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

Based on interview and record review, the facility failed to assess a resident timely for 1 of 3 residents reviewed. This deficient practice resulted in a delay of treatment regarding sending the resident to hospital. The resident required acute medical care and remained in hospital for twenty days. (Resident 31) Finding includes:During an interview on 5/17/2026 at 11:07 A.M., Resident 31 indicated he had been recently hospitalized for sepsis, but could not recall the events that lead to him being sent to the hospital. Resident 31 indicated he woke up in the local Emergency Department and stayed in the hospital for over two weeks. Resident 31's record review was completed on 5/19/2026 at 10:00 A.M. Diagnoses included, but were not limited to: urinary tract infection, benign prostatic hyperplasia, obstructive and reflux uropathy, stage four chronic kidney disease, type two diabetes mellitus, peripheral vascular disease and congestive heart failure. A Quarterly Minimum Data assessment dated [DATE] indicated Resident 31 had not rejected care, had not had any behaviors and had intact cognition. Resident 31 had an indwelling urinary catheter and had been dependent for toileting, personal hygiene, showering and all mobility/transfer needs from the facility's staff.A Microbiology Specimen Summary dated 3/5/2026, indicated Resident 31 had a urinary tract infection. A Physicians' order dated 1/14/2026, indicated Resident 31 had an indwelling catheter and catheter care should be completed every shift.A Physician's order dated 3/5/2026, indicated Resident 31 was to be administered 500 milligrams (mg) of cephalexin (antibiotic) by mouth three times a day. A Care Plan, initiated on 3/5/2026 indicated Resident 31 had received antibiotics related to a urinary tract infection. Interventions to the Care Plan included, but were not limited to: administering medications per order, monitoring labs and cultures and report abnormal findings. A review of Resident 31's March Medication Administration Record indicated Resident 31 had not been administered his morning and mid-day dose of cephalexin on 3/7/2026, and lacked the documentation to indicate why the resident had not been administered the two doses of cephalexin. A review of the facility's Antibiotic Log indicated on 3/8/2026 the final results from the culture and sensitivity test of Resident 31's urine analysis had indicted the infection was from an organism called citrobacter previndii, and the antibiotic had been updated to sulfamethoxazole-trimethoprim. A Physician's order dated 3/8/2026, indicated Resident 31 was to be administered a 800-160 mg sulfamethoxazole-trimethoprim (antibiotic) tablet twice a day. A Nursing Progress Note dated 3/12/2026 at 6:00 P.M., and signed by the facility's Assistant Director of Nursing (ADON) indicated the Social Services Director had called the ADON at home to tell the ADON a psychologist had visited Resident 31 and found his mentation to be off. The psychologist notified the nurse responsible for Resident 31, but also reported the resident's change of condition to the SSD. The note indicated, Writer contacted the facility and spoke with the LPN on duty regarding the report. The LPN stated that the resident had been assessed and alteration from the resident's cognitive baseline was identified. The LPN was instructed to continue to monitor the resident for an changes in cognitive status or condition and to notify the provider and/or send the resident for further evaluation if a change from baseline is observed.Resident 31's record lacked the documentation that any assessment had been completed after Resident 31's psychologist reported the change in the resident's cognition. A Nursing Progress Note dated 3/13/2026 at 7:45 A.M. indicated Resident 31 had been sent to a local ED for evaluation.A Change of Condition assessment dated [DATE] at 7:30 A.M. indicated Resident 31 was nonresponsive, had a blood glucose of 65 (70-149 is normal), had a blood pressure of 85/43 (normal 90-119/60-90) and respirations of 12 per minute (normal 12-20 per minute). The nurse contacted Emergency Services (911), and the resident was sent to the local ED. A review of the ED note dated 3/13/2026 indicated Resident 31 arrived by ambulance with a blood pressure of 85/47, a rectal temperature of 94.6 F (normal range 97.9 F- 100.4 F) and had been admitted to the Intensive Care Unit (ICU) for sepsis. A review of Resident 31's hospital discharge records indicated the resident was in the hospital from 3/13-4/2/2026.An interview with the Director of Nursing (DON) was completed on 5/19/2026 at 2:21 P.M. The DON indicated that on 3/12/2026 she had been the ADON and the person who had written the Nursing Progress Note on 3/12/2026 at 6:00 P.M. The DON indicated on 3/13/2026, the SSD had called her and reported that Resident 31's psychologist believed Resident 31's cognition had been off from the Resident's normal cognitive baseline. The DON called the facility, and because it had been shift change, the DON spoke to both the first shift nurse (6:00 A.M.- 6:30 P.M) and the second shift nurse (6:00 P.M. - 6:30 A.M.). The DON indicated the first shift nurse had reported that she had assessed Resident 31 and there was no change of condition. The DON indicated she had told both nurses to continue to monitor Resident 31 and send him to the local Emergency Department (ED) if his cognition was off from his baseline. The DON indicated Resident 31 should have had a head-to-toe assessment, including a cognitive check and vital signs (blood pressure, blood oxygen saturation level, pulse, temperature and respirations per minute). The DON indicated Resident 31's record lacked any documentation to indicated Resident 31 had had an assessment or any vital signs taken after the psychologist had reported Resident 31's change of condition to the nurse. During an interview on 5/20/2026 at 2:30 P.M., LPN 6 indicated she had been responsible for Resident 31 on 3/12/2026. LPN 6indicated she had been notified by the psychologist that Resident 31 seemed confused. LPN 6 indicated she assessed Resident 31 and found nothing to be off about his mentation. LPN 6 indicated when assessing Resident 31, the assessment included LPN 6 listening to the resident's lungs and asking the resident if was ok. LPN 6 indicated Resident 31 had told her he was fine and he was tired. LPN 6 indicated she did not ask him any other questions. LPN 6 believed she had taken a set of vitals and indicated if she had taken Resident 31's vitals, the vitals would be charted in Resident 31's medical record. During an interview on 5/21/2026 at 10:00 A.M., LPN 7indicated nurses work twelve-hour shifts and she worked from 6:00 P.M. on 3/12/2026 until 6:30 A.M. on 3/13/2026. LPN 7 denied speaking to the ADON about any concerns related to Resident 31. LPN 7 indicated the LPN 6 had given her report on Resident 31 at shift change and had not included any concerns. LPN 6 indicated she was familiar with the resident and she had not assessed Resident 31's cognition on 3/13/2026. LPN 7 indicated she woke Resident 31 up to give him his bedtime medication and that was the only time she had talked to the resident during her shift. If LPN 7 had known of any concerns related to Resident 31, she would have done a full assessment, including an assessment of the resident's cognition and a set of vital signs. LPN 7 indicated she had not seen the Nursing Note added by the facility's ADON on 3/12/2026 at 6:00 P.M during her shift. During an interview on 5/21/2026 at 11:00 A.M., RN 5 indicated she had been the nurse responsible for Resident 31 when he had been sent to the ED on 3/13/2026. RN 5 indicated she had not been made aware of any concerns related to Resident 31 by the previous shifts' nurse. RN 5 indicated Resident 31 had a dialysis appointment the morning of 3/13/2026 and she had been unable to wake the resident up. RN 5 indicated she had gotten a set of vitals and because Resident 31's blood pressure was low, had a low blood glucose of 65, had not responded to verbal stimuli and had respirations of twelve, she had called 911 and requested the resident be sent out to the local ED for evaluation. On 5/21/2026 at 10:00 A.M., the DON provided an undated policy titled, Guidelines for Assessments, and identified it as the policy currently used by the facility. The policy indicated, .Nurses and other qualified health professionals will perform appropriate assessments of the resident as indicated based on the routine schedule as well as when a change in condition or circumstances and/or an event takes place that requires assessment by a qualified medical professional On 5/21/2026 at 11:00 A.M., the DON provided an undated policy titled, Change in Resident's Condition or Status, and identified it as the policy currently used by the facility. The policy indicated, .The nurse will notify the resident's attending physician when: . There is a significant change in the residents' physical, mental or psychological status . 6. The nurse will record in the resident's medical record any changes in the resident's medical condition or status 410 Indiana Administrative Code 16.2-3.1-37

Based on observation, interview and document review, the facility failed to ensure food was handled properly to prevent foodborne illness for 18 of 38 residents who consumed food being served at mealtime. Findings include:During a dining observation on 5/17/2026 between 11:48 A.M-12:02 P.M., Employees 4, 11, and 16 served a total of 14 cups and/or glasses of beverages and 6 plates of food touching the eating and drinking surfaces of the cups, glasses and plates. In addition, Employee 4's fingers were noted to be touching pudding and masked potatoes while she served food. During an interview with Administrator on 5/21/2026 at 11:05 A.M. he acknowledged that putting employee hands on the eating surface of plates of food was note a a proper way to serve food. During an interview with the Administrator, on 5/21/2026 at 11:10 A.M., a policy was requested from the administrator regarding proper food service techniques, but one was not provided prior the end of the survey. 3.1-21(i)(1) and (3)

Based on interview and record review, the facility failed to make a reasonable accommodation for a resident who required a grab bar on his bed for self-transfers for 1 of 8 resident's reviewed. (Resident 32) Finding includes:During an interview on 5/18/2026 at 8:56 A.M. Resident 32 indicated he was unable to get out of bed to use the bathroom by himself because he did not have an enabler bar on his bed. Resident 32 indicated he had been told on two different occasions, by the Maintenance Director (MD), that an enabler bar for the bed had been ordered, but the enabler bar had not yet been installed on his bed. During an interview with the MD on 5/19/2026 at 9:48 A.M., he indicated he had spoken to Resident 32 twice about the enabler bar after the facility had put in an order for the resident to have an enabler bar installed on the Resident 32's bed. The MD indicated Resident 32 was able get out of bed by himself, without the bar, but getting out of bed had caused the resident more pain in his right shoulder. The MD indicated Resident 32 had an older style bed and the enabler bars the facility had did not attach to the resident's bed correctly so the facility had ordered a new bed for Resident 32. After the invoice for the new bed was requested, the MD indicated the newer beds had previously been ordered and had already arrived at the facility before Resident 32 had even been admitted to the facility. The MD indicated he had been waiting for another resident with a newer bed to be discharged , in order to give Resident 32 a bed with an enabler bar. Resident 32's record was completed on 5/19/2026 at 2:00 P.M. Diagnoses included, but were not limited to: chronic diastolic congestive heart failure, depression, Parkinson's disease, epilepsy, osteoarthritis and chronic kidney disease. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 32 had intact cognition and required moderate assistance for all transfers. A current Care Plan, initiated on 4/15/2026, indicated Resident 32 had been at increased risk for pain and discomfort related to Parkinson's disease, decreased strength and mobility and osteoarthritis. Current interventions included, but were not limited to: encourage me to sit, stand or lie a comfortable position, encourage frequent positioning changes to prevent strain on muscles and joints and administer analgesic (pain) medication as ordered per the Plan of Care.A Side Rail (enabler bar) assessment dated [DATE], indicated Resident 32 was safely able to use an enabler bar and had been educated on the risks and benefits of an enabler bar, and had given his consent for the use of an enabler bar. A current Physician's order dated 4/29/2026, indicated Resident 32 was to have had an enabler bar attached to his bed. On 5/20/2026 at 2:30 P.M., the Executive Director provided an undated policy titled, Guidelines to Provide Reasonable Accommodations of Needs, and identified the policy as the one currently used by the facility. The policy indicated, .It is the intent of this facility to provide, at minimum, reasonable accommodations as dictated by CMS, for those persons (residents) residing in the nursing home facility. The resident has the RESIDENT RIGHT to receive care and services with reasonable accommodation of needs and preferences except when the health or safety of the resident could be jeopardized . 3. The following are examples of areas of focus . Assistive devices for turning in bed or walking or moving up in bed (such atrapeze if ordered and recommended by therapy), visual or hearing enhancers or any equipment or device recommended by therapy or the physician will be obtained as indicated according to their individualized circumstances andassessment and also per their orders and care plan 410 Indiana Administrative Code 16.2-3.1-3(v)(1)

Based on record review and interview, the facility failed to ensure the physician was notified of elevated blood glucose levels timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 36) 1. A Record review for Resident 36 was completed, on 5/19/2026 at 10:11 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, peripheral vascular disease, neuropathy and intellectual disabilities.A Quarterly Minimum Data Set (MDS) assessment, dated, 4/20/2026, indicated Resident 36 was cognitively intact and received insulin injection for 7 days of the look back period.A Physician's Order, dated 1/20/2026, indicated Insulin Aspart Subcutaneous Solution Pen-injector 100 units/milliliter, inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units and call doctor; 401 - 450 = 12 units, subcutaneously four times a day for diabetes mellitus.The following blood sugars were recorded without notification to the physician:4/11/2026 at 4:57 P.M. 404 mg/dL (milligrams per deciliter)3/19/2026 at 10:32 P.M. 436 mg/dL3/18/2026 at 12:06 P.M. 406 mg/dL3/17/2026 at 8:51 P.M. 416 mg/dL3/14/2026 at 4:52 P.M. 404 mg/dL3/11/2026 at 9:45 P.M. 441 mg/dL3/1/2026 at 6:04 P.M. 402 mg/dL2/28/2026 at 4:41 P.M. 411 mg/dL2/23/2026 at 11:16 A.M. 435 mg/dL2/20/2026 at 9:41 P.M. 462 mg/dL2/20/2026 at 5:35 P.M. 421 mg/dL2/19/2026 at 4:52 P.M. 496 mg/dL2/18/2026 at 11:48 A.M. 407 mg/dL2/15/2026 at 12:24 P.M. 426 mg/dL2/9/2026 at 11:34 A.M. 425 mg/dL2/7/2026 at 9:39 P.M. 448 mg/dL A Care Plan, dated 11/26/2025, indicated Resident 36 was at risk for unstable blood sugars related to diabetes and required insulin. Interventions included, but were not limited to: administer insulin as ordered, document all insulin administrations and blood glucose readings and report any abnormal blood glucose readings or insulin results promptly to the provider.During an interview, on 5/21/2026 at 11:49 A.M., the Director of Nursing (DON) indicated when the resident had exhibited a blood sugar over 400 mg/dL, the provider/physician should have been notified.A Policy was provided, on 5/21/2026 at 1:22 P.M., by the Executive Director. The policy titled, Changes in Resident's Condition or Status, indicated, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status.1. Th nurse will notify the resident's attending physician when: There is a need to alter the resident's treatment plan significantly. 410 IAC (Indiana Administrative Code) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure a gradual dose reductions for psychotropic medications was attempted for 1 of 5 residents reviewed for unnecessary medications. (Residents 24) Findings include: 1. A record review for Resident 24 was completed on 5/19/2026 at 9:55 A.M. Diagnoses included, but were not limited to: anxiety, depressive disorder, and altered mental status. A physician's order initiated on 10/30/2025 for Lorazepam 0.5 mg, give 0.25 mg by mouth two times a day for anxiety. The order had been discontinued on 4/16/2026. A physician's order, dated 4/16/2026 indicated Lorazepam 0.5 mg, give 0.25 mg by mouth two times a day for anxiety had been reordered. A physician's order ,dated 10/07/2025 indicated behavior monitoring every shift for tearful periods, isolation, anxiety, depression. Observe for any new onset and/or worsening side effects with psychotropic drugs common side effects every shift. A review of behavior monitoring reports indicated the resident had exhibited no behaviors from December 14, 2025 through May 20, 2026. A pharmacy review of medications document, dated 12/14/2025, recommended reducing the Lorazepam from 0.25 mg twice daily to 0.25 mg daily. There was no provider's signature and date acknowledging receipt of the informaiton on the letter of recommendation. A pharmacy review of medication document, dated 2/20/2026, recommended reducing the Lorazepam dose from 0.25 mg twice daily to 0.25 mg daily. The FNP had agreed with recommendation on 2/20/2026 but the order had not been initiated in Resident 24's record. During an interview with the DON, on 5/22/2026 at 11:32 A.M. she indicated the change order should have been entered by the DON. A policy for following a physician's order was requested but none was provided prior the the survey's exit. 16.2 Indiana Administrative Code (IAC) 3.1-3(w)

Based on record review and interview, the facility failed to ensure 11 of 15 nursing staff (Director of Nursing, RN 5, LPNs 6, 7, 9, 10, 12 and 14, QMAs 8, 13 an 15) demonstrated competency related to following medication orders for 1 of 6 residents reviewed. (Resident 31)Finding includes: Resident 31's record review was completed on 5/19/2026 at 10:00 A.M. Diagnoses included, but were not limited to: urinary tract infection, benign prostatic hyperplasia, obstructive and reflux uropathy, stage four chronic kidney disease, type two diabetes mellitus, hyperthyroidism, major depressive disorder, anxiety disorder, peripheral vascular disease, hypertension and congestive heart failure. A Quarterly Minimum Data assessment, dated 2/26/2026, indicated Resident 31 had not rejected care, had not had exhibited any behaviors and had intact cognition. A review of Resident 31's February 2026 Medication Administration Record indicated Resident 31 had the following orders:- Give one 25 milligrams (mg) capsule of metoprolol succinate (anti-hypertensive) by mouth one time a day every Tuesday, Thursday, Saturday and Sunday. Hold if SPB <110 or DBP <80- Give 100 mg capsule of bupropion HCl (treats depression and anxiety) once a day- Give 50 micrograms (MCG) of cholecalciferol (Vitamin D) once a day- Give 75 mcg of levothyroxine sodium (treats hyperthyroidism) once a day Resident 31's February 2026 MAR indicated the resident was administered metoprolol without having had his blood pressure assessed prior to administration on the following dates: 2/1, 2/5, 2/7, 2/8, 2/10, 2/12, 2/14, 2/15, 2/17, 2/19, 2/21, 2/22, 2/24, 2/26 or 2/28/2026. The nursing staff administering the medications on those dates included RN 5, LPN 6, QMA 8, LPN 9 and LPN 10. In addition, Resident 31 was not administered bupropion, cholecalciferol or levothyroxine, as ordered, on the morning of 2/14/2026. The resident's record lacked any documentation indicating why the resident had not been administered the prescribed medications. A review of Resident 31's March 2026 Medication Administration Record indicated Resident 31 had the following orders:- Give one 25 mg capsule of metoprolol succinate by mouth one time a day every Tuesday, Thursday, Saturday and Sunday. Hold if SPB <110 or DBP <80- Give one 40 mg capsule of atorvastatin Calcium (treats hyperlipidemia) once daily-Give one 0.4 mg capsule of tamsulosin HCl (treats prostate) once daily-Give one 0.5 mg tablet of alprazolam (treats anxiety) twice a day-Give 5 mg of apixaban (blood thinner) twice a day-Give one 40 mg tablet of furosemide (water pill) twice a day-Give one 500 mg tablet of cephalexin (antibiotic) three times a day Resident 31's March 2026 MAR indicated the resident had been administered metoprolol without having had his blood pressure assessed prior to the administration of the medication on the following dates: 3/1, 3/5, 3/8, 3/10 and 3/12/2026. Nursing staff administering medication on those dates included QMA 8, LPN 6, LPN 9 and LPN 10. In addition, Resident 31 was not administered alprazolam, furosemide, cephalexin and apixaban on 3/7/2026. The clinical lacked the documentation indicating why the resident had not been administered the prescribed medications.A review of Resident 31's April 2026 Medication Administration Record indicated Resident 31 had the following orders:- Give one 25 mg capsule of metoprolol succinate by mouth one time a day every Tuesday, Thursday, Saturday and Sunday. Hold if SPB <110 or DBP <80 Resident 31's April 2026 MAR indicated the resident had been administered metoprolol without having had his blood pressure assessed prior to the administration of the medication on the following dates: 4/16, 4/18, 4/21, 4/25, 4/26 and 4/30/2026. The nursing staff involved included LPN 12, QMA 12 and LPN 14 In addition, Resident 31 was administered metoprolol with blood pressures assessed that indicated his medication should have been held on the following dates: 4/4, 4/5, 4/9, 4/11 and 4/12/2026. The nursing staff involved included the Director of Nursing, RN 5, QMA 8 and LPN 9. A review of Resident 31's May 2026 MAR indicated Resident 31 had the following order:- Give one 25 mg capsule of metoprolol succinate (anti-hypertensive) capsule by mouth one time a day every Tuesday, Thursday, Saturday and Sunday. Hold if SPB <110 or DBP <80Resident 31's May 2026 MAR indicated Resident 31 had been administered metoprolol without having had his blood pressure assessed on the following dates: 5/2, 5/3, 5/7, 5/9, 5/10, 5/12, 5/14, 5/15 and 5/19/2026. Nursing staff involved included LPN 7, LPN 12, QMA 13, LPN 14 and QMA 15. During an interview on 5/21/2026 at 10:00 A.M., LPN 7 indicated Resident 31 should not have been administered metoprolol if there had not been a blood pressure assessed and recorded for the resident at the time of the medication administration.During an interview on 5/21/2026 at 11:30 A.M., RN 5 indicated she should not have administered metoprolol in February, March or April 2026 if there had not been a blood pressure assessed at the time of the medication administration, or if the blood pressure results were out of range per the Physician's order.During an interview on 5/21/2026 at 11:45 A.M., the DON indicated Physician orders should be followed as written, and any time metoprolol was given without the staff taking a blood pressure, the staff had been incorrect regarding medication administration. The DON indicated if a medication was not given, there should have been documentation in the chart indicating why a medication had not been given per the Physician order. The DON indicated medication administration was part of the new hire orientation processes and all staff who passed medications had to have their medication administration skills checked and signed off by their trainer. A medication administration skill check included following parameters a medication may have when administering medications to residents. A review of the skills check off for medication administration was reviewed for the DON, RN5, LPN 6, LPN 7, QMA 8, LPN 9, LPN 10, LPN 12, QMA 13, LPN 14 and QMA 15. All of the included nursing employees had had their medication administration skill completed without any concerns before the staff member had administered medications without supervision. A policy for following the Physician's order was requested on 5/20/2026 at 2:30 P.M., but one was not provided prior to the exit of the survey on 5/21/2026 at 2:00 P.M. 410 Indiana Administrative Code 16.2-3.1-14(i)

Based on record review and interview, the facility failed to follow physician ordered medication monitoring based on physician orders for 1 of 5 residents reviewed for unnecessary medications. (Residents 6) Findings include:1. A record review for Resident 6 was completed on 5/18/2026 at 1:00 P.M. Diagnoses included, but were not limited to: acute on chronic diastolic congestive heart failure and hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 3/23/2026, indicated Resident 6 was cognitively intact and received a diuretic.A Physician's Order, dated 4/10/2026, indicated a weekly weight was to be obtained for congestive heart failure and the physician was to be notified of a weekly weight gain of two pounds or more.A review of Resident 6's weights for April 2026 and May 2026, indicated a weight had only been obtained for the weeks including the dates of 4/29/2026, 5/11/2026 and 5/13/2026.During an interview, 5/21/2026 at 10:32 A.M., the Director of Nursing (DON) indicated Resident 6's weight values should have been documented weekly in the medical record. She indicated an electronic prompt to document the weight had not been added to the physician order in the electronic clinical record.A Policy was provided, on 5/21/2026 at 1:22 P.M., by the Executive Director. The policy titled, Changes in Resident's Condition or Status, indicated, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status.1. Th nurse will notify the resident's attending physician when: There is a need to alter the resident's treatment plan significantly. 410 IAC (Indiana Administrative Code) 3.1-48(a)(3)

Based on observation, interview and document review, the facility failed to ensure time sensitive medications were dated when opened for 1 of 38 residents (R 25) on 1 of 3 nursing units. (Teal unit) Findings include:During an inspection of the medication cart on the Teal Unit on 5/20/2026 at 9:45 A.M., a bottle of eye drops, for Resident 25, opened had been opened, but did not have an open date on the bottle.During an interview with QMA 3, on 5/20/2026 at 9:52 A.M. she indicated the eye drops should have been dated when they were opened.A policy titled, Medication Storage in the Facility, provided by the administrator on 5/21/2026 at 1:22 P.M. and indicated the policy was the one currently used by the facility. The policy indicated.Outdated drugs will be immediately withdrawn from stock by the facility.A policy for dating medications when opened was requested but one was not provided.16.2 Indiana Administrative Code (IAC) 3.1-25(k)(6)

Based on interview, observation and record review, the facility failed to maintain an effective pest control program related to flies in a resident's room for 1 of 38 residents reviewed. (Resident 25)Finding includes:During an interview on 5/18/2026 at 10:38 A.M., Resident 25 indicated she had had a fly problem for about a year. Resident 25 indicated staff had been aware of the flies and the facility had had a local pest control company treat her room for drain flies. During an observation on 5/18/2026 at 10:40 A.M., a dozen flies could be seen on the walls of Resident 25's room, and six flies could be seen on the resident's bathroom walls. During a tour of the environment with the Maintenance Director (MD) and Housekeeping Supervisor (HS) on 5/19/2026 at 9:35 A.M., both the MD and HS denied knowledge of any reported issue in Resident 25's room and/or bathroom involving flies. During an interview with Resident 25's family member on 5/19/2026 at 9:38 A.M., the family member indicated Resident 25 had been dealing with drain flies for about a year. She indicated she had bought the resident E-Z traps ( fly trap with all four sides of the trap covered in sticky adhesive) to take care of the problem eight or nine months prior. The family member went into Resident 25's bathroom and removed the E-Z trap from behind the toilet and showed the MD and HS. The E-Z trap had four sides and was eighty percent covered in dead flies. During an interview with the MD and the HS on 5/19/2026 at 9:39 A.M., both the MD and HS indicated they were unaware Resident 25 had a drain fly problem and denied knowing there was an E-Z insect trap located behind Resident 25's toilet. The HS indicated housekeeping mopped the bathroom floors of the resident's rooms daily and should have noticed the E-Z trap. The MD indicated he toured the building daily and completed rounds on a handful of rooms once a month to identify possible areas of concern. The MD indicated he had been in Resident 25's room within the last six months and denied knowing there had ever been an issue with flies. A review of the pest control invoices, completed on 5/20/2026 at 9:00 A.M., indicated Resident 25's room had been inspected and treated on 6/25/2025 and 8/25/2025 for insect activity. On 5/21/2026 at 1:30 P.M., the Executive Director provided an undated policy titled, Guidelines for Pest Control, and identified it as the policy currently used by the facility. The policy indicated, It is the policy of the facility to ensure that an effective Pest Control Program is in place. An effective pest control program is defined as-measures to eradicate and contain common household pests. These include but are not necessarily limited to roaches, ants, mosquitoes, flies, gnats, maggots, bees, wasps, hornets, mice, rats, spiders, snake(s), ticks, termites, other . 2. The maintenance staff and all other staff will be cognizant of the necessity to maintain a clean, safe, and comfortable, homelike environment that is free of pests or rodents. 3. Upon a sighting of any pest or rodent or any evidence of a pest or rodent by any person In the facility, the Administrator will be notified. The problem will be addressed to include contacting the Pest Control vendor should an off-schedule visit be necessary 410 Indiana Administrative Code 16.2-3.1-19(f)(3)

Based on record review, observation and interview, the facility failed to develop and implement interventions to reduce the risk of falls for 2 of 4 residents reviewed for accidents, (Resident 27 and 247). This deficient practice resulted in a fall requiring hospitalization for 1 of 4 residents reviewed for accidents. (Resident 247). Findings Include: 1. The record for Resident 247 was completed on 01/08/2025 at 9:40 A.M. Resident 247 was admitted on [DATE]. Diagnosis included, but were not limited to subarachnoid hemorrhage, cardiomegaly, falls, insomnia and polyneuropathy. The Admission Minimum Data Set (MDS) assessment, completed on 12/18/2024 indicated Resident 247 was moderately cognitively impaired, required moderate/partial assistance for personal hygiene, toileting and transfers and substantial assistance for ambulation more than 10 feet. The resident was marked as having falls in the past 1 - 6 months prior to her admission. A Fall Risk review (assessment), dated 12/14/2024, indicated Resident 247 was at high risk for falls. A baseline Care Plan, dated 12/16/2024, indicated the resident had a history of falls and required two person physical assist for transfers. There were no goals or interventions on the care plan. A Nursing Progress Note, dated 12/14/2024 at 4:59 P.M., indicated Resident 247 was at high risk for falls but there were no interventions implemented to prevent falls. Daily Skilled Progress Notes, dated 12/21/2024, 12/22/2024 and 12/24/2024, all indicated resident 247 had unsteady balance, weakness and needed reminders to use a call light before transferring but there were no interventions implemented to prevent falls. A Nursing Progress Note, dated 12/24/2024 at 9:59 A.M., indicated the resident informed staff she was walking around the bed and tripped on her bed covers and hit her head on the wall. A small amount of bleeding was noted around the staples in the resident's head, which were in place prior to her admission due to a head injury from a fall prior to her admission. The staples were noted to be intact and the resident denied any pain. A Nursing Progress Note, 12/24/2024 at 2:04 P.M., indicated the staff spoke with Residents' son to inform him they had initially sent the resident out to a local hospital and then she was transferred to a level two trauma hospital in a nearby city and was treated in the Intensive Care Unit (ICU) for a brain hemorrhage. A facility IDT general note, dated 12/25/2024 at 9:15 A.M., indicated the resident had an unwitnessed fall on 12/24/2024 at 09:37 A.M. with an injury to the back of her head. The Resident's head was bleeding and due to the resident's recent history of brain bleed, she was sent to the local hospital emergency room and then transferred to a level two trauma hospital ICU unit due another brain hemorrhage in same area as her previous brain hemorrhage. An intervention was to be initiated, a sign placed in her room as a visual cue to use call light for help prior to getting out of bed or getting up to walk, when the resident returned from the hospital. A hospital history and physical assessment, dated 12/24/2024, indicated Patient was seen earlier this month for a fall with a head bleed. Diagnostic imaging today reveals a broad left subdural hematoma with two millimeters (MM) of left to right midline shift. There were no care plan interventions to prevent falls in place for Resident 247 to prevent this fall resulting in a subdural hematoma and subsequent hospitalization . A current Care Plan, initiated on 12/27/2024 after the resident had fallen and while the resident was hospitalized , indicated the resident was at risk for falls related to a closed head injury on admission. Interventions included, but were not limited to: Observe for side effects from medications that increase risk of falling such as dizziness and unusual drowsiness and notify the physician if observed, keep call light in reach when in room, encourage resident to use call light to seek assistance, refer to therapies as needed, and evaluate possible causes of falls and address issues to the extent possible. There were no interventions to increase supervision and/or providing any assistive devices to prevent falls. A Daily Skilled Nursing Note, dated 1/3/2024 at 11:04 P.M., indicated Resident 247 was alert and oriented with confusion, unsteady with weakness, tried to get up and walk without help and had to be reminded many times to ask for help before standing. There were no additional interventions implemented to prevent falls. A Daily Skilled Nursing Note, dated 1/4/2025 at 12:23 P.M., indicated Resident 247 was alert but very confused, kept walking around outside of her room, was unsteady with weakness and was reminded many times to ask for help before standing. There were no additional interventions implemented to prevent falls. A Daily Skilled Nursing Note, dated 1/8/2025 at 8:41 A.M., indicated Resident 247 was unsteady with weakness and had to be re-educated many times to ask for help before standing. There were no new interventions implemented to prevent falls. During a random observation, on 1/6/2025 at 10:20 A.M., Resident 247 was observed walking in her room unassisted, without an assistive device and there was no sign posted to remind the resident to use the call light. During a random observation, on 1/7/2025 at 9:56 A.M., Resident 247 was observed walking in her room unassisted, without an assistive device and there was no sign posted to remind the resident to use the call light. During a random observation, on 1/8/2025 at 1:15 P.M., Resident 247 was observed walking in her room unassisted, without an assistive device and there was no sign posted to remind the resident to use the call light. During an interview, on 1/8/2025 at 1:26 P.M., CNA 3 indicated she did not know what intervention had been implemented after Resident 247 fell and she would have to ask. During an observation, on 1/8/2025 at 1:36 P.M., CNA 3 handed Resident 247 a paper and educated the resident on using her call light. During an interview, on 1/8/2025 at 1:38 P.M., CNA 3 indicated the resident should have a reminder to use call light in room. During an observation, on 1/8/2025 at 1:40 P.M., Resident 247 was observed walking to her restroom unassisted without an assistive device. During an interview, on 1/9/2025 at 10:46 A.M., CNA 4 indicated staff were notified of changes through the electronic record, but sometimes she had to ask the charge nurse about changes. During an interview, on 1/9/2025 at 11:25 A.M., the DON indicated she did not believe a new intervention had been put in place after Resident 247's fall as the resident was in the hospital and would be treated as a new admission when she returned. She indicated staff were notified of new interventions by putting the new interventions in the electronic record and also telling staff at the shift change huddle. During an interview, on 01/09/2025 at 2:29 P.M., the MDS nurse indicated the baseline care plan did not have goals or interventions and that the comprehensive care plan for falls had not been completed until 12/27/24 while Resident 247 was at the hospital. 2. The record for Resident 27 was completed on 01/07/2025 at 2:48 P.M. Diagnosis included, but were not limited to arthritis, hypertension, obstructive and reflux uropathy, and glaucoma. A Quarterly Minimum Data Set assessment, completed on 11/15/2024 indicated Resident 27 was severely cognitively impaired, required substantial/extensive staff assistance for transferring, walking, personal hygiene, bed mobility and wheelchair mobility. The resident was marked as not having any falls since admission to the facility. The current Care Plan, initiated on 12/28/2022 and revised on 11/26/2024, indicated the resident was at risk for falls due to her condition, risk factors, decreased strength/endurance, general weakness, and osteoarthritis. Interventions included but were not limited to, bed in lowest position with fall mat next to bed, initiated on 12/31/2024, place call light in reach and encourage me to use and nursing staff to complete a fall risk assessment per facility protocol. An Interact Assessment, dated 12/28/2024 at 11:50 P.M., indicated Resident 27 had an unwitnessed fall and the physician was notified. The Nursing Progress Note related to the fall on 12/28/2024 at 11:50 A.M., completed on 12/29/2024 at 12:45 A.M., indicated Resident 27 was observed lying face down beside her bed and was assessed to have a bump to the left side of her head. An Interdisciplinary Team (IDT) note, dated 12/30/2024 at 9:00 A.M., indicated the root cause of the fall, on 12/28/2024 at 11:50 P.M., was rolling out of bed. A new intervention was for the bed to be placed in the lowest position with fall mat beside the bed. There were no new interventions implemented as a result of Resident 27's fall from bed on 12/28/2025. During a random observation, on 1/7/2025 at 2:18 P.M., Resident 27 was lying in bed with no mat beside her bed and the bed was not in lowest position. During a random observation, on 1/8/2025 at 1:13 P.M., Resident 27 was lying in bed with no mat beside her bed and the bed was not in lowest position. During an interview, on 1/8/2025 at 1:19 P.M., CNA 3 indicated she was not aware of any fall interventions for Resident 27 and would have to ask the nurse. On 01/08/25 at 01:25 P.M. CNA 3 was observed placing a fall mat in Resident 27's room. During an interview, on 01/08/25 at 01:27 P.M., CNA 3 indicated the resident is to have her bed in lowest position and a mat on floor next to the bed. During an interview, on 01/09/25 at 10:46 A.M., CNA 4 indicated they are notified of interventions by DON putting a message in PCC (computer) to let us know, but sometimes we have to ask the charge nurse. During an interview, on 01/09/25 at 11:25 A.M., the DON indicated new interventions should be on the care plan for staff and the DON talked to staff about them at the shift change huddle. She indicated she did not know why the new intervention for Resident 27 had not been observed to be in place on 1/7/2025 and 1/8/2025 while the resident was in bed. , The current facility policy, titled Guidelines for Incidents/Accidents/Falls, dated 6/30/2023, was provided by the Regional MDS Consultant on 1/9/2025 at 1:50 P.M., and indicated the policy was the one currently used by the facility. The policy indicated . 11. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. Note: each fall needs a new care plan intervention. Residents are assessed for fall risk upon admission, re-admission, quarterly and when there is a change of condition to include a fall. 15. The resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions related to unsealed and undated items in the freezer/cooler,expired foods in use, and dirty cooking utensils and appliances in the main kitchen. This deficient practice had the potential to affect 44 of 44 residents who received meals out of the kitchen. Findings include: 1. During the initial tour of the kitchen, on [DATE] at 9:25 A.M., with the Dietary Manager the following was observed: - the reach in freezer had dirty seals along the bottom of the freezer and the freezer floor had food debris - the walk-in freezer had a box of sausage links that was not sealed properly - an entire bag of Salisbury steak not sealed. - a bag of biscuits was opened and not sealed - the kitchen floor had stains and food debris. - the walk-in cooler had 2 water containers belonging to staff - there was an opened and undated jar of dill pickles in the walk in cooler. - an opened and undated bag of chicken gravy in the dry storage area. - 4 bags of navy beans with an expiration date of ,d+[DATE] /2024 were noted in the dry storage area - an opened and unsealed bag of sugar was in the dry storage area. - an opened and unsealed box of graham crackers was in the dry storage area - an opened and unsealed bag of thickener was in the dry storage area During an interview, on [DATE] at 9:32 A.M., the Dietary Manager indicated the foods should be sealed and the floor should have been swept. During an interview, on [DATE] at 9:40 A.M., the Dietary Manager indicated the personal items should not have been in the cooler and the other food items should have been dated and sealed. 2. During a second visit to the main kitchen, on [DATE] at 11:41 A.M., a metal spoon was observed under the food prep counter and a dish rag was seen underneath and between a second refrigerator. 3. During lunch service on [DATE] at 12:29 P.M., the cook was observed resting the plates against his uniform during the plating of the food. 4. During a revisit to the main kitchen on [DATE] at 9:40 A.M., the following things were observed: - the plate in the microwave was dirty with yellow debris. - the drinking glasses white powdery stains on the bottoms of the glasses. - an opened and undated jar of peanut butter - 1 metal pan had a greasy substance on it and was stored as clean - a rubber spatula with burnt areas to the end was stored as clean - a small, medium and large sized skillet with the Teflon coating scrapped and/or peeling off the cooking area During an interview, on [DATE] at 9:47 A.M., the Dietary Manager indicated the microwave plate should have been cleaned, the spatula should have been thrown away and the skillets should not be used. During an interview, on [DATE] at 10:04 A.M., [NAME] 12 indicated she had not added any sanitizing solution to the cleaning bucket. She indicated It's only water. The cook indicated she should have added the sanitizing solution. On [DATE] at 12:31 P.M., the Dietary manager provided the policy tilted, Storage of Refrigerated Foods, dated [DATE], and indicated the policy was the one used by the facility. The policy indicated . 13. Refrigerated items must have a label showing the name of the food and the dated it should be consumed or discarded . 14 . Monitor daily for expiration dates or 'used by' dates and discard all outdated items immediately . 16. Medications, employee lunches . shall not be stored in dietary refrigerators On [DATE] at 12:31 P.M., the Dietary Manager provided the policy titled, Labeling and Dating, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated . Leftovers and opened foods shall be clearly labeled with date food item is to be discarded On [DATE] at 12:31 P.M., the Dietary Manager provided the policy titled, Storage of Frozen Foods, undated, and indicated the policy was the one currently used by the facility. The policy indicated . 11. Food stored in the freezer shell be covered, labeled and dated On [DATE] at 12:31 P.M., the Dietary Manager provided the policy titled, Equipment Cleaning and Sanitizing, undated, and indicated the policy was the one currently used by the facility. The policy indicated .3. Wash, rinse, and sanitize all food contact surfaces of the equipment that are stationary On [DATE] at 12:31 P.M., the Dietary Manager provided the policy titled, Sanitation Bucket/Wiping Cloths food contact surfaces & equipment too large to rinse in the sink, undated, and indicated the policy is the one currently used by the facility. The policy indicated .Wiping cloths kept in a sanitation bucket containing a solution of water and chemical sanitizer are used to sanitize food contact surfaces . In the red sanitation bucket mix the water and the chemical sanitizer . The sanitation buckets are changed as often as necessary to maintain the correct concentration of sanitizing solution 3XXX,d+[DATE](i)(3)

Based on record review, observation and interview, the facility failed to ensure base line care plans were initiated for a resident with falls and receiving dialysis, and a resident at high risk for falls for 2 of 5 residents reviewed for base line care plans. (Resident B & 247) Findings include: 1. The record for Resident B was reviewed on 1/7/2025 at 11:34 A.M. Diagnoses included but were not limited to: fractured ribs, cancer, end stage renal disease, bipolar, repeated falls and malnutrition. An Admission Minimum Data Set (MDS) assessment, dated 7/30/2024 indicated Resident B was receiving dialysis. A Base Line Care Plan form, dated 7/30/2024, indicated the resident required dialysis and had previous falls with injury. The form lacked goals, interventions and any special needs to properly care for the resident. During an interview, on 1/8/2025 at 10:59 A.M., the MDS coordinator indicated the care plan summary should have had goals and interventions. 51598 2. The record for Resident 247 was reviewed on 1/8/2025 at 9:40 A.M. Resident 247 was admitted on [DATE]. Diagnosis included, but were not limited to subarachnoid hemorrhage, cardiomegaly, falls, insomnia, and polyneuropathy. A Nursing Progress Note, dated 12/14/2024 at 4:59 P.M., indicated Resident 247 was alert and oriented, transferred with 1 assist and was at high risk for falls. A fall risk review, dated 12/14/2024, indicated Resident 247 was at high risk for falls. A baseline care plan, dated 12/16/2024, indicated Resident 247 had a history of falls. The care plan lacked goals and/or interventions for falls. During an interview, on 1/09/2025 at 2:29 P.M., the MDS nurse indicated the baseline care plan did not have goals or interventions. The comprehensive care plan for falls was not completed until 12/27/2024 while Resident 247 was at the hospital. The current facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans, dated 3/23/2021, was provided by the Regional MDS Consultant on 1/9/2025 at 1:50 P.M., and indicated the policy was the one currently used by the facility. The policy indicated . the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions 3.1-30(a)

Based on record review and interview, the facility failed to ensure a PASARR (Pre-Admission Screening and Resident Review) was completed timely for 1 of 1 residents reviewed. (Resident B) Finding includes: The record for Resident B was reviewed on 1/7/2025 at 11:34 A.M. Diagnoses included, but were not limited to fractured ribs, cancer, end stage renal disease, bipolar, and malnutrition. A PASARR Level 1 for Resident B was completed on 6/16/2024. The Level 1 determined Resident B had a serious mental illness and/or intellectual disability and was placed in the Convalescence category - 60 Day Convalescence Care Approval. A 60 day or less stay in the NF (nursing facility) was authorized. The form indicated Re-screening must occur by or before the 60th day if the individual is expected to remain in the NF beyond the authorization timeframe On 1/8/2025 at 1:13 P.M., the Social Service consultant provided a Notice of Level 1 screen outcome. The level 1 screening form indicated it was valid for 60 days with an end date of September 14, 2024. The record for Resident B lacked the documentation to show a new level 1 screen had been completed before 9/14/2024. During an interview, on 1/8/2025 at 2:18 P.M., the Social Service consultant indicated there should have been another Level of Care (LOC) PASARR form completed in September. She indicated she had instructed the Business office manager (BOM) to initiate the process. On 1/9/2025 at 12:03 P.M. the Corporate MDS consultant provided a policy, titled Ascend-PAS and LOC, undated, and indicated the policy was the one currently used by the facility. The policy indicated . 5. Short term LOC a. 7- 14 days prior to expiration date, nursing facility (BOM) to initiate a new level 1 and LOC . 8. Update LOC audit tool with resident names, date of admission, date path tracker was completed, date level 1 was completed, if level 2 was needed, date LOC was completed, short term/long term status of LOC, and date if any of LOC ending date (BOM) 3.1-16(d)

Based on interview and record review, the facility failed to ensure a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form was provided following the end of Medicare skilled services for 2 of 3 residents who discharged from Medicare services and remained in the facility. (Resident 9 & 14) Finding includes: On 1/8/2025 at 9:07 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. 1. The form indicated Resident 9 was not issued an SNF-ABN form. Resident 9 was provided with a Notice of Medicare Non-Coverage (NOMNC) Form which indicated Resident 9's Medicare coverage would end on 8/28/2024. An Advanced Beneficiary Notice (ABN) was not provided to Resident 9. During an interview, on 1/9/2025 at 9:52 A.M., the Business Office Manager (BOM) indicated Resident 9 had 34 Medicare A days remaining to use and was provided with a NOMNC which indicated Resident 9 would be discharged from Medicare A services on 8/28/2024. 2. The form indicated Resident G was not issued an SNF-ABN form. Resident G was provided with a Notice of Medicare Non-Coverage (NOMNC) Form which indicated Resident G's Medicare coverage would end on 6/6/2024. An Advanced Beneficiary Notice (ABN) was not provided to Resident G. During an interview, on 1/9/2025 at 9:56 A.M., the BOM indicated Resident G had 57 Medicare A days remaining to use and was provided a NOMNC which indicated Resident G would be discharged from Medicare A services on 6/6/2024. She indicated anyone who received a NOMNC will receive an ABN after they are no longer covered by Medicare A services. She indicated she did not keep a copy of the ABN's provided. A policy for ABN administration was requested. On 1/10/2025 at 1:37 P.M., the Executive Director indicated a policy was not available for ABN notices/documentation. 3.1-4(f)(2)

Based on observation, record review and interview, the facility failed to complete a comprehensive care plan for 3 of 13 residents reviewed for comprehensive care plans. (Residents 18, 20 and 32) Findings include: 1. During an observation on 1/6/2024 at 9:53 A.M., Resident 18 had facial hair stubble. He indicated this was the longest his facial hair had been in a while and the CNA (Certified Nursing Assistant) was to assist him to shave. A record review for Resident 18 was completed on 1/8/2025 at 1:20 P.M. Diagnoses included, but were not limited to: cerebral infarction (stroke), spinal stenosis and chronic obstructive pulmonary disease (COPD). A Quarterly Minimum Data Set (MDS) assessment, dated 12/16/2024, indicated Resident 18 was cognitively intact, required partial/moderate assistance for bed mobility and substantial/maximal assistance for transfers and personal hygiene. A Care Plan for activities of daily living (ADLs) could not be located in the medical record. During an interview, on 1/9/2024 at 10:05 A.M., the MDS (Minimum Data Set) Coordinator indicated a care plan for ADLs was initiated on 12/8/2024 and resolved on 12/15/2024. The care plan for ADLS was no longer active. He indicated Resident 18 should have had a care plan for ADL care needs. 2. During an interview, on 1/6/2025 at 2:01 P.M., Resident 20 indicated he had a Foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body). A record review for Resident 20 was completed on 1/7/2025 at 1:05 P.M. Diagnoses included, but were not limited to: chronic kidney disease stage 4, obstructive and reflux uropathy and congestive heart failure. A Significant Change Minimum Data Set (MDS) assessment, dated 10/31/2024, indicated Resident 20 have moderate cognitive impairment and had an indwelling catheter. A Physician's Order, dated 12/19/2024, indicated a 16 French (5.3 millimeters) urinary catheter with a 10 milliliter balloon to be changed as needed and catheter care every shift during routine CNA (certified nursing assistant) care. A Care Plan for Foley (urinary) catheter care could not be located in the medical record. During an interview, on 1/9/2025 at 12:00 P.M., the MDS Coordinator indicated the care plan was created on 7/9/2024 and resolved on 7/22/2024. The care plan for the Foley catheter was no longer active. He indicated Resident 20 should have had a care plan for Foley (urinary) catheter care. 3. A record review for Resident 32 was completed on 1/7/2025 at 11:18 A.M. Diagnoses included, but were not limited to: underweight, disorientation and osteoarthritis. A Quarterly Minimum Data Set (MDS) assessment, dated 11/18/2024, indicated Resident 32 had moderate cognitive impairment. Hypothyroidism was not a diagnosis listed for active diagnoses. A Physician's Order, dated 11/25/2024, indicated levothyroxine sodium 75 mcg (micrograms) medication daily for high thyroid stimulating hormone. A Care Plan for hypothyroidism could not be located in the medical record. During an interview, on 1/9/2025 at 10:10 A.M., the MDS Coordinator indicated a care plan for hypothyroidism was not available and Resident 32 should have had a care plan for hypothyroidism. A policy was provided by the Director of Nursing, on 1/10/2025 at 11:28 A.M. The policy titled, Baseline Plan Assessment/Comprehensive Care Plan, indicated, .The Comprehensive Care Plan will further expand on the resident's risk, goals and interventions using the Person-Centered Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. These needs will be defined from observations, interviews, clinical record review and through assessment and CAAs [care area assessments]. The facility Interdisciplinary team in conjunction with the resident, resident's family, surrogate or representative as appropriate along with a hands on caregiver, such as a Certified Nursing Assistant will discuss and develop quantifiable objections along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident .3. The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAAs. The Comprehensive Care plan will include participation from IDT [interdisciplinary team] members as well as CNA[s] who deliver hands on care by the way of interview, some member of the food/nutritional service staff, restorative nursing team as applicable, as well as a Social Service Worker .9. The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum 3.1-35(a)

Based on record review and interview, the facility failed to ensure care plan meetings were held timely for 3 of 25 residents whose care plans were reviewed. (Residents 27, 30 and 38) Findings include: 1. The record for Resident 27 was reviewed on 01/07/2025 at 2:48 P.M. Diagnosis included, but were not limited to arthritis, hypertension, obstructive and reflux uropathy and glaucoma. A Care Plan meeting progress note, dated 4/4/2024, indicated Resident 27's POA (Power of Attorney) was present at the meeting. The record lacked documentation of any care plan meetings having been held after 4/4/2024. During an interview, on 1/8/2025 at 1:23 P.M., the Corporate Social Service Director (SSD) indicated a meeting was held in April and Resident 27 should have had two additional meetings since then, but no meetings have been held since April. 2. During an interview, on 1/6/2025 at 11:02 A.M., Resident 38's Power of Attorney (POA) indicated he had not had any care plan meetings since the initial admission meeting but he was just informed the meetings should have been held quarterly. The record for Resident 38 was reviewed on 1/8/2025 at 1:24 P.M. Diagnosis included, but were not limited to fracture of Rt. femur, hemiplegia and hemiparesis, contracture of muscle to right hand, calorie malnutrition, hx history of stroke, depression and dysphagia. A Care Plan meeting progress note, dated 7/10/2024, indicated Resident 38's POA was present at the meeting and Resident 38 had declined to attend the meeting. The record lacked the documentation of any care plan meetings having been held after 7/11/2024. During an interview, on 1/8/2025 at 1:23 P.M., the Corporate Social Service Director (SSD) indicated a meeting was held in July and Resident 38 should have had one in October. 49994 3. During an interview on 1/6/2025 at 10:35 A.M., Resident 30 indicated he had never been to a care plan conference. On 1/7/2025 at 11:23 A.M., a record review was completed for Resident 30 and indicated the resident was admitted to the facility on [DATE]. A record review indicated Resident 30 had a care plan conference on 10/2/2023, 11/17/2023 and 12/4/2024. The record lacked documentation that a care plan conference was held between 11/17/2023 and 12/4/2024. During an interview on 1/9/2025 at 8:48 A.M., the Administrator indicated care plan conferences were located in the resident's progress notes or documents. He indicated he would try and find the residents care plan conferences that were missing between 11/17/2023 and 12/4/2024. During an interview on 1/9/2025 at 10:09 A.M., the Regional MDS Consultant indicated the resident did not have any care conferences between 11/17/2023 and 12/4/2024 and should have. 3.1-35

Based on observation, record review and interview, the facility failed to ensure an incontinent resident remained free from an indwelling urinary catheter for 1 of 1 residents reviewed for urinary catheters. Finding includes: During an observation, on 1/7/2025 at 1:46 P.M., Resident 34 was lying in her recliner. The urinary drainage tubing was observed over her left thigh and the urinary drainage bag was hung on the wheelchair next to the recliner. A record review for Resident 34 was completed on 1/8/2025 at 10:04 A.M. Diagnoses included, but were not limited to: neuromuscular dysfunction of the bladder, kidney failure and history of urinary tract infections. Resident 34 was admitted to the facility on [DATE]. She was discharged on [DATE] and readmitted on [DATE]. An Admission Minimum Data Set (MDS) assessment, dated 10/1/2024, indicated Resident 34 was cognitively intact and was frequently incontinent of bladder. An Admission Minimum Data Set (MDS) assessment, dated 12/9/2025, indicated Resident 34 was cognitively intact and had an indwelling urinary catheter. A Bowel and Bladder Incontinence Screener assessment, dated 9/24/2024, indicated Resident 34 voided appropriately without incontinence always, was incontinent of bowel and was sometimes mentally aware of the need to use the toilet. The assessment indicated to proceed with a Bowel and Bladder Incontinence History Review for further evaluation to determine eligibility for a structured toileting program. A Bowel and Bladder Incontinence History Review was not completed. A Nursing Progress Note, dated 10/2/2024 at 1:25 P.M., indicated a Foley (urinary) catheter was anchored in the bladder. A Care Plan, dated 10/2/2024 and revised 12/17/2024, indicated Resident 34 was at risk for complications related to the use of a Foley catheter due to a neurogenic bladder. A Hospital History and Physical, dated 11/25/2024, indicated Resident 34 had a chronic Foley catheter placed in October 2024. The Foley (urinary) catheter was placed due to Resident 34 leaking urine constantly and no records suggested or supported a neurogenic bladder diagnosis. A Bowel and Bladder Incontinence Screener assessment, dated 12/2/2024, indicated Resident 34 voided appropriately without incontinence not always, but at least daily, was incontinent of stool 1-3 times per week and was usually aware of the need to use the toilet. The assessment indicated Resident 34 had a urinary/bowel collection device, remained continent at the time and do not proceed with Bowel and Bladder Incontinence History Review was marked. A Urinary Catheter Review assessment, dated 12/2/2024, indicated Resident 34 did not have a diagnosis for an unavoidable catheterization. A Urinary Catheter Review assessment, dated 12/3/2024, indicated Resident 34 had a post void residual of 200 milliliters or more, an inability to manage the retention/incontinence with intermittent catheterizations and persistent overflow incontinence, systemic infections and/or renal dysfunction. However, a post void residual or orders for intermittent catheterizations could not be located in the medical record. A Physician's Order, dated 12/3/2024, indicated a Foley urinary catheter 16 French 10 milliliter balloon and catheter care every shift. During an interview, on 1/10/2025 at 10:37 A.M., the Nurse Practitioner indicated Resident 34 may have some retention. During an interview, on 1/10/2025 at 12:08 P.M., Resident 34 indicated she was peeing all over herself and requested a urinary catheter to be placed. During an interview, on 1/10/2025 at 12:33 P.M., the Nurse Practitioner indicated Resident 34 had a neurogenic bladder. She indicated her thought process was Resident 34 had moisture associated skin dermatitis on her buttock and was unable to control her urine. Resident 34 would stand up and urine would flow, so a Foley (urinary) catheter was placed. The Nurse Practitioner indicated she did not try to implement a medication, complete a bladder scan or a toileting program prior to placement of the Foley (urinary) catheter. During an interview, on 1/10/2025 at 12:41 P.M., the Director of Nursing indicated a 3-day bowel and bladder assessment was completed upon admission and Resident 34 had a full medical examination for neurogenic bladder prior to admission. However, documents supporting the evaluation of neurogenic bladder were not available for review. A policy was provided, on 1/10/2025 at 8:37 A.M. by the Executive Director. The policy titled, Catheters, indicated, .It is the policy of the facility to ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. Further that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible 3.1-41(a)(1)

Based on record review, observation and interview, the facility failed to ensure nutritional supplements % (percentage) were documented for a resident with weight loss; failed to initiate RD recommendations for supplements for a resident with weight loss and failed to serve the appropriate diet to a resident receiving dialysis for 3 of 4 residents reviewed for nutrition. (Residents 1, 27 and E) Findings include: 1. During an interview, on 1/6/2025 at 10:17 A.M., Resident 1 indicated she had lost maybe another 25 pounds. The record for Resident 1 was reviewed on 1/9/2025 at 8:59 A.M. Diagnoses included, but were not limited to: diabetes, anxiety, kidney failure, and polyneuropathy. Current Physician Order, dated 12/23/2024, included the following: House shake with meals for Supplement- give 1 container/serving by mouth. Record % consumed. A Care Plan, initiated on 9/16/2024, indicated Resident 1 was at risk for nutritional deficit related to diagnoses of heart disease, diabetes, hypertension and gastro esophageal reflux disease. Weight loss. Interventions included but were not limited to: Diet is served as ordered. Snacks are available to me between meals upon request. Offer replacement for foods/beverages not consumed or if consumes 50% or less of meal. Monitor weights and intakes. Notify physician and resident & responsible party of significant weight changes. The December Medication Administration Record (MAR) indicated the percentage for the House Shakes was only documented three times. The January MAR dated 1/1 through 1/9/2025 lacked the documentation of the percentage consumed of the Health Shake. During an interview, on 1/9/2025 at 3:13 P.M., the Director of Nursing indicated she completed the order and did not put it in the electronic charting system correction. She indicated the percentages should have been documented. 51598 2. The record for Resident 27 was reviewed on 01/07/2025 at 2:48 P.M. Diagnosis included, but were not limited to arthritis, hypertension, obstructive and reflux uropathy and glaucoma. A current Care Plan revised on 8/22/2024, indicated the resident was at nutritional risk due to: diagnoses of hypertension, gastroesophageal reflux disease and hyperlipidemia. Receives diuretic treatment with anticipated weight fluctuations related to fluid shifts. Interventions include but were not limited to; diet served as ordered, offer replacement for foods/beverages not consumed or if consumes 50% or less of meal, monitor weights and intakes, and requires adaptive feeding devices of built-up handled silverware. The care plan does not mention any interventions for significant weight loss. A nutrition at risk review, dated 12/11/2024, indicated Resident 27 was on a regular diet, and weighed 135.2 pounds (lbs) on 11/27/2024 and 122.2 on 12/11/2024, indicating a loss of 9.6% in two weeks. The resident intakes were less than 50 percent of meals. The recommendations included, but were not limited to, house shakes three times a day (TID). A Nurse Practitioner Progress note, dated 12/11/2024, and signed electronically on 1/9/2025 indicated Resident 27 was being seen for a 10 percent weight loss and had poor oral intake. The recommendations related to abnormal weight loss included house shakes TID. A nutrition at risk review, dated 12/19/2024, indicated that Resident 27 was on a regular diet and had a weight of 120.8 lbs on 12/18/2024, indicating a loss of 10.1% in one month. The resident intake were less than 25 percent of meals. The recommendation included house shakes TID. A Physician's Order, dated 12/20/2024, indicated house shake TID, one container/serving, and record percent consumed. A Physician's Order, dated 12/23/2024 and revised on 1/9/2025, indicated house shake with meals. The order did not indicate record consumption or serving amount until 1/9/2025. A nutrition at risk review, dated 12/27/2024, indicated Resident 27 was on a regular diet with house shake at meals and had a weight of 120.8 lbs on 12/18/2024, indicating a loss of 10.1% in one month. The resident intake was less than 25 percent of meals and no new recommendations were made. A nutrition at risk review, dated 1/8/2025, indicated Resident 27 was on a regular diet with house shake at meals, continued to have weight loss, and weight on 1/5/2025 was 117 lbs, indicating a loss of 13.1 percent in 1 month. There were no new recommendations. During an interview, on 1/9/2025 at 11:25 A.M., the Director of Nursing (DON) indicated the Dietician would email her recommendations, and she would put the order in the computer. She indicated she did not know why the recommendation on 12/11/2024 was not implemented until 12/20/2024. The DON indicated she was not sure why the order was changed to not include documentation of amount consumed because the dietician would not know how effective the supplement was. The DON indicated when a resident had a significant weight loss, the resident would be added to the Skin-Weight-Assessment-Team program (SWAT). The DON indicated the resident was not currently followed by SWAT. On 1/10/2025 at 12:04 P.M., the Director of Nursing provided the policy titled,Guidelines for Physician Orders- Following Physician Orders, dated 6/18/2023, and indicated the policy was the one currently used by the facility. The policy indicated . 4. 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 The current facility policy, titled Dietician Referrals and Recommendations, dated 4/2017, was provided by the Regional Nurse Consultant on 1/10/2025 at 12:04 P.M., and indicated the policy was the one currently used by the facility. The policy indicated . the dietician will communicate recommendations to be carried out by the DON or nursing designee The current facility policy, titled S-W-A-T Program, was provided by the Regional Nurse Consultant on 1/10/2025 at 12:04 P.M., and indicated the policy was the one currently used by the facility. The policy indicated . 5 percent or more (undesirable) weight change in 30 days . and SWAT meets weekly to discuss residents who meet criteria as stated. as stated. A policy was provided, on 1/10/2025 at 12:41 P.M. by the Dietary Manager. The policy titled, Liberalized Diets, indicated, .Resident swill receive the least restrictive diet to maximize meal intake, improve quality of life, and increase Resident satisfaction .2. Each resident shall receive the least restrictive diet per physician order .4. Diet orders and diet spreadsheets shall match the facility approved terminology 3.1-46(a)(2) 45120 3. During an interview, on 1/6/2025 at 2:02 P.M., Resident 20 indicated he had just returned from his dialysis treatment. A record review for Resident 20 was completed on 1/7/2025 at 1:05 P.M. Diagnoses included, but were not limited to: chronic kidney disease stage 4, mild protein-calorie malnutrition, diabetes mellitus type 2 and gastroparesis. A Significant Change Minimum Data Set (MDS) assessment, dated 10/31/2024, indicated Resident 20 had moderate cognitive impairment and had no significant weight loss or gain. A Physician Order, dated 12/14/2024, indicated a consistent carbohydrate dialysis diet. A Physician's Order, dated 12/19/2024, indicated a gastroparesis diet with no lentils, seeds or nuts; no dried, raw or uncooked fruits and vegetables with skins; no fruits or vegetables with seeds; no fatty foods; no citrus drinks; and no highly sweetened foods. A Care Plan indicated Resident 20 was at risk for a nutritional deficit related to protein calorie malnutrition, chronic kidney disease with dialysis and diabetes mellitus type 2. Interventions included, but were not limited to: prepare and serve diet as ordered. During an observation, on 1/9/2025 at 11:53 A.M., Resident 20 had a meal tray served to his room. The food on the plate included mashed potatoes with gravy on top of a slice of bread and turkey, carrots and peach cobbler. However, according to the Menu Extension for special diets, Resident 20 should have been served fluffy rice in place of the mashed potatoes due to his need for a renal diet, and a half serving of 2 ounces for peach cobbler instead of 4 ounces due to the consistent carbohydrate diet requirements. During an interview, on 1/9/2025 at 12:12 P.M., Resident 20 indicated he had the choice of the main meal served or alternatives if he did not want the main meal. He indicated he likes rice, and should not have potatoes as they are high in potassium. Resident 20 indicated he had a list of foods to avoid that were high in potassium. This list was observed hanging on his closet door. During an observation, on 1/10/2025 at 12:16 P.M., Resident 20 had a meal tray delivered to his room. The meal tray included chicken cornbread bake, broccoli and chocolate cream pie. A meal ticket indicated no dairy products, no deli meats or hot dogs, no ground beet, no uncooked fruits or vegetables and no whole grain breads or cereal. The meal ticket indicated he had ordered the main meal. However, according to the Menu Extension for special diets, Resident 20 should have been served 5 ounces of baked chicken and rice pilaf in place of the chicken cornbread bake and sugar cookies in place of the chocolate cream pie due to his renal diet. During an interview, on 1/10/2025 at 12:21 P.M., the Dietary Manger indicated staff asked the residents for their meal preferences and Resident 20 had requested the main meal. He indicated Resident 20 should have been served baked chicken, rice pilaf and sugar cookies. He indicated he did not realize the main menu diet was different for the renal diet.

Based on observation, record review and interview, the facility failed to properly store oxygen therapy equipment and C-PAP (continuous positive airway pressure) equipment for 2 of 2 residents reviewed for oxygen therapy. (Resident 18 and 20) Findings include: 1. During an observation, on 1/6/2025 at 9:53 P.M. and 1/7/2025 at 10:37 A.M., Resident 18's C-Pap mask was observed on top of his personal refrigerator, unbagged. During an observation, on 1/8/2025 at 1:14 P.M., Resident 18's C-Pap mask was observed on the floor. During an observation, on 1/9/2025 at 11:27 A.M., a CNA came out of the Resident 18's room. The C-Pap mask was observed on top of the personal refrigerator, unbagged. At 1:30 P.M., the C-Pap mask was still on top of the resident's personal refrigerator. A record review for Resident 18 was completed on 1/8/2025 at 1:20 P.M. Diagnoses included, but were not limited to: cerebral infarction (stroke), congestive heart failure, obstructive sleep apnea and chronic obstructive pulmonary disease (COPD). A Quarterly Minimum Data Set (MDS) assessment, dated 12/16/2024, indicated Resident 18 was cognitively intact. The assessment did not indicate he received C-Pap therapy. A Physician's Order, dated 2/9/2024, indicated Resident 18 to wear the C-Pap at bedtime and for naps every shift. A Care Plan, dated 11/6/20924 and revised on 11/15/2024, indicated Resident 18 presented with altered sleeping and breathing functions secondary to obstructive sleep apnea. Interventions included, but were not limited to: utilization of the sleep apnea machine per doctor's orders and to set up the machine according to manufacturer's guidelines. During an interview, on 1/9/2025 at 1:31 P.M., CNA 9 indicated the C-Pap mask should be stored in the bedside table drawer, and should not be on the over the bed table. She indicated she has not seen a respiratory bag in use for storage of C-Pap masks. During an interview, on 1/9/2025 at 1:37 P.M., QMA 8 indicated C-Pap masks should be stored in a respiratory bag when not in use. 2. During an observation, on 1/6/2025 at 9:49 A.M., Resident 20's nasal cannula tubing was attached to the hydration chamber of the concentrator tank and on the floor. During an observation, on 1/6/2025 at 11:04 A.M., Resident 20's nasal cannula tubing was attached to the hydration chamber of the concentrator tank. The respiratory storage bag was intertwined in the nasal cannula on the floor. During an observation, on 1/6/2025 at 1:51 P.M., the nasal cannula was draped over the over the bed table at the end of the bed. During an observation, on 1/9/2025 at 11:38 A.M., the respiratory storage bag was observed intertwined with the nasal cannula on the floor. Resident 20 was wearing his nasal cannula. A record review for Resident 20 was completed on 1/7/2025 at 1:05 P.M. Diagnoses included, but were not limited to: congestive heart failure, anemia and cardiomyopathy. A Significant Change Minimum Data Set (MDS) assessment, dated 10/31/2024, indicated Resident 20 have moderate cognitive impairment. The assessment did not indicate he received oxygen therapy. A Physician's Order, dated 12/14/2024, indicated Resident 20 to wear oxygen at 4 liters per minute via nasal cannula continuously. A Care Plan, dated 2/8/2024, indicated Resident 20 had complications with gas exchange related to shortness of breath and oxygen saturations less than 90 percent. During an interview, on 1/9/2025 at 1:31 P.M., CNA 9 indicated oxygen tubing should be stored in a respiratory bag when not in use. She indicated the oxygen tubing should not drag on the floor. During an interview, on 1/9/2025 at 1:37 P.M., QMA 8 indicated nasal cannulas should be stored in a respiratory bag when not in use. A policy was requested for oxygen therapy and C-Pap guidelines. A policy was provided, on 1/10/2025 at 10:58 A.M., titled, Bi-Level Therapy. The employee indicated that oxygen and C-Pap storage was not included in the policy. 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to provide a dignity cover for a urinary indwelling catheter for 1 of 1 residents reviewed for urinary indwelling catheters. (Resident 34) Finding includes: During an observation, on 1/7/2025 at 1:46 P.M., Resident 34 was lying in her recliner. The urinary drainage tubing was observed over her left thigh and the drainage bag had a white side and a clear side. The urinary collection bag was observed from outside the room, hanging on the wheelchair next to the recliner, without a dignity cover and urine was able to be viewed through the clear side of the bag and was also leaking on the floor. During an observation, on 1/8/2025 at 9:11 A.M., the urinary collection bag was observed hanging from the bed frame without a dignity bag. Urine was visible in the collection bag. During an observation, on 1/8/2025 at 11:24 A.M., Resident 34 was transported via a wheelchair to the therapy room with the urinary drainage bag attached under the resident's wheelchair without a dignity bag. Urine was visible in the collection bag. During an observation, on 1/9/2025 at 11:26 A.M., Resident 34 was observed in the therapy room with the urinary drainage bag hanging from the wheelchair armrest without a dignity bag. Urine was visible in the collection bag. A record review for Resident 34 was completed on 1/8/2025 at 10:04 A.M. Diagnoses included, but were not limited to: neuromuscular dysfunction of the bladder, kidney failure and history of urinary tract infections. An Admission Minimum Data Set (MDS) assessment, dated 12/9/2025, indicated Resident 34 was cognitively intact and had an indwelling urinary catheter. A Physician's Order, dated 12/3/2024, indicated catheter care was to be provided every shift and staff were to ensure the catheter drainage bag was below the resident's waist height and covered. A Care Plan, dated 10/2/2024 and revised on 10/3/2024, indicated Resident 34 was at risk for complications related to the use of a Foley (urinary) catheter due to a neurogenic bladder. During an interview, on 1/9/2025 at 11:46 A.M., CNA 7 indicated the Foley catheter drainage bags should be covered. A policy was provided, on 1/10/2025 at 8:37 A.M., by the Executive Director. The policy titled, Catheters, did not indicate the need for dignity covers for indwelling urinary catheters. 3.1-3(t)