Every finding on record at Waters of Georgetown, The

Based on record review and interview, the facility failed to ensure concerns voiced during the Monthly Resident Council meetings were addressed in a timely manner by appropriate staff with the residents having received what the outcome of their concerns were at the next meeting. This deficient practice affected 6 of 7 Monthly Resident Council meetings. (January, February, March, April, May, and June 2026). Findings Include: During the review of the Resident Council minutes, dated January 14, 2026, the following concerns were documented: not enough staff; resident notes to staff were being disregarded and call lights were being turned off or not answered promptly; residents had to wait long periods of time for anything that required a second employee to come and help; and night shift aide had a very bad attitude towards a number of residents in Villa 2.Although the concerns were assigned to the Administration, Nursing, and Housekeeping Departments, no responses were given which addressed the issues.During the review of the Resident Council minutes, dated February 11, 2026, the following concerns were documented: certified Nursing Assistants (CNAs) were ignoring call lights and were not helping the residents while they were cleaning the kitchen; staffing changed too much; and medication pass was not being completed timely.No responses by the specific Department Heads to the issues had been given.During the review of the Resident Council minutes, dated March 11, 2026, the following concerns were documented: medications were being brought into the room by the nurse, left at bedside, with the nurse then leaving the room without making sure the residents took their medications. Medications were being allowed to run out without a refill in a timely manner; staff were loud (chatting, laughing, and gossiping) at night which made it hard to sleep; patios needed attention; and Villa 3's clothes were being mixed up and were not coming back clean.No responses by the specific Department Heads to the issues had been given except for The Housekeeping Department responded that the residents' clothing were to be washed separately.During the review of the Resident Council minutes, dated April 2026 (no specific date on form), the following concerns were documented: medications and insulin were being given late; nursing staff complained when they felt the residents were calling them too much; there was a shortage of nursing staff; pagers and pendants were turned off and not answered; and laundry was lost/missing/or torn up.The Director of Nursing (DON) addressed these issues (no date listed) to indicate she or her Designee would complete audits 5 times a week to monitor the situation and the Licensed nurses and Qualified Medication Aides (QMAs) were being in-serviced. No audits could be provided.During the review of the Resident Council minutes, dated May 13, 2026, the following concerns were documented: medications were late or residents were getting them at lunch time; medications were being left at bedside with the nurse then leaving the room; CNAs were suggesting the residents go to bed even though they wanted to stay up later; and laundry was being mixed up or not returned in a timely manner.On 5/28/26, the DON indicated education was being done with the nursing staff. No documentation of the education was provided. During the review of the Resident Council minutes, dated June 10, 2026, the following concerns were documented: Villa 2 questioned why they never had 2 CNAs and were usually short staffed; insulin was being given late; medications were being left on bedside tables in resident rooms and the nurses then left the room; and some of the CNAs had very bad attitudes.The DON responded to the issues of staffing and late medications (no date given) in which she explained staffing rationale and how the facility had to move people around sometimes.During the review of the Resident Council minutes, dated July 8, 2026, the following concerns were documented: CNAs were being changed too often from villa to villa; CNAs and nurses were being rude when residents put their pendants on for assistance; medications were being given late; and clothes were not being returned after they were washed. They were getting lost or were getting other people's laundry instead of their own.The DON spoke with staff related to attitudes and laundry. The situation, complaints and incidents were going to be monitored. On 7/22/26, the DON had a Town Hall meeting with the nursing staff. The issues discussed were: - no medications were to be left at bedside as staff were required to watch the resident to make sure they took their medication.- No resident should have late medications and compliance was going to be checked daily.- Notification any time there was an issue with medication, there must be a notification to the Nurse Practitioner (NP) and responsible party (RP). If the resident was out of a medication, nursing could not just put it was ordered. The NP and the RP must be notified and an order gotten to place the medication on hold until it arrived.- Laundry needed to be taken back timely after it was washed.- There was a lot of complaints about attitudes of the CNAs, and how residents were spoken to. This was to be fixed immediately and was not acceptable. Going forward, corrective action would be taken as complaints about attitudes with the residents were received.During an observation of the Resident Council Meeting on August 3, 2026 at 1:15 p.m., there were 11 residents in attendance. The Activity Director indicated all 11 residents were considered alert and oriented. The following concerns were identified by the residents during the meeting: issues from the Resident Council meetings were brought to Administration's attention, but nothing was being done about them for a year now; they rarely received a response back from any Department regarding action to be taken or why an issue could not be resolved; continuously laundry and their clothes were not being returned in a timely manner nor given to the right person; some nursing staff were still being snotty and not respectful towards the residents; it depended on who was working as to whether the pendants would be answered in a timely manner or if the pendants or the pagers were turned off; often times there was only CNA in certain villas; and if a resident required two staff members to operate the lift then those residents did not get up. During an interview with the Activity Director, on 8/4/26 at 1:00 p.m., she indicated she wrote out the concerns onto an Action Plan form and gave them to the specific Department Manager. The Executive Director (ED) was made aware of any concerns brought up at the meeting, but she did not have the ED sign the actual meeting notes. Only the Resident Council President signed the minute notes.During an interview with the DON, on 8/5/26 at 8:15 a.m., she indicated she was not aware of any of the issues the residents were experiencing with laundry, late medications, medications left at bedside or staff attitudes until the Town Hall meeting on 7/22/26.Review of the facility's current policy titled Resident Council Policy, dated effective 3/1/16, included, but was not limited to: Overview and Objectives: The Resident Council is an independent, organized group of residents who meet on a regular basis to create change, address quality and dignity of care provided in the facility .and discuss other matters brought before the council. The role of the Resident Council is to improve the quality of life of the residents who reside in the facility and to take part in actions to maintain a positive living environment .Regulations: . 6. When a resident .group exists, the facility must listen to the views and act upon the grievances and recommendations of the residents .concerning proposed policy and operational decisions affecting the resident care and life in the facility .Staff Facilitator: Duties of the Staff Facilitator may include: A. Provides assistance and responds to written group concerns .D. Facilitates communication between staff and council members .Group Concerns and Follow-Up: .The council group who voice a concern usually expect a timely response about the resolution of their concern. This must happen. The Administrator monitors this process This citation relates to Intake 3046441.410 IAC (Indiana Administrative Code) 16.2 -3.1-3(l)

Based on interview and record review, the facility failed to ensure the facility was sufficiently staffed to provide adequate care related to medication administration and assistance with daily living for the residents. This deficient practice had the potential to affect 59 of 59 residents residing in the facility. Findings include:1.On 3/26/26 at 12:33 p.m., the Administrator provided a copy of the March 2026 as worked staffing sheets and on 3/26/26; at 3:01 p.m., the Regional Nurse Consultant provided the March 2026 correlating timecards which indicated the following after review: On 3/14/26, Villa 7 had one nurse and no aide for dayshiftOn 3/16/26, Villa 3 and Villa 5 shared had one nurse and one aide on night shiftOn 3/16/26, Villa 1 and Villa 7 shared one nurse and one aide, on night shift, after 10:08 p.m.On 3/18/26, Villa 1 and Villa 7 shared one nurse and one aide, on night shift, after 10:00 p.m.On 3/19/26, Villa 1 and Villa 7 had a nurse scheduled on night shift, that did not clock in until 3/20/26 at 4:53 a.m.On 3/21/26, Villa 2 and Villa 4 shared one nurse and one aide on night shiftOn 3/22/26, Villa 3 and Villa 5 shared one nurse and one aide on night shiftOn 3/23/26, Villa 2 and Villa 4 shared one nurse and one aide on night shift:On 3/23/26, Villa 3 and Villa 5 shared one nurse and one aide on night shiftOn 3/27/26, Villa 2 and Villa 4 shared one nurse and one aide until 9:30 p.m. The facility staffing shift times were from 7:00 a.m. to 7:00 p.m. for day shift and from 7:00 p.m. to 7:00 a.m. on night shift. During the survey period, from March 26 through March 30, Staff Member 7 indicated staffing had been awful in March 2026. They had been told there would be either one nurse and one aide per Villa or two aides per Villa with one nurse for two [NAME]. On 3/14/26, on day shift, Staff Member 8 had to work Villa 7 by herself as she did not have an aide. Staff Member 8 had to prepare the meals, wash dishes, administer medications, complete treatments and provide care to the residents, 9 in total resident's at the time. Staff Member 7 came in around lunch time and stayed for about 3 to 4 hours to help Staff Member 8 get caught up with the residents care. During the survey period, from March 26 through March 30, Staff Member 6 indicated the staff had been told there would be two aides in each Villa and that had not been happening. Recently, on several occasions, there had been one aide and a nurse who shared two [NAME] and the nurse passed medications in both [NAME]. There must be two staff members when using any transfer equipment, so the residents had to wait on the nurse or second aid for transfers. Staff Member 6 indicated medications were administered late due to having to stop the medication pass to assist the aides with the full body mechanical lifts or two staff member assisted resident transfers. During an interview, on 3/26/26 at 1:56 p.m., Resident M indicated he had not received his medication timely. He received his insulin, but all the other medications were late. During an interview, on 3/26/26 at 2:07 p.m., Resident O indicated it was hit and miss with getting your medications timely. The facility usually had one aide and one nurse, and the nurse shared another Villa. During an interview, on 3/27/26 at 11:46 a.m., Resident B indicated her medications were consistently late because they did not have enough staff. When there was one nurse and one aide, and the nurse had to pass medications in two different [NAME], the residents' medications were always late. During an interview, on 3/27/26 at 11:58 a.m., Resident N indicated she did not get her medications timely. She had to wait over an hour for her call light to be answered. This was supposed to be her home. They only had one aide and then one nurse for two [NAME] and the staff would constantly bounced back and forth. Residents were always told by the staff that they don't have enough time, and the residents always had to wait at night because there was not enough staff. During the survey period, from March 26 through March 30, Staff Member 5 indicated staffing was not good. Staff Member 5 not could complete any of the cleaning/laundry tasks daily. Staff Member 5 tried to complete those tasks on Sunday because there were no showers on Sundays. When Staff Member 5 worked, there was only herself and the nurse who had another Villa. Villa 7 had three residents that required full body mechanical lift for transfers and many times, the residents would have to wait to either get up and to be laid down since she had no one to help her when the nurse was in the other Villa. During the survey period, from March 26 through March 30, Staff Member 8 indicated on 3/14/26, she worked Villa 7 without an aide and it was very rough. Staff Member 8 had to get the residents changed and ready for breakfast, do the meal preparation for breakfast, lunch and dinner, wash the dishes, pass the medications and complete treatments as well as the daily charting. Staff Member 7 came in and helped her through lunch. Here lately, there had been multiple times where there was an aide in one Villa and the nurse in the other Villa and they would have to flip flop (walk from one free standing facility building outside to another free standing facility building while no staff were inside either facility building) so the nurse could pass medications. During an interview, on 3/30/26 at 10:44 a.m., Resident K was observed resting in her bed with a full body mechanical lift pad under her. Resident K indicated she has had to wait long periods to get up and to get put back in bed. During the survey period, from March 26 through March 30, Staff Member 3 indicated at 2:00 p.m. on 3/29/26, she was asked to pass the morning medications due at 8:00 a.m. to the residents in Villa 5. 1.a.The clinical record for Resident D was reviewed on 3/27/26 at 1:40 p.m. The resident's diagnoses included, but were not limited to, unilateral osteoarthritis (joint pain, stiffness, and reduced mobility) and right knee pain. The quarterly minimum data set (MDS) assessment, dated 12/23/25, indicated Resident D had intact cognition.The care plan, dated 12/23/25, indicated the resident had a self-care deficit and required a mechanical lift for safe transfers. During an interview, on 3/27/26 at 11:05 a.m., Resident D indicated she was not receiving her medications timely, including her pain medication and night shift was the worst. She used a mechanical lift for transfers, which required two staff members. On the night of 3/23/26, the staff did not get her to bed until midnight because they had one aide in Villa 2, one aide in Villa 4 and one nurse for both Villa 2 and Villa 4. It had happened several times and she preferred to be in bed between 10:00 p.m. and 10:30 p.m., at the latest. On 3/30/26 at 12:06 p.m., Resident D indicated on 3/27/26, on night shift, there was an emergency in Villa 2. She turned her call light on at 8:00 p.m. because she needed to use the restroom. She was told by the aide at that time that she would have to wait for the nurse to help the aide take her to the bathroom. During the wait time, at around 9:00 p.m., Resident D propelled herself, in her wheelchair, to her room door and did not see any staff. Resident L was sitting at the dining room table and told Resident D she had not been able to find anyone so she could get her pain medication and that there was not a single staff member in the Villa. Resident D sat at the table with Resident L for about 5 to 10 minutes and did not see a sole. She wet all over herself because she had to wait over 90 minutes for the nurse to come back and help. At around 9:30 p.m., the aide and nurse assisted her to the bathroom and then put her back in her wheelchair. She did not get her medications until 11:15 p.m. and was not assisted to bed until 11:30 p.m. Resident D's quarterly MDS assessment, dated 12/23/25, indicated the resident had intact cognition. 1.b. The clinical record for Resident E was reviewed on 3/30/26 at 2:45 p.m. The resident's diagnoses included, but were not limited to, diabetes (chronic high blood sugar levels, resulting from the body's inability to produce enough insulin or use it effectively) and morbid obesity. The quarterly MDS assessment, dated 1/28/26, indicated Resident E had intact cognition. During an interview, on 3/27/26 at 11:18 a.m., Resident E indicated he did not always get his medication on time. There were just not enough staff. He had the staff put him to bed around 6:30 p.m., at shift change, because there were two aides at that time. He really doesn't like going to bed that early but did not want to take a chance on having to be up after 10:00 p.m. or 11:00 p.m. to get to bed. The facility cannot seem to keep help and the good ones are leaving because they work them to death. There had never been two aides working in his Villa on day shift, only one and the nurse had two [NAME].During an interview, on 3/30/26 at 11:44 a.m., Resident E requested to speak to surveyor. Upon entrance to the resident's room, Resident E was visibly upset. He indicated on 3/27/26, on night shift, there was no nurse or aide in the Villa with the residents. He turned his call light on at 8:40 p.m. No one answered his call light until 9:20 p.m. He asked the aide where she had been, and she told him she was in another Villa. He was not sure how long the Villa was without staff, but he never heard a sole out there from 8:30 p.m. until 9:20 p.m. The care plan, dated 1/27/26, indicated the resident required a full body mechanical lift for safe transfers and would be transferred with two physical staffs' assistance when using a Mechanical lift or when using a Sit-to-Stand lift. The care plan, dated 1/27/26, indicated the resident had diabetes and would be provided with medications as ordered. The physician's order, dated 1/21/26, indicated the resident was to receive Insulin Glargine (long-acting insulin) 20 units subcutaneously between 8:00 p.m. and 11:00 p.m. Review of the March 2026 medication administration record (MAR) indicated the resident received the insulin late on the following dates and times:-3/04/26 administered on 3/05/26 at 12:03 a.m.-3/07/26 administered on 3/08/26 at 12:26 a.m.-3/08/26 administered on 3/09/26 at 12:42 a.m.-3/10/26 administered on 3/11/26 at 12:34 a.m.-3/15/26 administered on 3/16/26 at 12:29 a.m.-3/17/26 administered on 3/18/26 at 12:36 a.m.-3/22/26 administered on 3/23/26 at 4:46 a.m.-3/23/26 administered on 3/24/26 at 12:13 a.m.-3/25/26 administered on 3/26/26 at 2:38 a.m. 1.c. The clinical record for Resident H was reviewed on 3/30/26 at 3:58 p.m. The resident's diagnoses included, but were not limited to, diabetes, acquired absence of the left foot and a right below knee amputation. The Medicare 5-day MDS assessment, dated 2/18/26, indicated Resident H had intact cognition. During an interview, on 3/30/26 at 10:55 a.m., Resident H indicated she has had to wait to get out of bed and be put back into the bed because the Villa only had one aide and the full body mechanical lift required two staff for transfers. She has had to wait for her medication because the nurse was busy in another Villa since she had two [NAME] to pass medications in. The care plan, dated 2/12/26, indicated the resident required a full body mechanical lift for safe transfers and would be transferred with two staffs' assistance when using the full body mechanical lift or when using a sit-to-stand lift. The care plan, dated 2/12/26, indicated the resident had diabetes and medications would be provided as ordered. The physician's order, dated 2/12/26, indicated the resident was to receive Insulin Lispro (fast-acting insulin), 12 units subcutaneously before meals for diabetes at 7:00 a.m., 11:00 a.m. and 4:00 p.m. Review of the March 2026 MAR indicated the insulin was administered late on the following dates and times:-3/01/26, 11:00 a.m. dose was administered at 12:43 p.m.-3/02/26, 11:00 a.m. dose administered at 12:09 and the 4:00 p.m. dose administered at 5:13 p.m.-3/03/26, 7:00 a.m. dose administered at 8:43 a.m.-3/04/26, 7:00 a.m. dose administered at 8:55 a.m.-3/04/26, 11:00 a.m. dose administered at 2:23 p.m.-3/05/26, 7:00 a.m. dose administered at 8:22 a.m.-3/07/26, 7:00 a.m. dose administered at 9:05 a.m. and the 11:00 a.m. dose administered at 12:46 p.m.-3/08/26, 7:00 a.m. dose administered at 8:49 a.m.-3/10/26, 7:00 a.m. dose administered at 9:33 a.m., 11:00 a.m. dose administered at 12:44 p.m., and the 4:00 p.m. dose administered at 5:33 p.m.-3/15/26, 11:00 a.m. dose administered at 12:53 p.m.-3/18/26, 7:00 a.m. dose administered at 8:41 a.m.-3/22/26, 4:00 p.m. dose administered at 6:51 p.m.-3/23/26, 11:00 a.m. dose administered at 12:47 p.m. and 4:00 p.m. dose administered at 5:43 p.m.-3/27/26, 11:00 a.m. dose administered at 12:24 p.m.-3/30/26, 11:00 a.m. dose administered at 1:03 p.m. 1.d. The clinical record for Resident L was reviewed on 3/30/26 at 4:24 p.m. The resident's diagnosis included, but was not limited to, diabetes. The annual MDS assessment, dated 1/5/26, indicated Resident L had intact cognition. During an interview, on 3/30/26 at 11:55 a.m., Resident L indicated on 3/27/26, on the night shift, between 8:15 p.m. and 9:15 p.m., there was no staff members in the Villa. She sat out at the dining room table and waited because she wanted to get her pain pill. There were other residents looking for help too prior to someone coming back to the Villa. Every time we needed something, there was some sort of crisis in Villa 4. She was here at the facility for the management of her pain and management for her diabetes. The facility did not do either because she cannot get her pain medication or diabetic medication on time. The care plan, dated 1/7/26, indicated the resident had diabetes and to provide medications as ordered. The physician's order, dated 7/25/25, indicated the resident was to receive Lantus (long-acting insulin), 10 units subcutaneously in the morning at 9:00 a.m. for hyperglycemia. The March 2026 MAR indicated the resident received the insulin late on the following dates and times:-3/02/26 at 11:15 a.m.-3/03/26 at 11:11 a.m.-3/06/26 at 11:02 a.m.-3/09/26 at 11:32 a.m.-3/10/26 at 11:02 a.m.-3/12/26 at 10:58 a.m.-3/13/26 at 11:19 a.m.-3/16/26 at 11:16 a.m.-3/17/26 at 10:20 a.m.-3/19/26 at 10:57 a.m.-3/21/26 at 10:18 a.m.-3/23/26 at 11:13 a.m.-3/24/26 at 11:41 a.m. The physician's order, dated 8/7/25, indicated the resident was to receive Humalog (short-acting insulin) per sliding scale before meals and at bedtime at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 10:00 p.m. The March 2026 MAR indicated the resident received the insulin late on the following dates and times:-3/01/26, 4:30 p.m. dose was administered at 6:03 p.m.-3/02/26, 11:30 a.m. dose was administered at 12:40 p.m.-3/03/26, 11:30 a.m. dose was administered at 12:57 p.m.-3/04/26, 10:00 p.m. dose was administered at 11:52 p.m.-3/07/26, 10:00 p.m. dose was administered on 3/8/26 at 12:25 a.m.-3/09/26, 7:30 a.m. dose was administered at 10:50 a.m. and 11:30 a.m. dose was administered at 12:53 p.m.-3/10/26, 11:30 a.m. dose was administered at 1:02 p.m.-3/12/26, 7:30 a.m. dose was administered at 10:56 a.m.-3/15/25, 10:00 p.m. dose was administered on 3/16/26 at 12:28 a.m.-3/16/26, 11:30 a.m. dose was administered at 12:46 p.m.-3/19/26, 4:30 p.m. dose was administered at 5:45 p.m.-3/21/26, 4:30 p.m. dose was administered at 6:23 p.m.-3/24/26, 11:30 a.m. dose was administered at 1:07 p.m.-3/25/26, 4:30 p.m. dose was administered at 6:40 p.m. On 3/30/26 at 2:21 p.m., the Regional Director of Operations provided a current copy of the document titled Standard Supervision and Monitoring dated 11/25/11. It included, but was not limited to, Purpose.This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical.needs.Staff assignments are based on the resident needs as far as their acuity.and their person-centered care planning. Therefore the requirement of meeting those needs to include physical.will be accomplished by provision of as much hands on care as necessary. This Citation relates to Intakes 7243599, 2960736 and 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-17(a)410 IAC 16.2-3.1-17(b)

Based on interview and record review, the facility failed to ensure the residents received their medication timely within an hour before or after the prescribe time for 3 of 3 resident reviewed for pharmacy services. (Resident E, Resident H, and Resident L) Findings include: 1. The clinical record for Resident E was reviewed on 3/30/26 at 2:45 p.m. The resident's diagnosis included, but was not limited to, diabetes (chronic high blood sugar levels, resulting from the body's inability to produce enough insulin or use it effectively). The quarterly minimum data set (MDS) assessment, dated 1/28/26, indicated Resident E had intact cognition. The care plan, dated 1/27/26, indicated the resident had diabetes and would be provided with medications as ordered. The physician's order, dated 1/21/26, indicated the resident was to receive Insulin Glargine (long-acting insulin) 20 units subcutaneously between 8:00 p.m. and 11:00 p.m. Review of the March 2026 medication administration record (MAR) indicated the resident received the insulin over one hour past the scheduled medication administration time of 8:00 to 11:00 p.m. on the following dates and times:-On 3/04/26, the resident's insulin was administered on 3/05/26 at 12:03 a.m.-On 3/07/26, the resident's insulin was administered on 3/08/26 at 12:26 a.m.-On 3/08/26, the resident's insulin was administered on 3/09/26 at 12:42 a.m.-On 3/10/26, the resident's insulin was administered on 3/11/26 at 12:34 a.m.-On 3/15/26, the resident's insulin was administered on 3/16/26 at 12:29 a.m.-On 3/17/26, the resident's insulin was administered on 3/18/26 at 12:36 a.m.-On 3/22/26, the resident's insulin was administered on 3/23/26 at 4:46 a.m.-On 3/23/26, the resident's insulin was administered on 3/24/26 at 12:13 a.m.-On 3/25/26, the resident's insulin was administered on 3/26/26 at 2:38 a.m. During an interview, on 3/27/26 at 11:18 a.m., Resident E indicated he did not always get his medication on time. 2. The clinical record for Resident H was reviewed on 3/30/26 at 3:58 p.m. The resident's diagnoses included, but were not limited to, diabetes, acquired absence of the left foot and a right below knee amputation. The Medicare 5-day MDS assessment, dated 2/18/26, indicated Resident H had intact cognition. During an interview, on 3/30/26 at 10:55 a.m., Resident H indicated she had to wait for her medication because the nurse was busy in another Villa since she had two [NAME] to pass medications in. The care plan, dated 2/12/26, indicated the resident had diabetes and medications would be provided as ordered. The physician's order, dated 2/12/26, indicated the resident was to receive Insulin Lispro (fast-acting insulin), 12 units subcutaneously before meals for diabetes at 7:00 a.m., 11:00 a.m. and 4:00 p.m. Review of the March 2026 MAR indicated the insulin was administered over one hour past the scheduled medication dose time on the following dates and times:-On 3/01/26, the resident's 11:00 a.m. insulin dose was administered at 12:43 p.m.-On 3/02/26, the resident's 11:00 a.m. insulin dose was administered at 12:09 and the 4:00 p.m. insulin dose was administered at 5:13 p.m.-On 3/03/26, the resident's 7:00 a.m. insulin dose was administered at 8:43 a.m.-On 3/04/26, the resident's 7:00 a.m. insulin dose was administered at 8:55 a.m.-On 3/04/26, the resident's 11:00 a.m. insulin dose was administered at 2:23 p.m.-On 3/05/26, the resident's 7:00 a.m. insulin dose was administered at 8:22 a.m.-On 3/07/26, the resident's 7:00 a.m. insulin dose was administered at 9:05 a.m. and the 11:00 a.m. insulin dose was administered at 12:46 p.m.-On 3/08/26, the resident's 7:00 a.m. insulin dose was administered at 8:49 a.m.-On 3/10/26, the resident's 7:00 a.m. insulin dose was administered at 9:33 a.m., 11:00 a.m. insulin dose was administered at 12:44 p.m., and the 4:00 p.m. insulin dose was administered at 5:33 p.m.-On 3/15/26, the resident's 11:00 a.m. insulin dose was administered at 12:53 p.m.-On 3/18/26, the resident's 7:00 a.m. insulin dose was administered at 8:41 a.m.-On 3/22/26, the resident's 4:00 p.m. insulin dose was administered at 6:51 p.m.-On 3/23/26, the resident's 11:00 a.m. insulin dose was administered at 12:47 p.m. and 4:00 p.m. insulin dose was administered at 5:43 p.m.-On 3/27/26, the resident's 11:00 a.m. insulin dose was administered at 12:24 p.m.-On 3/30/26, the resident's 11:00 a.m. insulin dose was administered at 1:03 p.m. 3. The clinical record for Resident L was reviewed on 3/30/26 at 4:24 p.m. The resident's diagnosis included, but was not limited to, diabetes. The annual MDS assessment, dated 1/5/26, indicated Resident L had intact cognition. The care plan, dated 1/7/26, indicated the resident had diabetes and to provide medications as ordered. The physician's order, dated 7/25/25, indicated the resident was to receive Lantus (long-acting insulin), 10 units subcutaneously in the morning at 9:00 a.m. for hyperglycemia. The March 2026 MAR indicated the resident received the insulin over one hour past the scheduled medication dose on the following dates and times:-On 3/02/26, the resident's 9:00 a.m. insulin dose was administered at 11:15 a.m.-On 3/03/26, the resident's 9:00 a.m. insulin dose was administered at 11:11 a.m.-On 3/06/26, the resident's 9:00 a.m. insulin dose was administered at 11:02 a.m.-On 3/09/26, the resident's 9:00 a.m. insulin dose was administered at 11:32 a.m.-On 3/10/26, the resident's 9:00 a.m. insulin dose was administered at 11:02 a.m.-On 3/12/26, the resident's 9:00 a.m. insulin dose was administered at 10:58 a.m.-On 3/13/26, the resident's 9:00 a.m. insulin dose was administered at 11:19 a.m.-On 3/16/26, the resident's 9:00 a.m. insulin dose was administered at 11:16 a.m.-On 3/17/26, the resident's 9:00 a.m. insulin dose was administered at 10:20 a.m.-On 3/19/26, the resident's 9:00 a.m. insulin dose was administered at 10:57 a.m.-On 3/21/26, the resident's 9:00 a.m. insulin dose was administered at 10:18 a.m.-On 3/23/26, the resident's 9:00 a.m. insulin dose was administered at 11:13 a.m.-On 3/24/26, the resident's 9:00 a.m. insulin dose was administered at 11:41 a.m. The physician's order, dated 8/7/25, indicated the resident was to receive Humalog (short-acting insulin) per sliding scale before meals and at bedtime at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 10:00 p.m. The March 2026 MAR indicated the resident received the insulin over one hour past the scheduled medication time on the following dates and times:-On 3/01/26, the resident's 4:30 p.m. insulin dose was administered at 6:03 p.m.-On 3/02/26, the resident's 11:30 a.m. insulin dose was administered at 12:40 p.m.-On 3/03/26, the resident's 11:30 a.m. insulin dose was administered at 12:57 p.m.-On 3/04/26, the resident's 10:00 p.m. insulin dose was administered at 11:52 p.m.-On 3/07/26, the resident's 10:00 p.m. insulin dose was administered on 3/8/26 at 12:25 a.m.-On 3/09/26, the resident's 7:30 a.m. insulin dose was administered at 10:50 a.m. and the 11:30 a.m. dose was administered at 12:53 p.m.-On 3/10/26, the resident's 11:30 a.m. insulin dose was administered at 1:02 p.m.-On 3/12/26, the resident's 7:30 a.m. insulin dose was administered at 10:56 a.m.-On 3/15/25, the resident's 10:00 p.m. insulin dose was administered on 3/16/26 at 12:28 a.m.-On 3/16/26, the resident's 11:30 a.m. insulin dose was administered at 12:46 p.m.-On 3/19/26, the resident's 4:30 p.m. insulin dose was administered at 5:45 p.m.-On 3/21/26, the resident's 4:30 p.m. insulin dose was administered at 6:23 p.m.-On 3/24/26, the resident's 11:30 a.m. insulin dose was administered at 1:07 p.m.-On 3/25/26, the resident's 4:30 p.m. insulin dose was administered at 6:40 p.m. During an interview, on 3/30/26 at 11:55 a.m., Resident L indicated she was here at the facility for the management of her pain and management for her diabetes. The facility did not do either because she cannot get her pain medication or diabetic medication on time. During the survey period, from March 26 through March 30, Staff Member 6 indicated medications were administered late due to having to stop the medication pass to assist the aides with the full body mechanical lifts, two staff member assisted resident transfers, or cover two Villa's (separate free standing buildings with going outside to get from one Villa to another while trading places with the aid in the other Villa). On 3/30/26 at 4:22 p.m., the Regional Director of Operations provided a current copy of the document titled Medication Administration Policy Guideline dated 1/25/19. It included, but was not limited to, Policy.Medications are administered as prescribed, in accordance with good nursing principles and practices.Procedure.The resident's MAR is initialed by the person administering the medication. This Citation relates to Intakes 7243599, 2960736 and 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on interview and record review, the facility failed to ensure the death of a resident (Resident C) was verified by two staff nurses for 1 of 1 resident; and failed to ensure physicians' orders were transcribed, in a timely manner for 1 of 3 residents reviewed for quality of care. Findings include:1.The clinical record for Resident C was reviewed on [DATE] at 12:27 p.m. The resident's diagnoses included, but were not limited to, nontraumatic chronic subdural hemorrhage (slow accumulation of blood and its breakdown products between the dura mater and arachnoid membrane, often triggered by trivial events, spontaneous atrophy, or anticoagulants), heart failure and dementia (mental decline). The progress note, dated [DATE] at 1:39 a.m., indicated the aide (CNA) informed the nurse that the resident had expired. Upon entering the resident's room, the resident was unresponsive, pale, cold and not breathing. The resident had a do not resuscitate order (DNR). The resident's time of death was 10:22 p.m. The physician and family were informed. The clinical record lacked documentation of a second nurse's assessment of the deceased resident. During the survey period, Staff Member 7 indicated two nurses had to verify the death of a resident with a DNR status. 2. The clinical record for Resident D was reviewed on [DATE] at 1:40 p.m. The resident's diagnoses included, but were not limited to, macular degeneration (common eye disease and leading cause of vision loss in people aged 50 and older) and glaucoma (a group of eye diseases that damage the optic nerve often due to high fluid pressure inside the eye). The optometrist note, dated [DATE] at 11:35 a.m., indicated Resident D was seen on [DATE] with the following medications prescribed on the visit:- Artificial Tears 0.1-0.3% 1 drop in both eyes three times a day for dry eyes-Preservision, AREDS 2 250 mg (milligrams) 90mg-40mg 1 capsule twice daily for macular degeneration-Discontinue Latanoprost eye drops-Start Brimonidine, 0.1% - dorzolamide 2% eye drops, 1 drop to both eyes twice daily for glaucoma. The clinical record lacked documentation of the physician's orders prescribed on [DATE] and not documented until [DATE]. During the survey period, Staff Member 6 indicated orders should be transcribed on the day the physician wrote/ordered them. On [DATE] at 4:05 p.m., the Regional Director of Operations provided a current copy of the document titled Guidelines for Physician Orders-(Following Physician Orders) dated [DATE]. It included, but was not limited to, Policy .It is the policy of the facility to follow the orders of the physician .Procedure .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received This citation relates to Intakes 2743599, 2960736 and 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on observation, interview and record review, the facility failed to ensure resident's (Resident F and Resident G) had properly functioning motion sensors in place and failed to ensure a resident (Resident F) had a physician's order in place for a motion sensor alarm for 2 of 3 residents reviewed for accidents. Findings include:1.The clinical record for Resident F was reviewed on 3/30/26 at 3:06 p.m. The resident's diagnoses included, but were not limited to, dementia (mental decline) with moderate anxiety and Parkinsonism (neurological disorders that cause movement problems similar to Parkinson's disease).During an observation on 3/30/26 at 10:35 a.m., Resident F was observed sitting up in his wheelchair in his room. There was small alarm box sitting on the handrail just outside and to the left of the resident's door entrance. In the resident's room, to the right of the bathroom door, on the floor was a smaller box. A yellow light was observed to come on with motion present, however, the alarm outside of the door did not come on ( in sync), with the motion light. During an interview, on 3/30/26 at 10:37 a.m., the Regional Director of Operations (RDO) indicated the chime on/chime off switch was set in the middle and not all the way up to the on position. The clinical record lacked documentation of a physician's order for the alarm and family notification related to the placement of the alarm. During an interview, during the survey period, Staff Member 9 indicated the motion sensor chime should be on when residents', considered at risk for falls, were in their rooms alone to alert staff of attempted self-transfers. During an interview, during the survey period, Staff Member 6 indicated residents' motion sensors could not be put in place without a physician's order. During an interview, on 3/30/26 at 5:17 p.m., the RDO indicated the resident had been attempting to transfer without assistance and a staff member had placed the motion sensor for the resident's safety. They were currently getting an order for the resident's motion sensor. On 3/30/26 at 2:40 p.m., the RDO provided a current, undated copy of the document titled SAFETY ALARM DEVICES. It included, but was not limited to, Purpose.Safety alarms/devices are utilized when deemed appropriate.Policy.The use of a personal alarm will be on the order of a physician.The resident's family/representative must be informed of and agree to the placement of an alarm.The personal alarm should sound at he Nurse's station if at all possible. 2. The clinical record for Resident G was reviewed on 3/30/26 at 3:43 p.m. The resident's diagnoses included, but were not limited to, dementia, chronic pain, anxiety and lack of coordination. The physician's order, dated 9/5/25, indicated the resident was to have a motion sensor alarm for safety every shift. The physician's order, dated 12/10/25 indicated staff were to check for proper functioning of the resident's motion sensor alarm every shift. The care plan, dated 11/24/25, indicated the resident was at risk for fall and was to have a motion sensor alarm as ordered for safety. During an observation, on 3/30/26 at 10:32 a.m., there was an alarm box sitting on the handrail just outside and to the left of the resident's door entrance. Resident G was observed resting in her bed with her eyes open and she was confused. observed on the floor, to the right of the resident's dresser was a small box. A yellow light was observed to come on with motion in front of the box, however the alarm box outside of the resident's room did not chime. During an interview, on 3/30/26 at 10:37 a.m., the Regional Director of Operations (RDO) indicated the chime on/chime off switch was not on. This citation relates to Intake 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure medication administration records coincided with the administration of narcotic pain medication for 3 of 4 residents reviewed for medical records. (Resident E, Resident H and Resident L) Findings include:1. The clinical record for Resident E was reviewed on 3/30/26 at 2:45 p.m. The resident's diagnoses included, but were not limited to, osteoarthritis (joint pain, stiffness, and reduced mobility), lymphedema (chronic, localized swelling caused by a buildup of lymph fluid in tissues), diabetes (chronic high blood sugar levels) and depression. The physician's order, dated 1/21/26, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 6 hours as needed (PRN) for pain. The March 2026 controlled drug record indicated the resident received the narcotic pain medication on the following dates and times: 3/01/26 at 9:10 p.m., 3/02/26 at 9:00 p.m., 3/05/26 at 9:30 p.m., 3/06/26 at 9:00 p.m., 3/07/26 at 10:13 p.m., 3/08/26 at 8:00 p.m., 3/12/26 at 9:45 p.m., 3/13/26 at 9:00 p.m., 3/14/26 at 8:00 p.m., 3/15/26 at 9:10 p.m., 3/16/26 at 10:30 p.m., 3/18/26 at 9:26 p.m., 3/19/26 at 10:05 p.m., 3/20/26 at 10:26 p.m., 3/21/26 at 8:07 p.m., 3/22/26 at 8:00 p.m., 3/23/26 at 8:00 p.m., 3/25/26 at 11:00 p.m., and 3/26/26 at 10:52 p.m. The March 2026 medication administration record (MAR) lacked documentation of the administration of the above narcotic pain medication. During the survey period, from March 26 through March 30, Staff Member 6 indicated when an as needed pain medication was administered, the medication administration record should be signed off by the nurse. On 3/30/26 at 4:22 p.m., the Regional Director of Operations provided a current copy of the document titled Medication Administration Policy Guideline dated 1/25/19. It included, but was not limited to, Policy.Medications are administered as prescribed, in accordance with good nursing principles and practices.Procedure.The resident's MAR is initialed by the person administering the medication. 2. The clinical record for Resident H was reviewed on 3/30/26 at 3:58 p.m. The resident's diagnoses included, but were not limited to, diabetes and depression. The physician's order, dated 3/21/26, indicated the resident was to receive Tramadol (narcotic pain medication) 50 mg every 6 hours as needed for pain. The March 2025 controlled drug record indicated the resident received the medication on the following dates and times: 3/23/26 at 9:00 a.m., 3/24/26 at 3:40 p.m. and 9:15 p.m., 3/26/26 at 8:00 p.m., 3/28/26 at 8:00 a.m., and 3/29/26 at 8:00 a.m. The March 2026 MAR lacked documentation of the administration of the above narcotic pain medications. 3. The clinical record for Resident L was reviewed on 3/30/26 at 4:24 p.m. The resident's diagnoses included, but were not limited to, diabetes, depression and fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues). The physician's order, dated 5/21/25, indicated the resident was to receive Hydrocodone-5-325 mg every 4 hours as needed for pain. The March 2026 controlled drug record indicated the resident received the medication on the following dates and times: 3/01/26 at 12:15 p.m., 4:30 p.m. and 8:42 p.m.; 3/02/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/03/26 at 10:00 a.m. and 2:00 p.m.; 3/05/26 at 11:40 a.m. and 9:00 p.m.; 3/06/26 at 12:00 a.m. and 9:00 p.m.; 3/07/26 at 8:00 a.m., 12:15 p.m. and 8:54 p.m.; 3/08/26 at 8:00 a.m., 1:00 p.m. and 8:00 p.m.; 3/09/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/10/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/11/26 at 5:15 p.m. and 10:15 p.m.; 3/12/26 at 10:00 a.m. and 2:00 p.m.; 3/13/26 at 10:00 a.m., 2:00 p.m. and 10:30 p.m.; 3/14/26 at 9:00 a.m., 1:00 p.m. and 5:00 p.m.; 3/15/26 at 9:27 p.m.; 3/16/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/17/26 at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m.; 3/18/26 at 5:45 p.m. at 10:40 p.m.; 3/19/26 at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 9:58 p.m.; 3/20/26 at 5:00 p.m. and 9:33 p.m.; 3/21/26 at 8:37 p.m.; 3/22/26 at 10:00 p.m.; 3/23/26 at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m.; 3/24/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/25/26 at 12:33 p.m. and 11:15 p.m.; 3/26/26 at 9:00 a.m. and 2:00 p.m.; 3/27/26 at 8:30 p.m.; 3/28/26 at 4:00 a.m., and 4:30 p.m. and 10:00 p.m. The March 2026 MAR lacked documentation of the administration of the above narcotic pain medications. This citation relates to Intake 2743599 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure the facility was sufficiently staffed to provide adequate care related to medication administration and assistance with daily living for the residents. This deficient practice had the potential to affect 64 of 64 residents residing in the facility. Finding include:1.a. During the survey period, between 9/22/25 and 9/26/25 at 10:10 a.m., Staff Member 5 was observed passing medications in Villa 2. The staff member indicated the facility was running one aide in each villa and the nurse had 2 [NAME]. Staff Member 5 had only given medications to 5 residents in Villa 2 and 3 residents in Villa 4. It was now after 10:00 a.m. and the medications in villa 2 were due at 8 a.m. Staff Member 5 had to frequently stop the medication administration to assist the aides in providing resident care and in getting the residents up that required two staffs' physical assistance for mobility out of bed. The facility was supposed to have aides that floated between [NAME]; however, they were rarely seen. Most of the time, the floats were pulled due to other staff calling off work. Staffing issues were daily. Staff Member 5 had checked the residents blood sugar levels (BS) but had not yet given insulin and she was out of compliance (within timely medication administration) on the medication pass. Medications should be given either an hour before or an hour after the due time. When Staff Member 5 works 2 [NAME], the medication pass was always out of compliance. Staff member 5 indicated there were 2 to 3 residents in Villa 4 that required two physical staff members for mobility/transfer and 5 residents that required two staff assistance for mobility in Villa 2. During the survey period, between 9/22/25 and 9/26/25 at 10:15 a.m., Staff Member 6 indicated she spends at least 6 hours, sometimes more, on warming, preparing and serving 3 meals a day as well as washing the dishes after each meal. It makes it very hard to provide good quality patient care. If the facility does not assign more than one float, Staff Member 6 cannot even start on her showers until after lunchtime. The nurses have 2 [NAME] each and it does not allow them to help the aides out at all. It was not a safe working environment, for the residents or staff. Staff Member 6 refused to get residents up that requires a full body mechanical lift by herself. The residents have to wait until she can get someone to help her. The residents then get upset because they are still in bed and call their families, who then call Staff Member 6, upset, wanting to know why their loved one was not up yet. They need at least 2 people at all times in the [NAME] to provide care. During the survey period, between 9/22/25 and 9/26/25 at 11:01 a.m., Staff Member 7 indicated the facility was short staffed. She can complete all her patient care assigned but cannot get the assigned deep cleaning and laundry done. She has had residents miss showers as she did not have time to give them. The nurses have 2 [NAME] and when the nurse was at another villa, it was hard to provide care and watch the residents who are a fall risk. The night shift staff were supposed to do laundry and don't because they are short staffed too. The aides spend too much time in the kitchen when the nurse has 2 [NAME]. It makes it very hard to get cleaning, showers and patient care completed. They really need one nurse and one aide per villa and things would go smoother. During the survey period, between 9/22/25 and 9/26/25 at 1:57 p.m., Staff Member 8 indicated the facility was utilizing one nurse and 2 aides per villa on day shift. Then, two weeks after State cleared them, they changed it back to one aide per villa and one nurse for 2 [NAME]. They put on the staffing sheets that there would be aides floating and then they end up not have any. Aides are providing care by themselves because the nurses are in the other villa. If the aide was in a room providing care to a resident, and then a fall alarm goes off, you have to stop what you are doing and go check on the alarm, and then go back and finish. The residents deserve better care than they are getting. The aides are expected to provide care, prepare 3 meals, serve 3 meals, clean the kitchen, clean resident rooms and complete laundry. The management does not help at all. During the survey period, between 9/22/25 and 9/26/25 at 11:26 a.m., Staff Member 9 indicated medications were not given timely and out of compliance (the window of appropriate administration times) when passing medications for 2 [NAME]. During the survey period, between 9/22/25 and 9/26/25 at 11:35 a.m., Staff Member 10 indicated she could never get the assigned cleaning completed or activities done with residents because she did not have time. Patient care came first. The facility needs more staff. The facility was staffing 2 aides in each villa. Last month, in August, it changed to one aide in each villa and the nurses had 2 [NAME] each. They also assigned 2 to 3 aides to float but someone usually called in which took one of the floats away. There were 3 residents in Villa 7 that required the assistance of 2 staff members for transfers and 3 residents in Villa 5. During the survey period, between 9/22/25 and 9/26/25 at 11:47 a.m., Staff Member 11 indicated she could not complete the medication pass for 2 [NAME] timely. Staff Member 11 had to consistently stop the medication pass and assist the aides in the [NAME] with patient care and transfers. They try to have aides float to help, but usually someone calls in and the float had to fill the spot of the call in. There were a total of 2 residents in Villa 3 that required two physical staff members with assistance for the transfers. During the survey period, between 9/22/25 and 9/26/25 at 12:15 p.m., Staff Member 12 indicated there are times when she had been unable to complete all her assigned tasks. Staff Member 12 worked 12-hour shifts and half of the day was in the kitchen for 3 meals. The aides warm up each meal, serve the meal and then do the dishes. It was just hard to provide good care to the residents when the aides were responsible for serving 3 meals daily, housekeeping and completing laundry. There were 6 residents in Villa 6 that required 2 staff members for transfers. During the survey period, between 9/22/25 and 9/26/25 at 1:45 p.m., Staff Member 15 indicated having 2 [NAME] to pass medications for, and complete timely, was very difficult. Once you complete the morning medication pass in one villa, you go to the next villa and do the medication pass over there. An hour later, the nurse must start another medication pass for both [NAME] and then again in the late afternoon. It felt like passing medications was all she did. Staff Member 15 felt the accuracy of the resident assessments were not safe and not fair to the residents when the nurse worked 2 [NAME]. During an interview, on 9/24/25 at 11:10 a.m., Resident T indicated the nighttime medication pass was the worst. She did not get her Sunday night medications until 11:15 p.m. She was supposed to get them by 10 p.m. The nurses' having 2 [NAME] makes them run late with the medicine. The resident resided in Villa 2 During an interview, on 9/24/25 at 1:10 p.m., Resident E indicated her night medications were usually late because the nurse passes the medication in the other villa first. She received her night medications usually between 10:00 p.m. and 11:00 p.m. when they were due way before then. The resident resided in Villa 4 During an interview, on 9/24/25 at 1:18 p.m., Resident P indicated she received her medications late on both days and nights. It was not the nurse's fault because they pass medications in 2 [NAME] and everyone wants their medicine. One night she did not receive her medication until midnight. On dayshift, the latest she received her medication was between 11:00 a.m. and 12:00 p.m. The aides have too much to do. They give showers, serve breakfast, lunch and dinner, wash dishes and clean all while trying to provide care to the residents, which was ridiculous. She turned her light on to go to the bathroom. It took the aide 45 minutes to get to her. They need more staff. The resident resided in Villa 4. Between 9/22/25 and 9/26/25, during the survey period, Staff Member 18 indicated she could not pass medication in 2 [NAME] without being out of compliance. Between 9/22/25 and 9/26/25, during the survey period, the following number of residents per villa that require two physical staff members assistance for transfers and/or used a full body mechanical lift were as follows: Villa 2 - total of 5 residentsVilla 3 - total of 2 residentsVilla 4 - total of 2 to 3 residentsVilla 5 - total of 3 residentsVilla 6 - total of 6 residentsVilla 7 - total of 3 residents 1. 1.b. The clinical record for Resident D was reviewed on 9/23/25 at 1:50 p.m. The resident's diagnosis included, but was not limited to, diabetes. The resident resides in Villa 6.The physician's order, dated 5/1/25, indicated the resident was to receive Lantus (long-acting insulin), 12 units twice daily for diabetes at 8:00 a.m. and 9:00 p.m.The August 2025 and September 2025 medication administration records (MAR) indicated the medication was administered late on the following dates and times:-On 8/08/25, the resident's 9:00 p.m. insulin was administered on 8/9/25 at 12:43 a.m.-On 8/11/25, the resident's 8:00 a.m. insulin was administered at 9:20 a.m.-On 8/14/25, the resident's 8:00 a.m. insulin was administered at 9:30 a.m.-On 8/14/25, the resident's 9:00 p.m. insulin was administered at 10:41 p.m.-On 8/15/25, the resident's 9:00 p.m. insulin was administered on 8/16/25 at 5:38 a.m.-On 8/21/25, the resident's 8:00 a.m. insulin was administered at 9:14 a.m.-On 8/22/25, the resident's 8:00 a.m. insulin was administered at 10:19 a.m.-On 8/22/25, the resident's 9:00 p.m. dose of insulin was administered on 8/23/25 at 12:20 a.m.-On 8/23/25, the resident's 9:00 p.m. dose of insulin was administered at 10:51 p.m.-On 8/24/25, the resident's 9:00 p.m. dose of insulin was administered on 8/25/25 at 1:32 a.m.-On 8/26/25, the resident's 9:00 p.m. dose of insulin was administered at 10:22 p.m.-On 8/29/25, the resident's 9:00 p.m. dose of insulin was administered on 8/30/25 at 12:57 a.m.-On 9/03/25, the resident's 9:00 p.m. dose of insulin was administered at 10:26 p.m.-On 9/04/25, the resident's 8:00 a.m. dose of insulin was administered at 9:37 a.m.-On 9/05/25, the resident's 9:00 p.m. dose of insulin was administered at 10:59 p.m.-On 9/08/25, the resident's 9:00 p.m. dose of insulin was administered at 12:45 a.m. on 9/09/25-On 9/09/25, the resident's 9:00 p.m. dose of insulin was administered at 10:18 p.m.-On 9/12/25, the resident's 8:00 a.m. dose of insulin was administered at 9:22 a.m.-On 9/12/25, the resident's 9:00 p.m. dose of insulin was administered at 10:27 p.m.-On 9/15/25, the resident's 8:00 a.m. dose of insulin was administered at 11:25 a.m.-On 9/19/25, the resident's 9:00 p.m. dose of insulin was administered at 10:59 p.m.-On 9/24/25, the resident's 9:00 p.m. dose of insulin was administered at 11:09 p.m. The physician's order, dated 5/1/25, indicated the resident was to receive Novolog (short-acting insulin) per sliding scale before meals and bedtime at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m.The August 2025 and September 2025 MAR's indicated the medication was administered late on the following dates and times:-On 8/08/25, the resident's 7:30 a.m. dose of insulin was administered at 8:55 a.m.-On 8/08/25, the resident's 9:00 p.m. dose of insulin was administered at 12:43 a.m. on 8/09/25-On 8/11/25, the resident's 7:30 a.m. dose of insulin was administered at 9:19 a.m.-On 8/12/25, the resident's 11:30 a.m. dose of insulin was administered at 1:51 p.m.-On 8/14/25, the resident's 7:30 a.m. dose of insulin was administered at 9:29 a.m.-On 8/14/25, the resident's 9:00 p.m. dose of insulin was administered at 10:41 p.m.-On 8/15/25, the resident's 9:00 p.m. dose of insulin was administered at 5:38 a.m. on 8/16/25-On 8/19/25, the resident's 11:30 a.m. dose of insulin was administered at 1:16 p.m.-On 8/19/25, the resident's 4:30 p.m. dose of insulin was administered at 6:21 p.m.-On 8/21/25, the resident's 4:30 p.m. dose of insulin was administered at 5:45 p.m.-On 8/22/25, the resident's 9:00 p.m. dose of insulin was administered at 12:19 a.m. on 8/23/25-On 8/23/25, the resident's 7:30 a.m. dose of insulin was administered at 8:52 a.m.-On 8/23/25, the resident's 9:00 p.m. dose of insulin was administered at 10:51 p.m.-On 8/24/25, the resident's 9:00 p.m. dose of insulin was administered at 1:31 a.m. on 8/25/25-On 8/26/25, the resident's 9:00 p.m. dose of insulin was administered at 10:22 p.m.-On 8/27/25, the resident's 7:30 a.m. dose of insulin was administered at 9:07 a.m.-On 8/27/25, the resident's 11:30 a.m. dose of insulin was administered at 12:47 p.m.-On 8/28/25, the resident's 7:30 a.m. dose of insulin was administered at 9:08 a.m.-On 8/28/25, the resident's 4:30 p.m. dose of insulin was administered at 6:26 p.m.-On 8/29/25, the resident's 11:30 a.m. dose of insulin was administered at 1:11 p.m.-On 8/29/25, the resident's 4:30 p.m. dose of insulin was administered at 5:41 p.m.-On 8/30/25, the resident's 7:30 a.m. dose of insulin was administered at 9:09 a.m.-On 9/01/25, the resident's 4:30 p.m. dose of insulin was administered at 6:31 p.m.-On 9/03/25, the resident's 9:00 p.m. dose of insulin was administered at 10:26 p.m.-On 9/08/25, the resident's 4:30 p.m. dose of insulin was administered at 5:57 p.m.-On 9/09/25, the resident's 4:30 p.m. dose of insulin was administered at 6:35 p.m.-On 9/10/25, the resident's 7:30 a.m. dose of insulin was administered at 8:51 a.m.-On 9/10/25, the resident's 11:30 a.m. dose of insulin was administered at 1:17 p.m.-On 9/11/25, the resident's 4:30 p.m. dose of insulin was administered at 5:52 p.m.-On 9/13/25, the resident's 4:40 p.m. dose of insulin was administered at 5:52 p.m.-On 9/15/25, the resident's 11:30 a.m. dose of insulin was administered at 2:20 p.m.-On 9/17/25, the resident's 7:30 a.m. dose of insulin was administered at 8:46 a.m.-On 9/18/25, the resident's 7:30 a.m. dose of insulin was administered at 8:51 a.m.-On 9/18/25, the resident's 11:30 a.m. dose of insulin was administered at 1:27 p.m.-On 9/23/25, the resident's 4:30 p.m. dose of insulin was administered at 5:56 p.m.-On 9/24/25, the resident's 11:30 a.m. dose of insulin was administered at 1:10 p.m.-On 9/24/25, the resident's 4:30 p.m. dose of insulin was administered at 6:01 p.m.-On 9/24/25, the resident's 9:00 p.m. dose of insulin was administered at 11:09 p.m. 2. 1.c. The clinical record for Resident F was reviewed on 9/23/25 at 2:57 p.m., the resident's diagnosis included, but was not limited to, diabetes.During an interview, on 9/24/25 at 10:50 a.m., Resident F indicated that, at times, he received his medication and insulin later than he should. The physician's order, dated 2/22/25, indicated the resident was to receive Insulin Glargine (long-acting insulin), 10 units subcutaneously, at 8:00 a.m. and 10:00 p.m. for diabetes.The August 2025 and September 2025 MAR's indicated the medication was administered late on the following dates and times:-On 8/09/25, the resident's 10:00 p.m. dose of insulin was administered at 11:54 p.m.-On 8/10/25, the resident's 10:00 p.m. dose of insulin was administered on 8/11/25 at 12:57 a.m.-On 8/12/25, the resident's 8:00 a.m. dose of insulin was administered at 9:34 a.m.-On 8/13/25, the resident's 10:00 p.m. dose of insulin was administered on 8/14/25 at 12:49 a.m.-On 8/15/25, the resident's 10:00 p.m. dose of insulin was administered at 11:29 p.m.-On 8/18/25, the resident's 10:00 p.m. dose of insulin was administered on 8/19/25 at 2:59 a.m.-On 8/19/25, the resident's 10:00 p.m. dose of insulin was administered on 8/20/25 at 12:59 a.m.-On 8/20/25, the resident's 10:00 p.m. dose of insulin was administered at 11:45 p.m.-On 8/22/25, the resident's 8:00 a.m. dose of insulin was administered at 11:58 a.m.-On 8/24/25, the resident's 8:00 a.m. dose of insulin was administered at 9:22 a.m.-On 8/25/25, the resident's 8:00 a.m. dose of insulin was administered at 10:16 a.m.-On 8/25/25, the resident's 10:00 p.m. dose of insulin was administered on 8/26/25 at 3:07 a.m.-On 8/26/25, the resident's 8:00 a.m. dose of insulin was administered at 9:37 a.m.-On 8/26/25, the resident's 10:00 p.m. dose of insulin was administered at 11:53 p.m.-On 8/27/25, the resident's 10:00 p.m. dose of insulin was administered at 11:36 p.m.-On 9/01/25, the resident's 10:00 p.m. dose of insulin was administered on 9/02/25 at 1:00 a.m.-On 9/02/25, the resident's 8:00 a.m. dose of insulin was administered at 9:58 a.m.-On 9/02/25, the resident's 10:00 p.m. dose of insulin was administered at 11:30 p.m.-On 9/04/25, the resident's 10:00 p.m. dose of insulin was administered at 11:24 p.m.-On 9/06/25, the resident's 8:00 a.m. dose of insulin was administered at 10:55 a.m.-On 9/07/25, the resident's 8:00 a.m. dose of insulin was administered at 10:05 a.m.-On 9/09/25, the resident's 10:00 p.m. dose of insulin was administered on 9/10/25 at 12:07 a.m.-On 9/10/25, the resident's 10:00 p.m. dose of insulin was administered at 11:58 p.m.-On 9/15/25, the resident's 8:00 a.m. dose of insulin was administered at 10:30 a.m.-On 9/15/25, the resident's 10:00 p.m. dose of insulin was administered on 9/16/25 at 12:06 a.m.-On 9/16/25, the resident's 10:00 p.m. dose of insulin was administered on 9/17/25 at 1:51 a.m.-On 9/18/25, the resident's 8:00 a.m. dose of insulin was administered at 9:30 a.m.-On 9/18/25, the resident's 10:00 p.m. dose of insulin was administered at 11:58 p.m.-On 9/20/25, the resident's 10:00 p.m. dose of insulin was administered on 9/21/25 at 12:53 a.m.-On 9/21/25, the resident's 8:00 a.m. dose of insulin was administered at 9:36 a.m.-On 9/21/25, the resident's 10:00 p.m. dose of insulin was administered on 9/22/25 at 4:56 a.m.-On 9/22/25, the resident's 8:00 a.m. dose of insulin was administered at 9:22 a.m.-On 9/22/25, the resident's 10:00 p.m. dose of insulin was administered on 9/23/25 at 12:04 a.m. 3. 1.d. The clinical record for Resident G was reviewed on 9/23/25 at 3:22 p.m. The resident's diagnoses included, but was not limited to encephalopathy and diabetes.During an interview, on 9/23/25 at 1:10 p.m., the resident indicated he had received his medications late.The physician's order, dated 9/18/25, indicated the resident was to receive Insulin Glargine, 20 units subcutaneously, at 8:00 a.m.The September 2025 MAR's indicated the medication was administered late on the following dates and times:-On 9/22/25, the resident's 8:00 a.m. dose was administered at 11:55 a.m.-On 9/24/25, the resident's 8:00 a.m. dose was administered at 9:14 a.m.-On 9/25/25, the resident's 8:00 a.m. dose was administered at 9:33 a.m. 4. 1.e. The clinical record for Resident H was reviewed on 9/23/25 at 3:35 p.m. The resident's diagnoses included, but were not limited to, diabetes and hyperlipidemia. The resident resided in Villa 6.The physician's order, dated 8/13/25, indicated the resident was to receive Insulin Glargine, 15 units subcutaneously, at 9:00 p.m. for diabetesThe August 2025 MAR indicated the insulin was administered late on the following dates and times:-On 8/15/25, the resident's 9:00 p.m. dose was administered on 8/16/25 at 4:29 a.m.-On 8/20/25, the resident's 9:00 p.m. dose was administered at 10:42 p.m.-On 8/22/25, the resident's 9:00 p.m. dose was administered on 8/23/25 at 12:16 a.m.-On 8/23/25, the resident's 9:00 p.m. dose was administered on 8/24/25 at 5:03 a.m.-On 8/24/25, the resident's 9:00 p.m. dose was administered on 8/25/25 at 1:37 a.m. 5. 1.f. The clinical record for Resident L was reviewed on 9/23/25 at 4:18 p.m. The resident's diagnoses included, but were not limited to, depression and diabetes. The resident resided in Villa 5.During an interview, on 9/24/25 at 1:53 p.m., the resident indicated there were times that he received his medication later than usual, but the staff are very busy.The physician's order, dated 10/15/24, indicated the resident was to receive Insulin Aspart (fast-acting insulin), 25 units subcutaneously, twice daily at 8:00 a.m. and 5:00 p.m. for diabetes.The August 2025 and September 2025 MAR indicated the insulin was administered late on the following dates and times:-On 8/08/25, the resident's 8:00 a.m. dose was administered at 9:30 a.m.-On 8/15/25, the resident's 8:00 a.m. dose was administered at 9:30 a.m.-On 8/20/25, the resident's 8:00 a.m. dose was administered at 9:38 a.m.-On 8/23/25, the resident's 8:00 a.m. dose was administered at 10:00 a.m.-On 8/24/25, the resident's 8:00 a.m. dose was administered at 9:59 a.m.-On 8/25/25, the resident's 8:00 a.m. dose was administered at 10:23 a.m.-On 8/31/25, the resident's 8:00 a.m. dose was administered at 9:48 a.m.-On 9/02/25, the resident's 8:00 dose was administered at 10:46 a.m.-On 9/04/25, the resident's 8:00 a.m. dose was administered at 9:24 a.m.-On 9/05/25, the resident's 5:00 p.m. dose was administered at 6:33 p.m.-On 9/10/25, the resident's 5:00 p.m. dose was administered at 6:20 p.m.-On 9/12/25, the resident's 5:00 p.m. dose was administered at 6:17 p.m.-On 9/13/25, the resident's 8:00 a.m. dose was administered at 11:04 a.m.-On 9/14/25, the resident's 5:00 p.m. dose was administered at 6:17 p.m.-On 9/16/25, the resident's 8:00 a.m. dose was administered at 11:54 a.m.-On 9/18/25, the resident's 8:00 a.m. dose was administered at 9:41 a.m.-On 9/19/25, the resident's 5:00 p.m. dose was administered at 6:33 p.m.-On 9/20/25, the resident's 8:00 a.m. dose was administered at 9:49 a.m. 6. 1.g. The clinical record for Resident M was reviewed on 9/23/25 at 4:40 p.m. The resident's diagnoses included. but were not limited to, hyperlipidemia and diabetes. The resident resided in Villa 5 During an interview, on 9/24/25 at 2:35 p.m., the resident indicated that sometimes her medications were on time and sometimes they were late, depending on where the nurse starts. The nurse had to pass medications in 2 [NAME] and her medications were late sometimes. The physician's order, dated 5/20/25, indicated the resident was to receive Basaglar (long-acting insulin), 12 units subcutaneously, at 8:00 a.m. and 10:00 p.m. for diabetes. The September 2025 MAR indicated the insulin was administered late on the following dates and times:-On 9/01/25, the resident's 10:00 p.m. dose was administered at 11:20 p.m.-On 9/02/25, the resident's 8:00 a.m. dose was administered at 11:32 a.m.-On 9/03/25, the resident's 10:00 p.m. dose was administered on 9/4/25 at 2:01 a.m.-On 9/04/25, the resident's 10:00 p.m. dose was administered at 11:52 p.m.-On 9/06/25, the resident's 10:00 p.m. dose was administered on 9/7/25 at 12:54 a.m.-On 9/07/25, the resident's 10:00 p.m. dose was administered at 11:34 p.m.-On 9/12/25, the resident's 8:00 a.m. dose was administered at 10:20 a.m.-On 9/13/25, the resident's 8:00 a.m. dose was administered at 11:31 a.m.-On 9/17/25, the resident's 10:00 p.m. dose was administered at 11:30 p.m.-On 9/19/25, the resident's 8:00 a.m. dose was administered at 9:12 a.m.-On 9/20/25, the resident's 8:00 a.m. dose was administered at 10:08 a.m.-On 9/23/25, the resident's 8:00 a.m. dose was administered at 9:42 a.m. 7. 1.h. The clinical record for Resident N was reviewed on 9/24/25 at 10:09 a.m. The resident's diagnoses included, but were not limited to, difficulty walking, repeated falls and hypertension. The resident resided in Villa 7.D During an interview, on 9/23/25 at 11:40 a.m., Resident N indicated last night, 9/22/25, he pushed his call pendant for assistance to get into bed. He waited a while and then rang the bell provided to him by the facility. No one ever came and after an hour, he got tired of waiting and put himself back into bed.T The care plan, dated 6/25/25, indicated the resident had a self-care deficit and usually required extensive physical assist of one staff with transfers. 8. 1. i. The clinical record for Resident O was reviewed on 9/25/25 at 11:24 a.m. The resident's diagnoses included, but were not limited to, peripheral vascular disease and diabetes. The resident resided in Villa 2. During an interview, on 9/24/25 at 10:54 a.m., Resident O indicated he did not receive his medications timely. Sometimes, on night shift, he did not receive his medications until after 10:00 p.m. and had received them as late as 12:00 a.m. The nurses on night shift had 2 to 3 [NAME] and usually started the evening medication pass in one of the other [NAME]. His morning medications were late too because the nurses had 2 [NAME]. His morning medications were due at 8:00 a.m. and he usually received them around 10:00 a.m. or so. They were very short staffed, especially since they did away with the QMA's (Qualified Medication Aide) working as nurses. The morale of the staff were at an all-time low which was sad. He has had to wait multiple times for available staff to get him up out of bed as he required a full body mechanical lift for transfers. They work the staff to death and have run off some of the good staff. Management had moved the aides around to different [NAME] and the aides don't know anything about the residents in the [NAME] where they do not normally work. The aides need to work in the villa they are used to. The physician's order, dated 7/25/25, indicated the resident was to receive Insulin Glargine, 20 units subcutaneously, at 8:00 p.m. for diabetes. The August 2025 and September 2025 MAR indicated the insulin was administered late on the following dates and times:-On 8/08/25, the resident's 8:00 p.m. dose was administered at 10:21 p.m.-On 8/09/25, the resident's 8:00 p.m. dose was administered on 8/10/25 at 12:01 a.m.-On 8/10/25, the resident's 8:00 p.m. dose was administered on 8/11/25 at 1:00 a.m.-On 8/11/25, the resident's 8:00 p.m. dose was administered at 11:11 p.m.-On 8/12/25, the resident's 8:00 p.m. dose was administered on 8/13/25 at 2:22 a.m.-On 8/13/25, the resident's 8:00 p.m. dose was administered on 8/14/25 12:50 a.m.-On 8/14/25, the resident's 8:00 p.m. dose was administered at 9:38 p.m.-On 8/15/25, the resident's 8:00 p.m. dose was administered at 11:32 p.m.-On 8/18/25, the resident's 8:00 p.m. dose was administered on 8/19/25 at 2:55 a.m.-On 8/19/25, the resident's 8:00 p.m. dose was administered on 8/20/25 at 1:09 a.m.-On 8/20/25, the resident's 8:00 p.m. dose was administered at 11:42 p.m.-On 8/22/25, the resident's 8:00 p.m. dose was administered at 9:51 p.m.-On 8/25/25, the resident's 8:00 p.m. dose was administered at 10:55 p.m.-On 8/26/25, the resident's 8:00 p.m. dose was administered on 8/27/25 at 12:03 a.m.-On 8/27/25, the resident's 8:00 p.m. dose was administered at 11:31 p.m. -On 9/01/25, the resident's 8:00 p.m. dose was administered on 9/2/25 at 12:57 a.m.-On 9/02/25, the resident's 8:00 p.m. dose was administered at 11:28 p.m.-On 9/03/25, the resident's 8:00 p.m. dose was administered at 11:25 p.m.-On 9/04/25, the resident's 8:00 p.m. dose was administered at 11:19 p.m.-On 9/05/25, the resident's 8:00 p.m. dose was administered at 10:56 p.m.-On 9/06/25, the resident's 8:00 p.m. dose was administered at 11:32 p.m.-On 9/08/25, the resident's 8:00 p.m. dose was administered on 9/9/25 at 12:58 a.m.-On 9/09/25, the resident's 8:00 p.m. dose was administered on 9/9/25 at 12:04 a.m.-On 9/10/25, the resident's 8:00 p.m. dose was administered at 11:53 p.m.-On 9/11/25, the resident's 8:00 p.m. dose was administered at 9:23 p.m.-On 9/12/25, the resident's 8:00 p.m. dose was administered at 9:51 p.m.-On 9/14/25, the resident's 8:00 p.m. dose was administered at 9:24 p.m.-On 9/15/25, the resident's 8:00 p.m. dose was administered on 9/16/25 at 12:02 a.m.-On 9/16/25, the resident's 8:00 p.m. dose was administered on 9/17/25 at 1:47 a.m.-On 9/17/25, the resident's 8:00 p.m. dose was administered at 11:21 p.m.-On 9/18/25, the resident's 8:00 p.m. dose was administered at 11:51 p.m.-On 9/19/25, the resident's 8:00 p.m. dose was administered at 11:02 p.m.-On 9/20/25, the resident's 8:00 p.m. dose was administered on 9/21/25 at 12:56 a.m.-On 9/21/25 the resident's 8:00 p.m. dose was administered on 9/22/25 at 4:59 a.m.-On 9/22/25, the resident's 8:00 p.m. dose was administered on 9/23/25 at 12:11 a.m.-On 9/23/25, the resident's 8:00 p.m. dose was administered at 9:59 p.m. Review of the staffing sheets indicated the following: Between 8/1/25 through 8/4/25, the facility scheduled one nurse and one aide for each villa.Between 8/5/25 through 8/6/25, the facility scheduled one nurse for 2 [NAME] with 2 aides per villaBetween 8/7/25 through 8/19/25, the facility scheduled one nurse and one aide per villa On 8/20/25, the facility schedule changed to one nurse for 2 [NAME], one aide per villa with 1to 3 floats scheduled On 8/8/25, during night shift starting at 10:00 p.m., there was only one nurse for [NAME] 1, 2, 3 and 4 On 8/23/25, during night shift, there was only one nurse for [NAME] 1, 2, 3 and 4 after the QMA completed the evening medication pass in [NAME] 2 and 4 On 9/8/25, during night shift, there was one nurse for Villa 1 and 3 and the nurse also worked as the aide in Villa 3 due to a call in. On 9/13/25, during night shift, after 10:46 p.m., there was only one nurse for Villa 1, 2, 3 and 4 This Citation relates to Intakes 2583741, 2597221, 2599540, 2608512 and 2613322 3.1-17(a)

Based on observation, interview and record review, the facility failed to ensure monitoring and flush orders were in place for a resident (Resident D and Resident G) with a midline; failed to ensure documentation was in place for the removal of a midline (Resident D); failed to ensure a pulse was obtained, as ordered, prior to the administration of a hypertensive medication (Resident L); and failed to ensure a blood pressure medication was held, as ordered, for a resident (Resident C) with out of parameter blood pressures for 4 of 6 residents reviewed for quality of care. Findings Include:1.The clinical record for Resident C was reviewed on 9/23/25 at 1:29 p.m. The resident's diagnosis included, but was not limited to, chronic hypotension. The physician's order, dated 6/18/25, indicated the resident was to receive Midodrine HCl (medication used to increase blood pressure) 5 mg (milligrams) by mouth three times a day at 8:00 a.m., 2:00 p.m. and 10:00 p.m. The medication was to be held for a systolic blood pressure (SBP) greater than 130 or less than 90. The care plan, dated 4/24/25, indicated the resident had a diagnosis of hypotension and to administer medications as ordered.Review of the August 2025 and September 2025 medication administration record indicated the resident was administered the medication with an out of parameter SBP on the following dates and times:-On 8/07/25 at 10:00 p.m., when the resident's SBP was 89.-On 8/15/25 at 8:00 a.m., when the resident's SBP was 137.-On 8/19/25 at 10:00 p.m., when the resident's SBP was 133.-On 8/20/25 at 8:00 a.m., when the resident's SBP was 133.-On 8/25/25 at 8:00 a.m., when the resident's SBP was 132.-On 8/30/25 at 8:00 a.m., when the resident's SBP was 138.-On 9/06/26 at 8:00 a.m. and 2:00 p.m., when the resident's SBP was 163.-On 9/12/25 at 8:00 a.m., when the resident's SBP was 131.-On 9/16/25 at 8:00 a.m. and 2:00 p.m., when the resident's SBP was 147.-On 9/21/25 at 8:00 a.m., when the resident's SBP was 132. During the survey period, between 9/22/25 and 9/26/25, Staff Member 18 indicated if a resident's blood pressure was out of parameters, the medication should have been held. 2. The clinical record for Resident D was reviewed on 9/23/25 at 1:50 p.m. The resident's diagnoses included, but were not limited to, vascular dementia, right sided hemiplegia and hemiparesis and neuromuscular dysfunction of the bladder. On 9/23/25 at 12:10 p.m., the resident was observed sitting up in a scoot chair in the dining room eating dinner. The resident was not observed with a midline in place. The September 2025 medication administration record indicated, on 9/7/25, a midline was to be placed for IV (intravenous) antibiotic therapy. The physician's order, with a start date of 9/8/25, indicated the resident was to receive Piperacillin Sod-Tazobactam (antibiotic for urinary tract infections), 3.375 grams intravenously every 6 hours for 7 days at 12:00 p.m., 6:00 p.m., 12:00 a.m. and 6:00 a.m. The September 2025 medication administration record lacked documentation of the administration of the medication on 9/9/25 at 6:00 a.m., midline flush orders before/after medication administration, monitoring the midline site for infiltration and signs/symptoms of infection and the removal of the midline to ensure the midline catheter tip was in place upon removal. During the survey period, between 9/22/25 and 9/26/25, Staff Member 18 indicated residents with a midline should have flush orders in place prior to and after administration. The nurse should be monitoring the site for signs and symptoms of infection and infiltration every shift. 3. The clinical record for Resident G was reviewed on 9/23/25 at 3:22 p.m. The resident's diagnoses included, but were not limited to, encephalopathy, diabetes and a urinary tract infection. The September 2025 medication administration record indicated on 9/23/25, the resident was to have a midline placed for intravenous antibiotic therapy for a urinary tract infection. On 9/23/25 at 1:10 p.m., the resident was observed with a midline to his right upper arm, dated 9/23/25. The physician's order, dated 9/23/25, indicated the resident was to receive Meropenem, one gram intravenously for a urinary tract infection every 8 hours at 12:00 a.m., 8:00 a.m. and 4:00 p.m. On 9/25/25 at 10:30 a.m., the September 2025 medication administration record indicated the resident had been administered the following doses of the antibiotic medication:-9/24/25 at 12:00 a.m., 8:00 a.m. and 4:00 p.m.-9/25/25 at 12:00 a.m. and 8:00 a.m. The clinical record lacked documentation of the midline flush orders before/after medication administration, monitoring the midline site for infiltration and signs/symptoms of infection from 9/24/25 at 12:00 a.m. through 9/25/25 at 8:00 a.m. 4. The clinical record for Resident L was reviewed on 9/23/25 at 4:18 p.m. The resident's diagnosis included, but was not limited to, hypertension. The current care plan, dated 11/18/21, indicated the resident had a diagnosis of hypertension and to administer medications as ordered. The August 2025 and September 2025 medication administration record indicated the resident was to receive Succinate (medication for high blood pressure) extended release, 50 mg daily. The medication was to be held if the resident's pulse was less than 60.Review of the August 2025 and September 2025 vital signs report lacked documentation of an obtained pulse for the resident on the following dates: 8/12/25 through 8/14/25, 8/16/25, 8/17/25, 8/26/25, 8/30/2, 9/11/25 through 9/13/25, 9/18/25, and 9/22/25. During the survey period, between 9/22/25 and 9/26/25, Staff Member 18 indicated all physician's orders should be followed. This Citation relates to Intakes 2597221, 2608512 and 2613322 3.1-37

Based on interview and record review, the facility failed to ensure a resident's (Resident D) urine output was documented, as ordered, for 1 of 3 residents reviewed for Indwelling catheters. Findings include: The clinical record for Resident D was reviewed on 9/23/25 at 1:50 p.m. The resident's diagnosis included, but was not limited to, neuromuscular dysfunction of the bladder. The physician's order, dated 5/3/25, indicated staff were to monitor the resident's Indwelling catheter output every shift. The August 2025 and September 2025 medication administration records indicated the resident's urine output was not documented on the following dates and shifts:-On 8/07/25 on day shift,-On 8/12/25 on day shift,-On 9/08/25 on night shift,-On 9/16/25 on night shift, and-On 9/18/25 on night shift. During the survey period, between 9/22/25 and 9/26/25, Staff Member 18 indicated physician orders must be followed. On 9/26/25 at 10:39 a.m., the Regional Director of Operations provided a current, undated copy of the document titled Physician Orders. It included, but was not limited to, Policy .It is the policy of the facility to follow the orders of the physician .The facility will follow physician orders to provide essential care to the resident, consistent with the resident's .physical status This Citation relates to Intake 2599540 3.1-41(a)(2)

Based on record review and interview, the facility failed to identify an unresolved quality deficiency which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiency through the quality assessment and assurance (QAA) process, as evidenced by a repeated deficiency for sufficient staffing. This deficient practice had the potential to affect 64 of 64 residents residing in the facility. Findings include:The Quality Assurance and Performance Improvement (QAPI) plan was a general outline of how to set up a QAPI committee and what the committee should do. The QAPI plan was a data driven, proactive approach for improving the quality of life, care and services in long term care. The activities of QAPI involved members at all levels of the organization to identify opportunities for improvement, address gaps in systems or processes, develop and implement and improvement or corrective plan and continuous monitoring of interventions. The following deficiency was cited on this survey and had been cited previously: -F725 Sufficient Staffing was previously cited on Complaint survey completed on 12/31/24.-F725 Sufficient Staffing was previously cited on Complaint survey completed on 3/27/25.-F725 Sufficient Staffing was previously cited on the Annual Survey completed on 6/17/25. Review of the facility QAPI meetings for January 2025 and September 1025 included the following:January 2025 - documented terminations and new hiresFebruary 2025 - no documentationMarch 2025 - documented open positions and terminationsApril 2025 - documented open positions from the previous monthMay 2025 - no documentationJune 2025 - no documentationJuly 2025 - open positions documentedAugust 2025 - documented open positions and new hiresSeptember 2025 - documented open positions and new hires The QAPI workbook provided lacked documentation of interventions implemented or systemic changes for the continued deficient practice.The QAPI Performance/Peer Review, dated 8/1/25 and updated 9/1/25, indicated the problem was staffing. The corrective actions included, but were not limited to, adjust staffing to ensure CNAs have assistance, monthly rounding, every other month staff interviews, and staffing assignment review. No other information was provided except for the Performance/Peer review Plan document. During an interview, on 9/25/25 at 3:07 p.m., the Regional Director of Operations indicated they had been utilizing one nurse and one aide in each villa. The aides complained that the nurses were not helping them. They then utilized one nurse per 2 [NAME], one aide per villa, and added floats to assist the aides when needed.Review of the staffing sheets indicated the following: Between 8/1/25 through 8/4/25, the facility scheduled one nurse and one aide for each villa.Between 8/5/25 through 8/6/25, the facility scheduled one nurse for 2 [NAME] with 2 aides per villaBetween 8/7/25 through 8/19/25, the facility scheduled one nurse and one aide per villa On 8/20/25, the facility schedule changed to one nurse for 2 [NAME], one aide per villa with 1 to 3 floats scheduled On 8/8/25, during night shift starting at 10:00 p.m., there was only one nurse for [NAME] 1, 2, 3 and 4 On 8/23/25, during night shift, there was only one nurse for [NAME] 1, 2, 3 and 4 after the QMA completed the evening medication pass in [NAME] 2 and 4 On 9/8/25, during night shift, there was one nurse for Villa 1 and 3 and the nurse also worked as the aide in Villa 3 due to a call in. On 9/13/25, during night shift, after 10:46 p.m., there was only one nurse for Villa 1, 2, 3 and 4 3.1-52(b)(2)

2. During random observations of Villa 6, between 6/9/25 and 6/11/25, Residents 6, 7, and 20 were in a recliner asleep in the common area. No activities were going on either by the Activity Director or the CNAs. During random observations of Villa 2, between 6/9/25 and 6/11/25, Residents 19, 49, and 3 were in the dining room area just sitting at the table sipping coffee. No activities were going on either by the Activity Director or the CNAs. Resident 1 was observed in her recliner in the common area during random observations, between 6/9/25 and 6/12/25. The resident was usually asleep or just looking around. No activities were occurring on any of the observations. An Activities Care Plan, with a start date of 5/20/22 and a revision date of 2/2/25, indicated Resident 1 had been sitting in a recliner in the day room for long periods of time. The resident indicated she was open to attending all group activities as she was a very social person, but needed to be invited and encouraged to attend due to dementia. The goal was for her to participate in activities of interest in both her and other [NAME] three times a week. The interventions included, but were not limited to, encourage her to participate in all activities; socialize with staff and others during meals and care; and staff to assist her to all activities of interest. During a confidential interview, between on 6/9/25 and 6/16/25, Staff 102 indicated that truthfully, the CNAs had too many tasks to do. The CNAs' had to cook the meals sent over, serve the residents meals and cleaning up, cleaning the rooms, vacuuming and doing laundry, resident care, toileting, ADLs on those that needed help and showers, and the CNAs were expected to do the activities. The Activity Director came in every morning and dropped off some coloring pages and the Daily Chronicle for the residents. She then left the villa. Most of the time, the coloring pages went into the trash as none of the residents wanted to color. If no one was up or out of their room when they came to the villa, they would leave and go to another villa. She did not wait for any of the residents to come nor go around and let them know what the activity was. The activities really were not occurring according to the calendar. Staff 102 indicated they would love to have the time to do the ladies nails, but that was also something activities could do with the residents, but they didn't. The ladies loved it when they got their nails and hair done. One time in Villa 5 the activity staff took the residents outside on the patio, had some drinks for them and they listened to the radio. It was great the residents had fun. But it had not been done since a long time ago. During a confidential interview, between 6/9/25 and 6/16/25, Staff 104 indicated there was only one CNA for each villa and the Qualified Medication Aide(QMA) or the nurse would help if they could. Doing activities was also one of the duties the aide was expected to do. Although she made sure to interact with her residents every day, she really was not able to do the activities that were scheduled. During a confidential interview, between 6/9/25 and 6/16/25, Staff 105 indicated she tried to do hair and nails for the ladies one time a week if able, but was unable to do any of the other activities During an interview with the Activity Director, on 6/12/25 at 10:25 a.m., she indicated she was hoping for an activity assistant, but was not sure she would get one. She indicated the morning activity was to have coffee and the daily chronicle to read in the mornings and watched TV news. She would leave coloring pages and a newsletter in each villa for the residents to do. Then, in the afternoon was her big activity and she would go to each villa and spend 30 minutes for activities every day. During random observations, of Villa 2 and Villa 6, between 6/9/25 and 6/12/25, no activities were occurring. The Activities Director was also not observed to be spending 30 minutes in each villa at any time from 6/9/25 through 6/13/25. During an interview with Resident 20, on 6/12/25 at 1:00 p.m., she indicated she stayed in her bed most of the time, but would like to know what activities were occurring and when they were scheduled in case she wanted to go. No one ever came around to tell her. During a confidential interview, between 6/9/25 and 6/16/25, Staff 101 indicated the Activities Director was in the villa earlier and played balloon toss she thought with about five residents for about five minutes and then left. During a confidential interview and observation, between 6/9/25 and 6/16/25 from 8:00 a.m. to 2:00 p.m., Staff 102 indicated the Activity Director was in the villa earlier for a few minutes, a balloon toss was scheduled for this afternoon, but no balloon toss or any other activity had occurred. Two balloons were sitting on the dining room table with four residents and a family member. The family member indicated the Activity Director was going to be right back with ice cream for the residents. He also indicated the balloon toss did not occur. A review of the activity calendar which hung on the wall in a villa, on 6/12/25 at 2:00 p.m., indicated the Baking with Residents activity was canceled. The Activities Director she was going to be passing ice cream to the CNAs for National CNA Week and then to the residents. During the Resident Council meeting, on 6/10/25 at 1:01 p.m., Resident 8 indicated there were no outings, but she would like to have those. Resident 20 indicated the monthly calendar of activities provided to the residents was small and she couldn't read it. The activities were not held in every villa but were only held at specific [NAME]. There were not a lot of activities, at the [NAME], but they did have a musical in one villa a long time ago and she enjoyed that. The staff used to bring residents to activities at a villa at that time. The evenings had no activities. Bingo was listed on the calendar several times, but they didn't know where it was, if any. She would attend more activities, if she only knew where they were at. During a confidential interview, between 6/9/25 and 6/16/25, Staff 106 indicated activities were completed by CNAs and they didn't have time. If they tried to do activities then showers weren't done. Coloring was all the residents had for activities. The Activities Director completed the Resident Council meeting but was only at the meeting for 5 minutes. The Activity Director just documented from a small list of questions. The Activity Director wasn't provided with help to do the activities in all the [NAME]. Staff were supposed to conduct activities and were asked to take residents to activities in other [NAME] if a resident asked to go. Staff would take turns staying in the villa if a resident wanted to go to an activity. During multiple observations, between 6/9/25 and 6/16/25, three residents were sitting at the dining table in their wheelchairs or in a dining chair. No activity was being performed, and the residents were not usually communicating with each other. Other residents were observed lying in their beds asleep. During random observations, between 6/9/25 and 6/16/25 from 10:00 a.m. to 10:20 a.m., of Villa 8 the following concerns were identified: - Two residents were conducting therapy. The remaining residents were in their rooms in bed. No activities were occurring. - Two residents were sitting at the dining table, and one resident was sitting in a recliner in the hearth area. The TV was on, but no residents were observed watching it. No activity was occurring. During random observations, between 6/9/25 and 6/16/25 from 10:00 a.m. to 10:20 a.m., of Villa 7 the following concerns were identified: - Two female residents were sitting alone at the dining table and one resident was at the kitchen counter. A CNA was in a resident's room assisting a resident. The TV was on in the hearth without sound and no activities were occurring. During an interview, on 6/11/25 at 9:18 a.m., the Executive Director (ED) indicated anyone in a villa could transfer a resident into another villa for an activity. She had transferred residents herself. She would make sure that a staff member was in the building before leaving with a resident. During an observation of the Monthly calendar, on 6/11/25 at 9:27 a.m., the activities were to begin daily at 10:00 a.m. with Daily Chronicles. No specific villa location was on the calendar. During an observation, on 6/11/25 at 11:06 a.m., the Activities Director entered Villa 7 and indicated to the CNA that a karaoke day in Villa 2 would be conducted at 2:00 p.m. She checked the coloring sheets and indicated, Oh good, they have only one of those sheets left. During an observation, between 6/9/25 and 6/13/25, the Activities Director entered the villa, and a staff member asked her why the activities were held in Villa 2 most of the time. The Activities Director indicated it was because more residents in [NAME] 3, 4, and 2 attended the activities and it was closer for them to go to Villa 2. The Activity Director's Job Description, dated 1/24/24, included, but was not limited to, . The Activity Director will be held accountable and responsible for the decision making and must assure that an ongoing program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident . 4. Involves residents in planning facility activity programs . 20. Assists bed residents by visiting with them, writing letters, running errands, making appointments, etc., as necessary . 16. Supervises activities as necessary . 3.1-33(a) 3.1-33(c) Based on observation, record review and interview, the facility failed to ensure an ongoing activity program designed to meet the interest and support the physical, mental, and psychosocial well being of each resident. This deficient practice had the potential to affect 66 of 66 residents residing in the facility. ([NAME] 2, 3, 4, 5, 6, 7, and 8) Findings include: 1. During a random observations, on 6/9/25 from 10:00 a.m. to 2:30 p.m., of [NAME] 3, 4, 7, and 8 there were four residents sitting in the dining area. No activities were taking place. The activity schedule indicated reading the news and chronicles at 10:00 a.m., trivia games at 1:00 p.m., and music class at 2:00 p.m. None of the activities took place. During random observations, between 6/10/25 and 6/13/25, Residents 29 and 47 were observed sitting in a recliner during the day except for mealtimes. The residents were not engaged in any activities During an observation, on 6/11/25 at 2:15 p.m., no activities were observed. There were no activity staff in the villa. The Certified Nursing Aide (CNA) provided resident care. At 2:00 p.m., the scheduled activity was karaoke. This activity did not take place, and no residents were taken to another villa for the activity. During random observations, on 6/12/25 from 1:15 p.m. to 1:45 p.m., [NAME] 3, 7, and 8 were observed for activities. The residents were scheduled at 1:00 p.m., for an activity called balloon volley. The were no activities observed throughout the day. The Activity Director was observed pushing a cart with boxes of ice cream. She indicated she was passing out ice cream to the CNAs in each villa related to CNA appreciation week. During an interview, on 6/11/25 at 11:20 a.m., Licensed Practical Nurse (LPN) 4 indicated the residents barely had any activities. The activities that the Activity Director brings around are puzzles and word searches. The residents on the dementia unit were unable to do the puzzles. She indicated the activities of puzzles and word searches for the dementia unit were not appropriate. During an interview, on 6/12/25 at 11:38 a.m., the family member of Resident 53 indicated she visited the resident daily. There were no activities observed while she was there. She tried to take the resident out of the facility for activities so she would have something to do. During an observation, on 6/10/25 at 1:00 p.m., Villa 4 did not have residents sitting in the dining room or the common areas and no activities were being conducted. During an interview, on 6/11/25 at 9:55 a.m., the CNA 11 indicated she was working alone in her position and QMA 12 was working on medication administration. CNA 11 indicated Villa 4 was hard to provide assistance with activities during the 12-hour shift, due to all the other duties she was required to do. During an observation, on 6/11/25 at 9:59 a.m., Villa 4 had one resident in the common area and no activities were being conducted. During an observation, on 6/11/25 at 10:57 a.m., Villa 5 did not have any residents sitting in the common area and no activities were being conducted. During an observation, on 6/12/25 at 9:05 a.m., the Activities Director brought papers that were for the residents to color and the daily news to read. No residents were in the common area at that time. During an observation, on 6/12/25 at 10:00 a.m., Villa 4 did not complete the scheduled activity of balloon toss. There was one pink balloon on the dining table with four residents sitting around the table. Two of those residents were finishing their breakfast. During an observation, on 6/12/25 at 10:10 a.m., Villa 5 did not complete the scheduled activity of balloon toss. There were two yellow balloons on the dining room table, but there were no residents in the dining room or the common area. During an interview, on 6/11/25 at 10:58 a.m., CNA 11 indicated she was the only staff working in Villa 5. She often worked alone in the villa. The tasks she had to do was cleaning, laundry, re-heating the meals on top of providing general resident care duties.

2. During a confidential interview, between 6/9/25 and 6/16/25, Staff 100 indicated there was only one CNA in each building. If a resident was a mechanical full body lift, sit to stand, or required two staff members for mobility/transfers or toileting, then they would have to call the nurse to come over and help, but sometimes there was a wait until they were free to come over. Some days were harder than others. Staff 100 indicated they had to make time to get all their work done, even on weekends. Showers were being given as they made sure they were. For the most part the villa cleaning got done, maybe not the full deep cleaning that was supposed to be done in 2 rooms every day. During a confidential interview between 6/9/25 and 6/16/25, Staff 101 indicated some [NAME] were harder out of all the [NAME] as there were residents who required a lot of care. There were several residents who required a full body mechanical lift to get up or to be put back to bed and that took two staff members to complete the task. The nurses were usually called from another villa to help the CNA do the mechanical full body lift or watched the villa while the CNA toileted residents or were giving showers. Sometimes there was a wait until the nurse finished what they were doing before coming over to help the CNA. During a confidential interview between 6/9/25 and 6/16/25, Staff 102 indicated there usually was a floater to several buildings to help that CNA with care of the heavier care residents. There was only one CNA for each building. Monday, Tuesday, and Wednesday were usually better than the four other days as that was when the number of floaters and staffing were good, not so on the other days. She indicated she worked several [NAME] and it was a struggle to get everything done by end of shift. The CNAs had too many tasks to do. They had to cook the meals sent over, serving them and cleaning up, cleaning the rooms, vacuuming and doing laundry, resident general care, toileting, ADL's (Activities of Daily Living) on those that needed help and showers. The CNAs were supposed to also do the activities. A lot of times a resident will suddenly tell the aide they needed to go to the bathroom in the middle of serving a meal. Staff would have to stop, take them to the bathroom, then came back and sanitized and re-gloved and had to re-heat the meal before finally serving the residents. The CNA had to make sure the nurse was in the villa before anyone was taken into the shower room or toileted. They were so afraid a resident would fall when the aide was in a room and might get hurt. When the shower or care was finished, they would come out and then the CNA tried to locate all the residents to be sure they were okay. She would not do a mechanical full body lift by herself for fear the resident would fall out of it and would get hurt. Some staff members just grabbed the mechanical full body lift and would go on even though two staff members were needed. Some days staff were just not able get to the daily cleaning of the rooms or the vacuuming as they were so busy. At times, staff had to put off a resident's shower because there was no time. Between one and two o'clock, they were able to get more done, but only if there were the supplies needed. If supplies or snacks/food from dietary were needed, they would have to call the another staff member to come over and cover the villa while the CNA went to get the items. If the staff member was not available, then they would have to call around to the other [NAME] or dietary to bring what was needed. She would love to have the time to do the ladies nails. The ladies loved it. Management did not come out and help. During a confidential interview, between on 6/9/25 and 6/16/25, Staff 103 indicated it was common for only one aide to be scheduled per villa. There were aides who floated between the [NAME] to help out. Having a floater really helped the CNA in doing care. Maybe there should be more CNAs to float. The aide really struggled to get the work done. During a confidential interview, between on 6/9/25 and 6/16/25, Staff 104 indicated there was only one CNA for each villa. There were times of not being able to get all the tasks done in caring for the residents although they tried really hard. If help was needed, they had to call the a staff member from the other [NAME] to come and help. They were usually alone with no floater. The staff were expected to do activities also. It got tough to get the residents all up, do their care, toilet or do showers, all the cleaning and vacuuming, cooking and laundry. With the assigned tasks, they were not able to do the activities that were scheduled. If a resident required two staff members for assistance or the use of a full body mechanical lift, they would have to call the nurse or other [NAME] to get someone to come over to help if available. Sometimes the residents had to wait on getting up or for care until the other person was free to come over and help. During a confidential interview, between 6/9/25 and 6/16/25, Staff 105 indicated they tried to do hair and nails for the ladies one time a week and would pitch in to help the single aide if able. They did not know who the floaters were but they never came to the villa. Some of the [NAME] really needed a second aide working depending on the acuity of the care the residents needed. It was tough for the day staff member as the night shift only got certain people up before they left. Then the day shift staff member had to get the rest of them up along with all their other duties. They remained a high risk for falls and skin issues with only one aide in each of the villa. It used to be two aides for the villa, but it changed about two years ago to one CNA. 4. During a confidential interview, between 6/9/25 and 6/16/25, Staff 107 indicated one aide and one floating nurse were alone on the floor and that was common. If a staff member was called to help in another villa and they were providing care, no one would take care of a resident in need, even if it was necessary. During an interview, on 6/10/25 at 1:01 p.m., Resident C indicated they had been left alone in a villa with no other staff recently. They had not had any trouble yet. They would have to go get someone if they needed help. During a confidential interview, between 6/9/25 and 6/16/25, Staff 106 indicated no other staff was present in the villa, when one staff provided care. Staff 106 indicated there was a total of only two staff in the villa. It happened often. They had a lot of fall risks and one staff member had to wait to do a shower until the other returned. There was a lot of work to complete in a villa. Resident care was a big part of it. It could cause a lot of stress for new hires. The main issue was call-ins or a lack of scheduled staff. Staff were supposed to conduct activities and were asked to take residents to activities in other [NAME]. Staff would take turns staying in the villa if a resident wanted to go to an activity. They really needed 2 staff to stay in each villa. One resident was a fall risk because he would just get up on his own. When a staff member gave a shower and no one else was there, it made giving care to others difficult. They had sometimes skipped giving a thorough shower or adequate grooming if a staff member was alone in a villa. Showers had not been skipped in a long time, but it wasn't a great shower. It took 20 to 30 minutes for each resident when staff got the resident up in the morning. The toilet wouldn't get cleaned and the vacuuming didn't get completed at times. During multiple observations, between 6/9/25 and 6/16/25, only one CNA and one nurse were in the villa. At times, no one was visible due to being in one resident's room. Three residents were sitting at the dining table in their wheelchairs or in a dining chair. No activity was being performed, and the residents were not usually communicating with each other. Other residents were observed lying in their beds asleep. Three female residents were observed sitting alone at the dining table and kitchen counter. The TV was on without sound in the hearth. A CNA was in a resident's room assisting a resident and no other staff were visible. Two residents required two staff for assistance with transfers. One of the two required a full body mechanical lift to be used and both were fall risks in a villa. During a confidential interview, between 6/9/25 and 6/16/25, Staff 108 indicated they had never worked in a villa where there were two CNAs and one nurse. The workload was difficult when there was only one CNA, because residents would have to wait on medications and communication with residents' families had to wait. Both staff had to perform physical transfers or when using a full body lift for transfers. One staff member had to monitor the villa when the other gave showers or was providing care. The review of the Villa Day Shift Duties, on 6/13/25 at 12:04 p.m., indicated the following was to be completed by a CNA each day: - Shower Schedule: Days Mondays and Thursdays for rooms [ROOM NUMBERS], Tuesdays and Fridays for rooms [ROOM NUMBERS], Wednesdays and Saturdays for rooms [ROOM NUMBERS], and Sundays for room [ROOM NUMBER]. - Shower Schedule: Nights Mondays and Thursdays for room [ROOM NUMBER], Tuesdays and Fridays for room [ROOM NUMBER], Wednesdays and Saturdays for room [ROOM NUMBER], and Tuesdays for room [ROOM NUMBER]. - If there was down time, please go to other [NAME] and grab any stock that was needed. - All toilets must be cleaned on every day, this was just days shift's responsibility. - Make sure all food was dated and labeled. - Deep cleans Mondays for rooms [ROOM NUMBERS], Tuesdays for rooms [ROOM NUMBERS], Wednesdays for rooms [ROOM NUMBERS], Thursdays for rooms [ROOM NUMBERS], and Fridays for rooms [ROOM NUMBERS]. -Get Report from night shift aides, Receive pager and key, Record temperatures for all refrigerators/freezers/pantry. -Prepare breakfast. Obtain the temperature of food and record. -Start morning get ups. Check and change round on all residents. -7:45 a.m., serve room trays, serve the dining table from 8:00 a.m. to 8:30 a.m. -Collect all breakfast dishes and begin cleaning the kitchen. Obtain the dish sanitizer temperature, pass ice water to all elders at 10:00 a.m. -Start POC charting. -First scheduled shower and complete skin man assessment. -Start the resident's laundry. -Do the remainder of the resident's get ups. -Check and change round on the residents. -Pick up and prepare lunch. -Set the dining room table. -Bring all residents out for lunch. -Lunch-Obtain food temperatures and record. -12:00 p.m., serve room trays, serve the dining table from 12:15 p.m. to 12:45 p.m. -Collect all lunch dishes and clean the kitchen. -Obtain the dish sanitizer temperature. -3:00 p.m. pass ice water to all residents. -Lay the residents down for afternoon naps. -Check and change rounds on the residents. -Conduct the second scheduled showers-Complete the skin man assessment. -Start resident's laundry. -Take lunch break. -Daily cleaning-Mondays and Thursdays mop the bathrooms, Wednesdays and Saturdays vacuuming. Tuesdays and Fridays delivery truck. -Begin getting residents up for dinner. -Check and change rounds on the residents. -Set the dining room table for dinner. -Dinner-obtain food temperatures and record. -5:00 p.m., serve room trays, 5:15 p.m. to 5:45 p.m., serve the dining table. -Wash the dinner dishes. Obtain the dish sanitizer temperatures. -Spot clean the remaining rooms. -Collect all trash from the resident's rooms and take it out. -Ensure all dirty cups and dishes are out of the rooms. -Turn in the sheet to the nurse to ensure all tasks were done. -Finish the remainder of the charting (charting must be completed before clocking out and leaving). -Write out the report sheet on the residents to give to the night shift. -Give the night shift aide report. Hand off the pager and key. Deep cleaning of the rooms included: -Dust the windows sills, blinds, and air conditioning units. -Wipe down the bed frame, dresser, nightstand, and TV. -Clean/straighten drawers and closet. -Straighten up the remainder of the room. -Vacuum the carpet. -Clean the mirror, bathroom counter, shower, and toilet. -Collect all trash from the room. -Gather the resident's laundry. Cross Reference F689 The facility failed to ensure adequate supervision for a resident at risk for elopement. Cross Reference F677 The facility failed to ensure Activities of Daily Living were provided. This Citation relates to Complaint IN00461158. 3.1-17(a) Based on observation, record review and interview, the facility failed to ensure sufficient nursing staff were always available to provide personal care and safety for residents reviewed for staffing. This deficiency had the potential to affect 66 of 66 residents residing in the facility. Findings include: 1. The record for Resident B was reviewed on 6/10/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease, and dementia. The care plan, dated 8/16/24 and revised on 5/23/25, indicated the resident was an elopement risk or wanderer, disoriented to place, impaired safety awareness, and a history of leaving a previous facility unsupervised. The interventions included, but were not limited to: assist in reorientation to the room and facility using verbal cues and reminders; the courtyard gate to be locked with padlock; distract the residents from wandering by offering pleasant diversions, (conversation or offer snack) structured activities, food, conversation, television, and/or book; notify social services and/or the administrator for persistent attempts to leave the building and not respond to redirection; observe for and document wandering and/or exit seeking behavior and attempted diversional interventions as needed; observe the resident's location with visual checks during rounds and as needed; and put familiar items in the resident's room to assist in identifying room. During an interview, on 6/11/25 at 11:20 a.m., Licensed Practical Nurse (LPN) 4 indicated she was the nurse on duty when the resident went out the gate. She was responsible for [NAME] 6 and 8. At the time the resident left the courtyard she was in Villa 6. There was 1 Certified Nursing Aide (CNA) was in the building, and she was assisting another resident. When she left villa 6, she entered the back entrance of Villa 8. As she entered the unit the CNA was coming out of a resident room. She heard the doorbell ring and when she answered the door the resident was standing there. The resident had a scared look on her face. Management had discontinued all wander guards, and she felt like the wander guards would help alert staff. During an interview, on 6/12/25 at 1:00 p.m., CNA 8 indicated she was assisting another resident to bed, and it took a while to get her in bed. After she assisted the resident to bed, she left the room and saw the nurse entering through the back door. She had been in another villa with those residents. They heard the doorbell ring, and the nurse went to answer the door, and it was Resident B. She walked out to the courtyard and observed the gate unlocked. The gate had a pad lock, but it was hanging on the latch unlocked. She did not know how the gate got unlocked. 3. During an interview, on 6/11/25 at 9:55 a.m., the CNA 11 indicated that she was working alone in her position and the Qualified Medication Aide (QMA) 12 was working on medication administration at the moment. The CNA indicated that in one villa there were 4 residents that require two-person physical assistance or the use of the mechanical lift. The CNA indicated the residents were supposed to have two showers a week. Sometimes it was hard to get two to three residents' daily baths done during a shift with all the other duties to complete. The residents who required two staff members for transfers would just receive a partial bed bath. During an observation, on 6/11/25 at 10:00 a.m., Resident 3 was ringing her bell and asked the CNA to get her out of bed. The CNA 11 told the resident that she could not get her up at this time due to being busy doing dishes and it had been a tense morning. The resident still had a gown on and her hair was greasy. She was lying on her back and had not been up out of bed yet. During an observation, on 6/11/25 at 10:10 a.m., Resident 3 was ringing her bell and asked the CNA 11 to get her out of bed. CNA 11 told the resident that she could not get her up at this time due to being busy putting the groceries away.

Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 1 of 2 months reviewed. (June 2025). This deficiency had the potential to affect the 66 of 66 residents currently residing in the facility. Finding includes: Review of the May and June 2025 as worked nursing schedule on 6/13/25, the following days were missing an RN or had the RN only scheduled for 5 hours: - On 6/5/25, only 6.5 hours of consecutive RN coverage was worked. - On 6/6/25, only 5 hours of consecutive RN coverage was worked. - On 6/7/25, only 5 hours of consecutive RN coverage was worked. - On 6/8/25, no RN coverage was worked - On 6/13/25, no RN coverage was worked. During an interview with the Regional Director of Clinical Operations, on 6/13/25 at 12:30 p.m., she indicated she was aware there might be missing days of RN coverage. The Director of Nursing (DON) was a working DON who covered a Villa as necessary and was involved in all aspects of the facility. 3.1-17(b)(3)

During a confidential interview, between 6/12/25 and 6/16/25, Staff 100 indicated there was only one CNA in each building. If a resident required the use of a full body mechanical lift, sit to stand, or required two staff members assistance for mobility/transfers or toileting, then the nurse would be called to come over and help. Sometimes there was a wait until the nurse was free to come over. Some days were harder than others. During an confidential interview, between 6/9/25 and 6/16/25, Staff 101 indicated some [NAME] were harder because there were some residents who required a lot of care. There were five out of ten residents who required the use of a full body mechanical lift to get up or be put back to bed. The lift would require the assistance of two staff members. The nurses were usually called from another villa to help the CNA do the lift, watched the villa while the CNA toileted residents, or was giving showers. Sometimes there was a wait until staff were finished what they were doing before coming over to help the CNA. During a confidential interview, between 6/9/25 to 6/16/25, Staff 102 indicated there were aides who floated between the buildings to help the CNA with care of the heavier care residents. There was only one CNA for each building. Monday, Tuesday, and Wednesday were usually better than the four other days. It was a struggle to get everything done by end of shift. Truthfully, the CNAs had too many tasks to do. The CNAs had to cook the meals sent over, serve the residents and clean up, cleaning the rooms, vacuuming and doing laundry, resident care, toileting, ADL's (Activities of Daily Living) on those that needed help and showers. Staff were supposed to also do the activities. A lot of times a resident would suddenly tell staff they needed to go to the bathroom while in the middle of serving. The CNA would have to stop, take them to the bathroom, then come back and sanitize and re-glove and re-heat the meal and then finally serve the residents. Staff G indicated that at times, staff had to put off a resident's shower because there was no time. During a confidential interview, between 6/9/25 and 6/16/25, Staff 103 indicated it was common for only one aide to be scheduled per villa. There were aides that floated between the [NAME] to help out. Having a floater really helped the CNA in doing care. The aide really struggled to get her work done. During a confidential interview, between 6/9/25 and 6/16/25, Staff 104 indicated there was only one CNA for each villa. At times, they could not get all of their tasks done in caring for the residents although she tried really hard. It got tough to get to all of the residents, do their care, toilet or do showers. Staff J indicated they were not able to do the activities that were scheduled. If a resident required two staff members assistance or the use of a full body mechanical lift, they would have to call the nurse or another villa to get someone to come over and help. Sometimes the residents had to wait on getting up or for care until the other person was free to come over and help. During a confidential interview, between 6/9/25 and 6/16/25, Staff 105 indicated some of the [NAME] really needed a second aide working depending on the acuity of the care the residents needed. It was tough for the day shift CNAs because the night shift only got certain people up before they left. Then the day shift CNA had to get the rest of the residents up along with all their other duties. The current facility policy, dated 09/21/23 titled, Guidelines for Bathing, which was provided by nursing staff, indicated the following: Policy: To cleanse the skin and to promote circulation .Verify bath schedule or need .never leave a resident in tub or shower room unattended . 3.1-38(a)(3) 3.1-38(a)(2)(A) 3.1-38(a)(2)(B) 3.1-38(A)(2)(C) Based on observation, record review and interview, the facility failed to ensure ADL's (Activities of Daily Living) were provided for 3 of 21 residents reviewed for ADL care. (Residents 3, 10, and 41) Findings include: 1. During an observation, on 6/11/25 at 10:00 a.m., Resident 3 turned on her call light and asked Certified Nurse Aide (CNA) 11 to assist her out of the bed. The CNA told the resident she could not get her up because she was busy washing the dishes and it had been a tense morning. Resident 3 still had a gown on, and her hair was unkept. During an observation, on 6/11/25 at 10:10 a.m., Resident 3 turned on her call light and asked CNA 11 to provide her with assistance getting out of bed. CNA 11 informed the resident that she could not get her up because she was busy putting the groceries away. During an observation, on 6/11/25 at 10:30 a.m., the Qualified Medication Aide (QMA) 12 indicated I don't even know who [Resident 3] is. or I could help. During an observation, on 6/11/25 at 12:50 p.m., Resident 3 remained in bed with her gown on and lying on her back. The resident's hair was still unkept and appeared unwashed. The resident indicated she had not gotten cleaned up or provided assistance out of the bed. During an observation, on 6/12/25 9:30 a.m., Resident 3 was lying in bed with her gown from yesterday on and lying on her back, her hair remained unkept. The record for Resident 3 was reviewed on 6/12/25 at 11:30 am. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications, nontraumatic subarachnoid hemorrhage, chronic respiratory failure, muscle weakness, cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage, dysphagia, neuromuscular dysfunction of bladder, and contracture of the right and left ankle. The Quarterly Minimum Data Set (MDS) assessment, dated 4/17/25, indicated the resident was moderately cognitively impaired, and required maximal staff assistance with transfers, bed mobility, personal hygiene and bathing. The care plan, dated 6/13/24 and revised on 2/18/25, indicated the resident had an ADL self-care performance deficit related to activity intolerance, impaired balance, musculoskeletal impairment, shortness of breath, and stroke. The interventions included, but were not limited to, a mechanical lift was indicated for transfers with assistance of two staff members, required staff assistance with turning and repositioning as needed. The review of the May and June task report indicated the following: - On 5/15/25, the record lacked documentation the resident received a shower or her hair washed. - On 5/19/25, the record lacked documentation the resident received a shower or her hair washed. - On 5/29/25, the record lacked documentation the resident received a shower or her hair washed. - On 6/2/25, the record lacked documentation the resident received a shower or her hair washed. - On 6/9/25, the record lacked documentation the resident received a shower or her hair washed. The resident did not refuse a shower or having her hair wash during the months of May and June. The nurse's note, dated 5/17/2025 at 10:17 a.m., indicated the resident was banging on the bedside table and was yelling at 7:15 a.m. The resident indicated that she wanted up out of bed. Staff members told the resident they could not get her up, but would get her up as soon as possible. A CNA took the resident her breakfast and the resident threw the dishes on the floor. A snack and drink was offered to the resident as well as a change in position in bed until staff were able to get her up out of bed, and she denied that offer and continued with behaviors. During an interview, on 6/11/25 at 9:55 a.m., CNA 11 indicated that she was working alone in her position and QMA 12 was administering medication to the residents. CNA 11 indicated in the villa there were four residents that require the assistance of two staff members for assistance or the use of a mechanical lift. The residents were supposed to have two showers a week. Sometimes it was hard to get two to three residents' daily baths done during a shift with all the other duties they were required to complete. The residents who required two staff members for transfers would receive a partial bed bath instead of a shower. 2. The record for Resident 41 was reviewed on 6/10/25 at 8:30 a.m. The residents' diagnoses included, but were not limited to Alzheimer's disease, Parkinson's disease with dyskinesia, chronic lymphocytic leukemia of b-cell type not having achieved remission, osteoarthritis, and presence of artificial hip joint. The Quarterly MDS assessment, dated 5/14 /25, indicated the resident's cognition was moderately impaired and the resident required substantial or maximum physical assistance for ADL care. The care plan, dated 1/27/25, indicated the resident had a self-care deficit related to needed assistance with ADLs to maintain the highest possible level or functioning. The interventions included, but were not limited to, mechanical lift with 2 participants for transfers, total assistance and one staff for bathing and dressing, required total assistance and one staff participant for personal hygiene and oral care. During an interview, on 6/10/25 at 1:16 p.m., Resident 41's family member indicated they don't have enough people here. She had visited the villa for over two hours on one occasion and did not see a single staff member during that length of time. The review of the May and June task sheet for the residents indicated Resident 41 did not have her hair washed in the months of May and June. During an observation, on 6/12/25 at 10:50 a.m., Resident 41 was observed lying in bed. The resident's room had a strong urine and body odor. The CNA entered the resident's room and indicated the resident's bed was urine soaked and she had to change the resident's gown, sheets, and underpad. 3.The record for Resident 10 was reviewed on 6/12/25 at 9:30 am. The resident's diagnoses included, but were not limited to, esophageal obstruction, epilepsy, moderate protein-calorie malnutrition, generalized anxiety disorder, muscle weakness, difficulty in walking, unspecified dementia with mood disturbance, and dysphagia. The Quarterly MDS assessment, dated 4/10/25, indicated the resident's cognition was moderately cognitively impaired and the resident required maximal staff assistance with personal hygiene, bathing, and dressing. Review of the May and June task report, indicated the resident was to receive a shower on 5/24/25, and 5/31/25. The resident received a partial bath (the face, hands, underarms, and genital area) on one occasion on 5/28/25. No other showers or baths were documented for May and June.

Based on record review and observation, the facility failed to ensure residents received respiratory care and maintenance for 4 of 4 residents reviewed for respiratory therapy. (Resident 3, Resident 38, Resident 54, and Resident 35) Findings included: 1. The record for Resident 3 was reviewed on 6/10/25 at 1:00 p.m. The resident's diagnosis included, but was not limited to, chronic respiratory failure. The current physician's order, dated 6/13/24, indicated for staff to always maintain the residents' oxygen at 3 liters per nasal cannula. The care plan, dated 6/13/24 and revised on 2/18/25, indicated the resident had Oxygen Therapy related to Ineffective gas exchange. The interventions included, but were not limited to, change the residents position every 2 hours to facilitate lung secretion movement and drainage, give medications as ordered by the physician, monitor for signs of respiratory distress and report to the physician, monitor for side effects and effectiveness, and oxygen via nasal cannula at 3 liters continuously. The current physician's order, dated 2/11/24, indicated staff were to change the resident's humidifier bottle once weekly on Sunday night shift and as needed. The current physician's order, dated 2/11/24, indicated staff were to change the resident's oxygen cannula/tubing once weekly on Sunday during the night shift and as needed. The review of the June 2025, Electronic Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) indicated that the humidifier bottle and oxygen cannula tubing was changed on 6/8/25. During an observation, on 6/9/25 at 10:00 a.m., the oxygen concentrator was in the resident room with a reusable water humidification canister and tubing was not dated. 2. The clinical record for Resident 54 was reviewed on 6/9/25 at 1:31 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease and respiratory failure with hypoxia. The physician's order, dated 3/21/24, indicated staff were to maintain the resident's oxygen at 2 liters per nasal cannula. During an observation, on 6/9/25 at 11:00 a.m., the resident's humidification bottle was empty of water and dated (Tuesday) 5/27/25. The oxygen tubing did not have a date. The plastic bag attached to the concentrator had a date of 5/27/25. 3. The clinical record for Resident 35 was reviewed on 6/9/25 at 12:31 p.m. The resident's diagnoses included, but were not limited to chronic obstructive pulmonary disease, and anxiety disorder. The physician's order, dated 3/27/2025, indicated the resident was to have Oxygen at 2 Liters via nasal cannula as needed for shortness of breath. The physician's order, dated 3/27/25, indicated staff were to change the resident's humidifier bottle once weekly on Sunday night shift and as needed. The physician's order, dated 3/27/25, indicated staff were to change the resident's oxygen cannula/tubing once weekly on Sunday during the night shift and as needed. During an observation, on 6/9/25 at 1:00 p.m., the humidification bottle was dated 5/27/25. The nasal cannula tubing did not have a date and the plastic bag attached to the concentrator had a date of 5/27/25. The last scheduled change of the oxygen supplies should have been dated 6/8/25. 4. The clinical record for Resident 38 was reviewed on 06/11/25 at 11:53 a.m. The resident's diagnosis included but were not limited to, COPD (chronic obstructive pulmonary disease). The physician's order, dated 5/4/25, indicated for staff to maintain the resident's oxygen at 3 liters per nasal at night only every night shift for COPD. During an observation, on 6/9/25 at 9:00 a.m., the resident's humidification bottle for oxygen was dated 5/27/25. The nasal cannula tubing did not have a date, the plastic bag attached to the concentrator had a date of 5/27/25. The current physician's order, dated 12/12/23, indicated staff were to change the resident's oxygen tubing, and humidification bottle, clean oxygen filter, inspect easy foam wraps (replace if soiled or missing), every Sunday for (SOA) shortness of air, and as needed The facility did not present a copy of the Respiratory Therapy policy. 3.1-47(a)(6)

Based on record review and interview, the facility failed to follow appropriate infection control guidelines related to complete surveillance documentation to analyze a pattern of know infectious symptoms and patterns. This had the potential to affect 66 of 66 residents residing in the facility. ([NAME] 2, 3, 4, 5, 6, 7, and 8) Findings include: The Quality Assurance Performance Improvement Meeting summary, dated 6/3/25, indicated the infection control book was not able to be located and the facility will continue to update the book for 2025. The Immediate Corrective Actions indicated Identified issue work on last 90 days continue to update. The review of the January 2025 updated Infection Control/Antibiotic Stewardship documentation, the following infections were documented: - 4 respiratory infections for residents. - 11 urinary tract infections (UTIs) for residents. - 4 skin infections for residents. The updated documentation lacked the date of onset, symptoms, culture date with results, re-culture date, isolation, resolution date, or whether the infection met the criteria. The villa floorplans lacked documentation of monitoring for patterns of infections. The review of the February 2025 updated Infection Control/Antibiotic Stewardship documentation, the following infections were documented: - 7 respiratory infections for residents. - 9 urinary tract infections (UTIs) for residents. - 2 skin infections for residents. The updated documentation lacked the date of onset, symptoms, culture date with results, re-culture date, isolation, resolution date, or whether the infection met criteria. The villa floor plans lacked documentation of monitoring for patterns of infections. The review of the March 2025 updated Infection Control/Antibiotic Stewardship documentation, the following infections were documented: -12 urinary tract infections (UTIs) for residents. - 5 skin infections for residents. - 1 blood/other for residents. The updated documentation lacked the date of onset, symptoms, culture date with results, re-culture date, isolation, resolution date, or whether the infection met criteria. The villa floorplans lacked documentation of monitoring for patterns of infections. The review of the April 2025 updated Infection Control/Antibiotic Stewardship documentation, the following infections were documented: - 9 respiratory infections for residents. - 8 urinary tract infections (UTIs) for residents. - 2 skin infections for residents. The updated documentation lacked the date of onset, symptoms, culture date with results, re-culture date, isolation, resolution date, or whether the infection met criteria. The review of the May 2025 updated Infection Control/Antibiotic Stewardship documentation, the following infections were documented: - 6 respiratory infections for residents. - 13 urinary tract infections (UTIs) for residents. - 2 skin infections for residents. - 3 blood infections for residents. The updated documentation lacked the date of onset, symptoms, culture date with results, re-culture date, isolation, resolution date, or whether the infection met criteria. The review of the June 1 through 14, 2025 updated Infection Control/Antibiotic Stewardship documentation, the following infections were documented: - 2 skin infections for a resident. - 2 blood infections for a resident. The updated documentation lacked the date of onset, symptoms, culture date with results, re-culture date, isolation, resolution date, or whether the infection met criteria. During an interview, on 6/11/25 at 10:32 a.m., the Director of Nursing (DON) and Infection Preventionist (IP), indicated the Infection Prevention for identifying, tracking, monitoring and reporting diseases would be in the binder and should stay up to date. It had not been kept up to date and they couldn't find the Infection Prevention binder. They reproduced it from January to June 2025. All monitoring was now caught up. They had gone backwards for trending and tracking. It was important to keep the Infection Prevention up to date for education for staff and residents and for resident monitoring needs for the prevention of disease spread. Infections came from other people, so the Infection Prevention documentation was important for monitoring. During an interview, on 6/13/25 at 12:41 p.m., the Regional Director of Clinical Operations (RDCO) indicated the Infection Prevention binder could not be located. They started a new 2025 binder, going back 90 days immediately on 6/3/25. They started to work to update the Infection Prevention binder back from January 2025 to now. A new IP had been recently hired and still had to be IP certified. Currently the Assistant Director of Nursing (ADON) was certified and monitored with the Infection Prevention. If she were to quit, the DON would take over the IP position to continue monitoring. The DON was also IP certified. The Guidelines For Infection Prevention and Control policy, dated 8/17/23, included, but was not limited to, . Surveillance: A surveillance system designed to do the following will be maintained. Identify possible communicable diseases or infections before they can spread to other persons in the facility. Ensure that any communicable diseases are identified and reported timely and to the required parties/agencies. Ensure that standard and transmission-based precautions are followed in an effort to prevent the spread of infection. Define when and how isolation should be used for a resident including, but not limited to: The type and duration of the isolation, depending on the infectious agent or organism involved; and Making certain that the isolation used is the lease restrictive possible for the resident under the current circumstances and findings. Being sure that no employee of the facility who exhibits a communicable disease or who had an infected skin lesion is allowed to have direct contact with any resident or with any resident's food---if direct contact could transmit the disease . 3.1-18(b)(1)(A) 3.1-18(b)(3)

Based on interview and record review, the facility failed to notify the physician and the resident's responsible party related to elevated blood surgar levels for 1 of 3 residents reviewed for notifications. (Resident 33) Findings included: The clinical record for Resident 33 was reviewed on 6/12/25 at 10:30 am. The resident's diagnoses included, but were not limited to atrial fibrillation, hypertension, edema, diabetes, right ankle wound, and unspecified dementia. The physician's order, dated 10/14/24, indicated the resident was precribed HumaLOG KwikPen Subcutaneous Solution (Insulin) Lispro with instructions for a sliding scale subcutaneously before meals and at bedtime. The sliding scale was as follows: Inject as per sliding scale: if resident's blood surgar (BS) level was 150 to 200 staff were to administer 2 units (U); 201 to 250, give 4U; 251 to 300, give 6U; 301 to 350, give 8U; 351 to 400, give 10U; for a BS grater than 400 give 10 units and call the physician. The physician's order, dated 10/14/24, indicated the resident was prescribed HumaLOG KwikPen Subcutaneous Solution with instruction to Inject 5 unit subcutaneously two times a day and to hold for a glucose reading less than 100. During an interview, on 6/12/24 at 01:33 p.m., RN (Registered Nurse) 13 indicated the provider and family should be notified immediately if the resident's blood glucose values were below the critical low or high range. During an interview, on 6/12/25 at 10:30 a.m., LPN 5 indicated if the residents' BS was grater than 400 the physician needed to be notified and then if new orders were received the family needed to be notified. Any change of condition in the resident would warrant a call to the provider and the family, then the nurse would document the change and who was notified. During a record review of the last 30 days, on 6/13/25 at 11:45 a.m., the review indicated that the resident had the following blood sugars greater than 400(mg/dL) milligrams per deciliter. - On 6/11/2025 at 3:37p.m., the resident's blood sugar level was 421 mg/dL. - On 6/10/2025 at 6:54p.m., the resident's blood sugar level was 445 mg/dL. - On 6/8/2025 at 5:18 p.m., the resident's blood sugar level was 520 mg/dL. - On 6/1/2025 at 5:53 p.m., the resident's blood sugar level was 400 mg/dL. - On 5/13/2025 at 7:56 a.m., the resident's blood sugar level was 418 mg/dL. The resident's record lacked documentation to indicate the physician or responsible party were notified of the resident's elevated blood glucose levels. Guidelines for notification of change in Resident's condition/status/treatment dated 6/29/24 was provided by the corporate nursing director on 6/13/25. The guidelines included, but was not limited to, .The objective of the notifications to the required parties .Nursing and other care staff are educated to identify changes in a resident's condition .Examples of situations .any critical lab value . 3.1-5(a)

Based on record review, and interview, the facility failed to ensure communication between the wound clinic, and documentation of wound assessments for 1 of 7 residents reviewed for wounds. (Resident 33) Findings include: The record for Resident 33 was reviewed on 6/10/25 at 8:49 a.m. The resident's diagnoses included, but were not limited to, type II diabetes and abrasion to the right ankle. The physician's order, dated 4/22/25, indicated the resident was to have a betadine moistened dressing to the wound, and covered with gauze and Coban. The physician's order, dated 5/20/25, indicated staff were to apply a collagen sheet (endoform) to the resident's wound bed, covered with a superabsorbent silicone border dressing. Change the dressing every other day. The physician's order, dated 6/8/25, indicated staff were to cleanse the resident's wound to the right lower extremity with normal saline, apply a collagen dressing, cover with a non-adherent dressing, wrap with a gauze, and secure with Coban every 48 hours for the wound. Staff were to date the dressing after the treatment was completed. The physician's orders, dated 6/10/25, indicated staff were to cleanse the resident's wound with hypochlorous acid (Vashe or similar) then apply a hypochlorous acid soaked 4 x(by) 4 gauze to the wound bed for 5 to 10 minutes after a wound assessment was completed. Apply acticoat to the wound bed and secure with gauze and Coban. Staff were to leave the resident's dressing intact until the next wound center appointment. The Quarterly Minimum Data Set (MDS) assessment, dated 4/16/25, indicated the resident was moderately cognitively impaired. The facility wound care notes, dated 4/1/25, indicated the resident had an abrasion to the right ankle. The measurements indicated the width was 2.50 centimeters (cm), the length was 2.50 cm and the depth was 0.30 cm. The wound had 30% (percent) granulation, 60% slough with serous drainage. The treatment indicated staff were to cleanse the resident's wound with wound cleanser and pat dry, medical grade honey, and apply calcium alginate with a bordered gauze. The wound assessment report, indicated the Nurse Practitioner (NP) was providing the treatments for the resident's wound, from 4/1/25 to 5/16/25. At that time the wound was classified as an abrasion. The clinical record lacked documentation of any wound assessments after 4/17/25. The clinical record lacked documentation of the wound center treatment, measurements, and appearance of the wound, from 4/17/25 through current (6/13/25). During an interview, on 6/11/25 at 10:00 a.m., Licensed Practical Nurse (LPN) 5 indicated when staff changed the residents wound dressing, they would do the measurements if needed. Staff documented the dressing changes and measurements in the treatment administration record (TAR). The resident's family did not want the wound care nurse at the facility to see the resident for wound care. The resident went weekly to the hospital wound care center. She would monitor for any signs and symptoms of infection such as increased pain, edema, redness, increased drainage, fever, increase in size, and odor. The resident was not on a low air mattress or wore pressure reducing boots. The interventions included, but were not limited to, repositioning every two hours and floating her heels. During an interview, on 6/12/25 at 10:30 a.m., the Regional Director of Clinical Operations (RDCO) indicated the wound care notes from the hospital wound care center had not been scanned into the clinical record for the nurses to read. During an interview, on 6/12/25 at 1:00 p.m., The RDCO indicated the medical records staff quit about 2 to 3 months ago. No staff member was responsible for scanning the resident documents. At that time the documents were not scanned in. During an interview, on 6/12/25 at 1:20 p.m., LPN 5 indicated the resident's wound was probably a stage II at that time. Staff were unable to see the wound report from the wound center at the hospital. The wound documents were not in the resident's clinical record. The wound center did not call the facility and give a verbal report. She indicated the only way she knew anything about the wound was when the resident's family members came in and told them. The LPN indicated she felt like the nurses should know measurements, and what treatment the wound care center provided. The Skin-Weight-Assessment policy, dated 10/9/23 included, but was not limited to, . It is the intent of the facility to assess the nutritional status as well as the skin condition status of each resident and to timely address any issues or any potential for issues related to weight and/or skin. The SWAT Team will monitor residents who meet the criteria (listed later) on a weekly basis to ensure that measures are in place to avoid loss in at risk for weight loss residents; as well as to avoid skin breakdown in residents at risk for skin breakdown---based on their medical assessments and overall health status .Ensure that care planned interventions are in practice. Ensure that trained nurses are performing treatments using Infection Control techniques .The Medical Director will review treatment protocols being used by Wound Care Specialists to include Wound Clinics and contracted Wound Care Providers to ensure that National Pressure Injury Advisory Panel Guidelines are being followed in treatment protocols . 3.1-37

Based on record review and interview, the facility failed to ensure adequate supervision for a resident at risk for elopement for 1 of 5 residents reviewed for accidents hazards. (Resident B). Findings include: The record for Resident B was reviewed on 6/10/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease and dementia. The care plan, dated 8/16/24 and revised on 5/23/25, indicated the resident was an elopement risk or wanderer, disoriented to place, impaired safety awareness, and a history of leaving a previous facility unsupervised. The interventions included, but were not limited to: assist in reorientation to the room and facility using verbal cues and reminders; the courtyard gate was to be locked with padlock; distract the resident from wandering by offering pleasant diversions, (conversation or offer snack) structured activities, food, conversation, television, and/or book; notify social services and/or the administrator for persistent attempts to leave the building and not respond to redirection; observe for and document wandering and/or exit seeking behavior and attempted diversional interventions as needed; observe the resident's location with visual checks during rounds and as needed; and put familiar items in the resident's room to assist in identifying room. The incident note, dated 5/22/25 at 5:45 p.m., indicated at approximately 5:45 p.m., the doorbell rang. The nurse answered the door and Resident B was at the door waiting to come in. When asked how Resident B got out there, she indicated, I can't tell you or you'll know my secret. A head-to-toe assessment was completed. The doors were checked and working properly. The patio gate lock was observed to be unlatched. The nurses note, dated 5/24/25 at 6:59 p.m., indicated the resident had been sitting outside on the patio. The resident walked up to the patio gate and started pushing on it. The resident asked the staff to open the doors so she could go outside for a walk. Once she asked to go outside to look for her car. The resident asked the staff if we could sneak outside. The nurse's note, dated 5/29/25 at 5:31 p.m., indicated the resident went out with a family member. The resident returned for lunch and family members and the resident went out for 30 to 60 minutes or longer. The resident had attempted to follow two sets of visitors out the front door when they left. During an interview, on 6/11/25 at 11:20 a.m., LPN 4 indicated she was the nurse on duty when the resident went out the gate. She was responsible for [NAME] 6 and 8. At the time the resident left the courtyard she was in Villa 6. There was 1 Certified Nursing Aide (CNA) in the building, and she was assisting another resident. When she left Villa 6, she entered the back entrance of Villa 8. As she entered the unit the CNA was coming out of a resident room. She heard the doorbell ring and when she answered the door the resident was standing there. The resident would not tell staff how she left the building. The resident had a scared look on her face. The resident couldn't have been gone any longer than 15 minutes. The staff inspected all the doors and alarms. When she inspected the courtyard gate it was unlocked and opened. The gate had a padlock on it and only the maintenance man and the nurse had a key. She never used the gate to go out. The resident would sit and watch the doors and had tried to leave with visitors before. Management had discontinued all wander guards, and she felt like the wander guards would help alert staff. During an interview, on 6/12/25 at 10:11 a.m., the Executive Director (ED) indicated they could not determine how the gate was unlocked. She indicated she did not know what happened. During an interview, on 6/12/25 at 1:00 p.m., CNA 8 indicated she was assisting another resident to bed, and it took a while to get her in bed. After she assisted the resident to bed, she left the room and saw the nurse entering through the back door. She had been in another villa with those residents. They heard the doorbell ring, and the nurse went to answer the door, and it was Resident B. They were unsure how the resident got out of the facility. Management was notified and all the exit doors were checked. They took a count of the residents and checked the alarms. Staff checked all areas of the [NAME] to make sure someone did come in and they weren't supposed to be there. She walked out to the courtyard and observed the gate unlocked. The gate had a padlock, but it was hanging on the latch unlocked. She did not know how the gate got unlocked. The Maintenance Director no longer worked at the facility, he left after the incident and was unavailable to interview. The Elopement and Missing Resident Prevention policy, dated 4/20/23, indicated .It is the policy of this facility that all residents are provided with adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that put them at risk for elopement . Cross Reference F725 The facility failed to ensure sufficient nursing staff were always available to provide personal care and safety for residents. 3.1-45(a)

Based on record review and interview, the facility failed to ensure insulins were administered as prescribed for 2 of 19 residents reviewed for pharmacy services. (Residents 33 and 37) Findings included: 1. The record for Resident 33 was reviewed on 6/12/25 at 10:30 a.m. The resident's diagnoses included, but were not limited to edema, diabetes, right ankle wound, and unspecified dementia. The physician's order, dated 10/14/24, indicated staff were to administer the resident's Humalog per a sliding scale. The sliding scale for before meals and at bedtime was as follows: if the resident's blood sugar (BS) level was 150 to 200 mg (milligrams per deciliters) mg/dL, the staff were to administer 2 U (units) ; 201 to 250 mg/dL, administer 4 U; 251 to 300 mg/dL, administer 6 U; 301 to 350 mg/dL, administer 8 U; 351 to 400 mg/dL, administer 10 U; for a blood sugar level grater than 400 mg/dL, administer 10 units and call the physician. During the review of the June Medication Administration Record (MAR), on 6/16/25 at 1:00 p.m., indicated the following insulin administration times were observed: - On 6/2/25, the resident's BS was 214 and the resident's insulin was to be administered at 11:30 a.m. The record indicated the insulin was administered at 3.00 p.m. - On 6/4/25, the resident's BS was 207 and the resident's insulin was to be administered at 8:00 p.m., The record indicated the insulin was given at 11:07 p.m. The physician's order, dated 10/14/24, indicated staff were to administer the resident's 5 units of Humalog 2 times daily, subcutaneously. The review of the June 2025 MAR indicated, on 6/6/25 at 1:00 p.m., the resident's 5 units for the 8:00 a.m. dose was not administered. The physician's orders, dated 5/9/25, indicated staff were to administer the resident's 30 units of Lantus in the morning, subcutaneously. Staff were to hold the administration if the resident's blood sugar was less than 100 mg/d. The review of the June 2025 MAR, indicated the resident's 30 units of Lantus was scheduled to be given at 9:00 a.m. on 6/2/25. The record indicated the resident's Lantus 30 units were not given until 2:59 p.m. During an interview, on 6/12/25 at 1:33 p.m., RN 13 indicated there was no reason why the resident's Lantus was not administered at the ordered time. 2.a The clinical record for Resident 37 was reviewed on 6/10/25 at 10:30 a.m. The resident's diagnoses included, but were not limited, diabetes mellitus due to underlying condition with diabetic neuropathy, hypokalemia, long term (current) use of insulin, and peripheral vascular disease. A physician's order, dated 7/22/24, indicated the staff were to administer the resident's Lantus Solution 100 UNIT/ML (Insulin Glargine) 10 units subcutaneously at bedtime. - On 6/1/25, the resident's insulin was to be given at 8:00 p.m. The documentation indicated the resident's insulin was administered at 5:43 a.m. on 6/2/25. - On 6/7/25, the resident's insulin was to be given at 8:00 p.m. The documentation indicated the resident's insulin was administered at 2:18 a.m. on 6/8/25. - On 6/8/25, the resident's insulin was to be administered 8:00 p.m. The documentation indicated the resident's insulin was administered at 2:05 a.m. on 6/9/25. - On 6/13/25, the resident's insulin was to be administered at 8:00 p.m. The documentation indicated the resident's insulin was administered at 11:08 p.m. - On 6/14/25, the resident's insulin was to be administered at 8:00 p.m. The documentation indicated the resident's insulin was administered at 1:59 a.m. on 6/15/25. - On 6/15/25, the resident's insulin was to be administered at 8:00 p.m. the documentation indicated the resident's insulin was administered at 1:56 a.m. on 6/16/25. 2.b. A physician's order, dated 10/14/24, indicated staff were to administer Resident 37's Humalog 5 unit subcutaneously two times a day. Staff were to hold the Humalog if the resident's BS level was less than 100. The review of the June 2025 MAR indicated the resident's Humalog was not administered on the following dates when the BS level was greater than 100 on the following dates and times: - On 6/13/25, the resident's a.m. dose was not administered for a blood sugar level of 131 mg/dL. - On 6/14/25, the resident's a.m., dose was not administered for a blood sugar level of 138 mg/dL. - On 6/15/25, the resident's a.m., dose was not administered for a blood sugar level of 135 mg/dL. - On 6/6/25, the resident's p.m., dose was not administered for a blood sugar level of 132 mg/d/L. - On 6/7/25, the resident's p.m., dose was not administered for a blood sugar level of 124 mg/dL. - On 6/13/25, the resident's p.m., dose was not administered for a blood sugar level of 129 mg. The Guidelines for Medication Administration, dated 1/25/2019 and last reviewed 3/29/24, included, but was not limited to, . 2) Medications are administered in accordance with written orders of the physician . 7) The licensed individual records the administration on the resident's MAR at the time the medication is given . 11) If a dose of regularly scheduled medication is withheld . 3.1-25(b)

Based on interview and record review the facility failed to ensure the resident received adequate supervision during transfers with a sit to stand lift. In that the resident who required assistance of two staff members sustained a fracture while being transferred with one staff member. This deficient practice affected one of four resident's requiring assistive devices. (Resident C). Findings include: The clinical record reviewed, on 05/18/2016 at 9:30 a.m., indicated Resident C's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 02/17/2016, for Resident C indicated a BIMS (Brief Interview Mental Status) score of 09 (8-11 indicated Moderate Impairment). Resident C required total dependence with two person physical assistance for transfers. Resident C's Risk for Falls care plan, dated 2/24/2016, indicated: Elder was at increased risk for falls r/t (Related to) resident requires extensive to total assistance with ADL's (Activities of Daily Living) and a lift for transfers. The CNA (Certified Nursing Assistant) assignment sheets, updated on 05/02/2016, indicated the resident was a two person assist for transfers. On 05/18/2016 at 10:00 a.m., review of the physician's orders [REDACTED]. On 05/18/2016 at 9:15 a.m., the Assistant Director of Nursing presented the incident report. Review of the incident report at that time indicated the following: on 05/06/2016 the resident reported to nurse c/o (complaints of) (L) (left) knee pain. Upon assessment the nurse noted swelling to (L) knee . X-ray completed, results are patella fx (Fracture) . Upon investigation, noted that Elder was being transferred with sit to stand lift . The review of the investigation report, dated 05/05/2016 at 10:00 a.m., indicated CNA #1 was transferring Resident C. When the resident stepped with the left leg his knee went out. CNA #1 indicated Resident C was gently lowered to the floor. CNA #1 indicated to LPN #1 there was something wrong with Resident C's leg and the resident was in a lot of pain. LPN #1 was in another resident's room when CNA #1 came to ask for assistance to move Resident C from the chair to the bed since the resident was unable to hold up on the sit to stand lift. LPN #1 indicated upon entering the room the resident was sitting in the wheelchair. In front of the resident was the lift to stand already hooked up. LPN #1 indicated, .we try (sic) to use the lift again .resident was weak and unable to stand up .we sat him back down and I went to get (CNA#4) to help us manually transfer (Resident C) to the bed. LPN #1 left for the day and CNA #1 indicated to LPN #2 that Resident C was in a lot of pain and the left knee was swelling. CNA #1 advised LPN #2 on the events that happened to Resident C prior that day. LPN #2 indicated, I did not report any injuries or chart that an incident occurred because I wasn't aware that anything happened. During an interview with Certified Nursing Assistant # 3 (CNA), on 5/8/16 at 10:30 a.m., she indicated when using a lift device for a resident there should be two staff present. During an interview with CNA #2, on 5/8/16 at 10:40 a.m., she indicated when using a lift device for a resident there should be two staff present. During an interview with the Administrator on 05/18/2016 at 11:15 a.m., she indicated, CNA #1 did not disclose to the nurse that Resident C had a fall. CNA #1 did not consider lowering an Elder (resident) to the floor was a fall. CNA #1 attempted to transfer Resident C without asking for assistance from another CNA and the resident's knee buckled. The resident was lowered to the floor by the CNA #1. During an interview with the DON (Director of Nursing) on 05/18/2016 at 11:45 a.m., she indicated Resident C's knee buckled during a transfer with the sit to stand lift. During the investigation CNA #1 was doing a one person assistance, although the resident required two persons. The undated policy and procedure, titled, The Volaro Stand Elder Lifting Device was received from the Executive Director on 5/18/16 at 11:40 a.m. The policy indicated, but was not limited, to the following: .1. Never use any type of lifting device alone. Always have another person in the room with you in case of emergency . A review of the Nurses Notes, on 05/18/2016 at 6:30 p.m., indicated no documentation was found for Resident C's fall incidence on 05/05/2016. This Federal tag relates to Complaint IN 764. 3.1-45(a)(2)