNA was doing this transfer by herself in violation of facility policy which requires the use of 2 staff for mechanical transfers. The D.O.N. provided documentation that CNA #1 had been trained in the proper use of a mechanical lift. The D.O.N. indicated CNA #1 had been terminated for this and other work performance issues. Resident B was observed on 6/03/16 at 2:50 P.M., and an attempt was made to interview her. She declined to answer questions. Her bed was noted to be arranged with the left side against the wall. A matt was on the floor next to the bed. The Administrator indicated she had safety concerns related to the use of a mechanical lift with the mat on the floor, but the family insisted on it being there. A facility document titled Mechanical Lift Transfers dated 6/12/105 received from the D.O.N. on 6/02/16 at 1:40 P.M., indicated: Purpose: To move a resident safely and with as little physical effort as possible .Two staff members (minimal) during the transfer itself . This Federal tag relates to Complaint IN 048. 3.1-45(a)(1) 3.1-45(a)(2)