Every finding on record at Waters of Wabash Skilled Nursing Facility East the

Based on observation, interview, and record review, the facility failed to ensure a resident's wound prevention interventions were implemented and the care plan was updated for 1 of 3 residents reviewed for wounds. (Resident C)Findings include: The following was observed on 3/16/26: At 9:50 a.m., Resident C laid on his back on an air mattress with his head elevated, a foot cradle (to keep the weight of the bed covering off a resident's feet and legs) was positioned at the end of the bed. His feet were directly on the mattress. His blankets covered his left foot, and he had a nonskid sock on his right foot. At 12:16 p.m., he was lying on his back on an air mattress with his head elevated. The foot cradle was positioned at the end of the bed. His feet were directly on the mattress. His blankets covered his left foot, and he had a nonskid sock on his right foot.At 3:23 p.m., he was lying on his back on an air mattress with his head elevated. The foot cradle was positioned at the end of the bed. His feet were directly on the mattress. His blankets covered both feet.Resident C's clinical record was reviewed on 3/16/26 at 11:35 a.m. Diagnoses included permanent atrial fibrillation, pulmonary fibrosis, type II diabetes mellitus with diabetic neuropathy, unspecified diastolic (congestive) heart failure, chronic kidney disease, peripheral vascular disease, unspecified protein-calorie malnutrition, post-polio syndrome, and other chronic pain. His current physician orders included bilateral heels to be elevated off bed with pillows every shift for preventative (11/5/24), Aquaphor external ointment (skin protectant) apply to bilateral legs/feet topically every day and evening shift for prevention (12/2/25), Pro-heal (promotes healing) give 30 milliliters (ml) twice daily (3/5/26), encourage moon boots (for heel protection) at all times except for bathing and care every shift (3/5/26), right root second toe (distal) cleanse with povidone iodine (skin antiseptic), cover with povidone iodine soaked gauze, cover with abdominal pad, wrap with gauze and secure with tape every day shift (3/13/26), right foot third digit (proximal) cleanse with povidone iodine, povidone iodine-soaked gauze, abdominal pad, rolled gauze, and secure with tape every day shift (3/13/26), right great toe, cleanse with povidone iodine, cover with povidone iodine-soaked gauze, cover with abdominal pad, wrap with gauze and secure with tape every day shift (3/13/26).A 2/11/26, quarterly, Minimum Data Set (MDS) assessment indicated he was severely cognitively impaired. He was dependent for toileting, upper/lower body dressing, putting on/taking off footwear, personal hygiene, and rolling from back to left and right side, and return to lying on his back in bed. He was at risk for developing pressure ulcers. He had a pressure reducing device to his bed and chair. A quarterly Braden Scale assessment (for predicting pressure ulcers) dated 2/27/26 indicated he was at a moderate risk for the development of pressure ulcers. A nurses note, dated 3/4/26 at 4:05 p.m., indicated a CNA reported new areas were found to the resident's toes during a shower. His right great toe had two areas measuring each 1.8 centimeters (cm) length (L) x 1.0 cm width (W) and 1.0 cm (L) x 0.5 cm (W), respectively. His right foot third toe with two areas measuring 1.0 cm (L) x 0.8 cm (W) and 1.0 cm (L) x 1.0 cm (W). The areas were cleansed with wound cleanser, calcium alginate was applied, and bordered gauze.He had a current care plan, revised on 2/11/26, for increased risk for impaired skin integrity related to decreased mobility, incontinence, right hand contracture, chronic diarrhea, chronic cardiovascular disease, type II diabetes mellitus, at risk for malnutrition, peripheral vascular disease, obesity, chronic kidney disease, he received an anticoagulant and an antiplatelet medication. Interventions included offload heels at all times while in bed and may use a pillow to ensure ankles and heels were floating (2/11/26), precautions for prevention of pressure ulcers would be completed: good peri care and drying of skin, apply protective barrier cream, reposition him frequently when in bed or chair and/or wheelchair, off load heels as needed, Certified Nurse Aide (CNA) shower/skin observations to be reported to the nurse for any unusual findings or changes in his skin integrity (2/11/26), and pressure reducing/relieving mattress per policy (2/11/26). He had care plans revised on 3/12/26 for an arterial/ischemic ulcer of the location: Right foot great toe, Right foot second toe distal, and Right Foot 3rd digit proximal related to: related to: Vascular insufficiency. Interventions initiated on 3/12/26 included inspect my feet daily, especially between the toes (3/12/26), keep the feet clean and dry (3/12/26), observe extremities for signs and symptoms or poor tissue perfusion (3/12/26), observe/document wound (3/12/26), observe/document/report as needed any signs or symptoms of infection (3/12/26), and weekly treatment documentation (3/12/26).During an interview on 3/16/26 at 12:28 p.m. QMA 5 indicated Resident C's wound prevention interventions included the foot cradle and moon boots while in bed.During an interview on 3/16/26 at 1:20 p.m. Resident C was observed lying on his back on an air mattress, his sheet and blanket were covering his left foot, and he had a nonskid sock on his right foot, and his feet were lying on the mattress. He indicated the facility was putting lotion and a sticker on his buttocks. He had problems with his right foot more than his left foot. He thought they did daily treatments to his right foot. He had pain in his feet and buttocks. At times they propped him on his side but seldom put pillows under his legs. He indicated that the foot cradle at the end of his bed was to keep the blankets from bothering his feet as he had his second toe amputated on his right foot. During an interview on 3/16/26 at 3:31 p.m. QMA 7 indicated Resident C's wound prevention interventions included moon boots at all times, wrapping his foot in gauze, the air mattress, and the foot cradle to keep the blankets off his feet and repositioning him every two hours. The moon boots were an intervention implemented in the last few weeks. During an interview on 3/17/26 at 11:45 a.m. the DON indicated Resident C's wound prevention interventions included moon boots, but he refused them at times, the foot cradle to keep his blankets elevated, off load his heels, reposition him, the air mattress and make sure his toes were nice and dry. He had multiple dopplers (ultrasound studies), he had a procedure at the vein clinic, and his second toe had been amputated. The MDS Coordinator was currently updating the care plans due to the corporation wanting to revise care plans. They normally updated interventions as a wound was discovered and as needed and remove old interventions if they were not appropriate. During an interview on 3/17/26 at 1:51 p.m. the ADON indicated she used to work in medical records and she would update the CNA sheets related to interventions. LPN 13 took over the Medical Records department and was getting acclimated to the position. The CNAs would go by the interventions on the CNA sheets, not the care plan in the resident's electronic health records. Review of CNA sheets at the time of the interview indicated, under the section Need to know, for Resident C included enhanced barrier isolation, left sided weakness, foot buddy to end of bed, diabetic, diabetic mechanical soft, thin liquids and Proheal per nurse.A current facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans and provided by the Administrator on 3/17/26 at 12:51 p.m. indicated the following: Policy .The Comprehensive Care Plan will further expand on the resident's risks, 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 . Procedure .9 .The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues. 10. The MDS/Care Plan Coordinator and/or ancillary MDS staff will attend the Morning /CQI meetings where in-depth review of the 24-Hour Report(s) since the prior Morning/CQI meeting are reviewed and discussed as well as new or changed orders, new admissions, readmissions, falls and other pertinent circumstances regarding the residents. They will then see that the care plans for these residents are revised and updated as necessary This citation relates to Intake 2788978. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure Qualified Medication Aides (QMA) were completing wound treatments within their scope of practice for 1 of 3 residents reviewed for wounds. (QMA 5, 7, 9 and Resident D)Findings include:Resident D's clinical record was reviewed on 3/16/26 at12:09 p.m. Diagnoses included chronic systolic (congestive) heart failure, chronic pain syndrome, personal history of other venous thrombosis and embolism (blood clots), unspecified protein-calorie malnutrition, unspecified atherosclerosis of native arteries of extremities, bilateral legs, and restless legs syndrome. A Nurse Practitioner (NP) wound note, dated 12/30/25 at 10:08 a.m., indicated an original wound to the left second toe noted on 8/19/25 was resolved, but a new wound developed on the left great toe, initially presenting with purple discoloration concerning for an evolving arterial ulcer. Although vascular studies later showed adequate perfusion, the great toe wound progressed with intermittent redness, dryness, fluctuating exudate, and periods of the resident's refusal of recommended dressings. The wound was later classified as trauma-related and likely from a transfer incident. The wound had improved, dry, without drainage and was smaller in size measuring 0.8 centimeter (cm) x 1.2 cm x 0.1 cm (length x width x depth) with full thickness loss. The January 2026 Medication Administration Record (MAR) included orders to cleanse left great toe with povidone iodine (skin antiseptic) and leave open to air every day shift. Monitor for signs and symptoms of infection or worsening and contact nurse practitioner or physician. QMA 5 documented that she completed the treatment on 1/1/26and 1/6/26. A nurses note, dated 1/29/26 at 8:59 p.m., indicated he had a wound to his left toe that was recurring. The wound had reopened and was bleeding. The wound was wrapped with gauze, but resident would not allow a measurement of the wound. An NP wound note, dated 2/3/26 at 9:50 p.m., indicated his left great toe wound measured 0.7 cm x 1.0 cm x 0.1 cm (length x width x depth). The wound had reopened with partial thickness loss. The February 2026 MAR included orders to cleanse left great toe with povidone iodine and leave open to air until resolved every day and evening shift. QMA 7 documented in the MAR that she completed the treatment on 2/3/26. The February 2026 MAR included cleanse left great toe with povidone iodine, paint with povidone iodine and leave open to air every day and evening shift. Monitor for signs and symptoms of infection or worsening and contact nurse practitioner or physician with any concerns. QMA 5 documented in the MAR that she completed the treatment on 2/11/26, 2/16/26, 2/17/26 and 2/25/26. QMA 7 documented that she completed the treatment on 2/10/26. QMA 9 documented that she completed the treatment on 2/11/26, 2/14/26, 2/15/26, 2/16/26, 2/18/26, 2/19/26 and 2/25/26. A NP wound note dated 2/24/26 at 10:30 p.m. indicated the left great toe wound measured 0.6 cm x 0.7 cm x 0.1 cm (length x width x depth). The wound was stable with partial thickness loss, and scabbed. The March 2026 MAR included cleanse left great toe with povidone iodine, paint with povidone iodine and leave open to air every day and evening shift. Monitor for signs and symptoms of infection or worsening and contact nurse practitioner or physician with any concerns. QMA 5 documented in the MAR that she completed the treatment on 3/1/26 and 3/12/26. QMA 7 documented that she completed the treatment on 3/6/26, 3/7/26, 3/8/26, 3/10/26, 3/12/26 and 3/13/26. QMA 9 documented that she completed the treatment on 3/1/26, 3/2/26, 3/5/26, 3/11/26 and 3/15/26. During an interview on 3/16/26 at 12:28 p.m. QMA 5 indicated a QMA was allowed to apply creams and powders to residents, but was not allowed to treat any stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area) or higher wounds. It was possible that she signed that she completed Resident D's wound treatments, but the wound had worsened and the QMAs stopped doing the treatment.During an interview on 3/16/26 at 3:31 p.m. QMA 9 indicated a QMA was allowed to apply creams and powders to residents, but nothing over a stage 1 wound or any wound that was open. She had watched the nurse complete Resident D's wound treatment, and she would sign them off in the MAR. She had not completed the treatment herself but thought she could apply povidone iodine to a wound. During an interview on 3/17/26 at 10:17 a.m. QMA 7 indicated a QMA was not allowed complete treatments above a stage 1, basically if the wound was open, she did not touch it. She was allowed to apply powders and creams to residents. She had not completed Resident 9's wound treatments as he had a crater on top of his toe. During an interview on 3/17/26 at 11:45 a.m. the DON indicated QMAs could not complete wound treatments above stage 2 (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.), wounds with bandages, or invasive treatments. She thought the QMAs could complete Resident D's wound treatments as his toe was left open to air and the nurse could assess the wound at any time. The facility's QMA job description, provided by the Administrator on 3/17/26 at 2:03 p.m., indicated the following: Position Summary .The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. Essential job functions .2. QMAs are not allowed to do any of the following .Any other invasive treatments as ordered The Qualified Medication Aide Scope of Practice was retrieved from the from the Indiana Department of Health (IDOH) website at https://www.in.gov/isdh/files/QMAScopeofPractice on 3/17/26 at 12:30 p.m. and indicated the following: .The following tasks are within the scope of practice for the QMA unless prohibited by facility policy . (3) .The QMA shall document in a resident's clinical record all medications that the QMA personally administered. The QMA shall not document in a resident's clinical record any medication that was administered by another person or not administered at all .(12) Apply topical medication to minor skin conditions such as dermatitis, scabies, pediculosis, fungal-infection, psoriasis, eczema, first degree burn, stage one decubitus ulcer .The following tasks shall NOT be included in the QMA scope of practice . (6) Administer a treatment that involves advanced skin conditions, including stage II, III, and IV decubitus ulcers This citation relates to Intake 2788978. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(2)

Based on interview and record review, the facility failed to protect a resident's right to be free from staff abuse during care for 1 of 3 residents reviewed for abuse. (Resident C)Findings include:Resident C's clinical record was reviewed on 2/13/26 at 12:50 p.m. Diagnoses included dementia and osteoporosis without fracture.A quarterly, 12/17/25, Minimum Data Set (MDS) assessment indicated Resident C's cognition could not be assessed. Resident C was dependent on staff members for toileting hygiene, maximum assistance for upper and lower body dressing, moderate assistance for changing from lying to a sitting position and maximum assistance.Resident C's current care plans included the following: I have a self-care deficit and require assistance with ADLs (activities of daily living) to maintain the highest possible level of functioning as evidenced by the following limitations and potential contributing factors: weakness, unsteady gait, and dementia. Interventions included: provide assistance with all ADLs as required per my dependence on needs: eating, transferring, bed mobility, dressing, personal hygiene, ambulation and personal hygiene, redirect me as needed.During an interview, on 2/16/26 at 9:47 a.m., CNA 4 indicated CNA 3 walked up to Resident C and started pulling on the resident's arm in a forceful way. Then, CNA 3 stated to Resident C we can do this the easy way or the hard way. While Resident C was clamping her legs shut, CNA 3 told Resident C to open your da** legs. Resident C didn't start becoming combative until CNA 3 started roughly yanking on Resident C's arm.During an interview, on 2/16/26 at 9:57 am., CNA 3 indicated she was training CNA 4 and there were claims that she (CNA 3) stated, we can do this the easy way or the hard way, but she meant it as we can do this in bed or in the bathroom. She was not going to force Resident C to open her legs. She would just shimmy the brief up her legs. CNA 3 denied pulling on residents' arm forcefully. She grabbed underneath Resident C's arm, as she was pulling Resident C up in bed, Resident C leaned backwards, which could make it look like she was pulling on Resident C's arm. CNA 3 did not recall using a curse word, and only remembered telling Resident C to open her legs, but would never force Resident C to do anything the resident didn't want to do.During an interview, on 2/16/26 at 11:13 a.m., RN 5 indicated CNA 4 came to her after providing care to Resident C. CNA 4 indicated CNA 3 had cursed and raised her voice toward Resident C, which made CNA 4 uncomfortable while providing care. RN 5 called the DON and Administrator to inform them of the incident. While CNA 4 was on the phone with them, RN 5 went to assess Resident C and to make sure CNA 3 was not providing any care to other residents. RN 5 walked CNA 3 out of the facility and the facility started their investigation into the allegations. A facility self-reported incident, submitted to the Indiana Department of Health on 2/9/26 at 10:01 p.m., indicated CNA 3 was being rude to Resident C during care while also stating you need to open your da** legs.During an interview, on 2/13/26 at 12:14 p.m., the Administrator indicated CNA 3 and 4 were providing care to Resident C. Resident C became combative during care. CNA 3 stated they could do this the easy way or the hard way, while also holding Resident C's arm down while providing care. CNA 4 didn't feel right about the situation. RN 5 called and informed the Administrator of the allegation, and he told RN 5 to send CNA 3 home. Review of staff statements provided by the facility, on 2/13/26 at 12:30 p.m., indicated the following:A written statement indicated that the Administrator spoke with CNA 3 regarding the incident. CNA 3 admitted she used inappropriate language with Resident C, stating we can do this the easy way or the hard way. CNA 3 stated she said that to herself under her breath. CNA 3 stated it was not meant to be heard, and she would never harm a resident. The hard way was having to shimmy the resident's brief up her legs rather than the resident's legs being open. Regardless, the language resulted in her employment being terminated.A written statement indicated that the Administrator spoke with CNA 4 regarding the incident. CNA 4 indicated CNA 3 used rude language and had been rough while providing care to Resident C. Resident C was combative during care causing CNA 3 to firmly grasp Resident C's arm to prevent further hitting or slapping from the resident. While performing care, CNA 3 stated we can do this the easy way or the hard way in a quiet tone.Review of an Employee Disciplinary Action report, on 2/13/26, indicated CNA 3 had violated work performance, customer service, safety violation, code of conduct, compliance violation and failure to follow instructions. The report indicated, on 2/3/25, CNA 3 was sent home due to an altercation with a resident who had dementia. On another occasion, CNA 3 stated in front of a resident that their bowel movement smelled and it was going to make her sick.A current facility policy, dated 7/15/21, revised on 5/15/23, titled Abuse Reporting Policy, provided by the Administrator, on 2/16/26 at 11:22 a.m., indicated the following: .Policy: This facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals. Verbal abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability This citation relates to Intake 2739361.3.1-27(b)

Based on record review and interview, the facility failed to ensure an allegation of staff to resident physical and verbal abuse was reported to the State Agency (Indiana Department of Health) for 1 of 3 residents reviewed for abuse. (Resident E)Findings include:Resident E's clinical record was reviewed on 12/10/25 at 9:50 a.m. Diagnoses included dementia and major depressive disorder.Current physician's orders included behavior monitoring every shift for restlessness, nervousness, mood disturbances (8/7/25), memantine 10 mg give one tablet by mouth every morning and at bedtime for dementia (11/2/23), and sertraline 100 mg give one table in the morning for depression (3/7/25).A quarterly Minimum Data Set (MDS) assessment, dated 9/17/25, indicated Resident E was severely cognitively impaired, did not experience hallucinations or delusions, and displayed no physical or verbal symptoms towards others during the assessment period.A care plan, initiated 11/17/25, indicated Resident E displayed behavioral symptoms related to dementia which included restlessness, nervousness, and mood disturbances. Interventions included administering psycho-active medications as ordered, recording behavioral symptoms of verbal/physical aggression and inappropriate behaviors, intervene when any inappropriate behavior was observed, and use creative refocusing to alter behavioral patterns.During an interview with the Dietary Manager (DM), on 12/8/25 at 12:59 p.m., she indicated, on 11/3/25, she observed CNA 2 become aggressive with Resident E during lunch. Resident E was sitting at her dining table when CNA 2 placed a drink for another resident on the table. When Resident E and CNA 2 reached for the drink at the same time, Resident E scratched the CNA's hand. CNA 2 grabbed both Resident E's wrists and in a very loud voice said, Don't scratch me!. The DM indicated she went to the DON's office to report the incident. She was later told, by the Administrator, there were no findings regarding the incident. The DM asked the Administrator if he needed her written statement and he said he did not need one.During an interview with the Administrator on 12/8/25 at 1:24 p.m., he indicated there had been no report(s) of abuse from staff in the past 60 days and no grievances were filed during that time.During an interview with the Administrator on 12/8/25 at 3:16 p.m., he indicated he was ill the week of the alleged incident. Resident E required cues or reminders to eat. CNA 3 first brought the incident to his attention on an unknown date. CNA 3 heard the DM talking about something happening during lunch service. He did an investigation but had no findings. The Administrator indicated the DM was not a reliable witness. Approximately two weeks before the 11/3/25 incident, during an interdisciplinary team meeting (IDT), the DM had told him she wanted CNA 2 fired or she would walk that day. The DM and CNA 2 had a history outside of working at the facility. The Administrator did not think the 11/3/25 incident was reportable. He talked to CNA 2, who told him she said We don't scratch like that, honey when Resident E tried to scratch her. He had no complaints from residents regarding CNA 2. He did have complaints from other staff members regarding CNA 2. He had not heard about hands being put on Resident E until the next IDT meeting. The DM had tried to do her own investigation and reported the incident to the DON while he was out sick. He later went to the DM and told her that at no point should she ever be doing her own investigation. If she truly thought she witnessed abuse, she would have called the police. The Administrator indicated he should have reported the allegation of abuse to IDOH.During an interview with CNA 3 on 12/8/25 at 3:33 p.m., she indicated she did not see anything between Resident E and CNA 2, but was standing at the service window to the kitchen when she heard the DM telling another staff member about the alleged incident. The DM said she was sick and tired of CNA 2 treating the residents poorly and putting their hands on them. CNA 3 had never seen CNA 2 put her hands on residents or speak rudely to them. CNA 3 did not know the reason but knew the DM and CNA 2 did not like each other.During an interview with the DON on 12/8/25 at 4:05 p.m., she indicated she was in the Social Services Director's (SSD) office when the DM entered and said she had tried to check the cameras because she saw CNA 2 grab Resident E by the face. The DM wanted to report the incident to the Administrator. The DON contacted the Administrator at home. After the DM left the office, CNA 3 reported the DM was slamming things in the kitchen, saying CNA 2 grabbed Resident E by the face. CNA 3 did not see or hear anything during the lunch service. CNA 2 was interviewed and was completely confused about the allegation of abuse. CNA 2 described the incident where Resident E tried to take a drink and tried to scratch the CNA. CNA 2 pulled away and said No, we don't scratch. The DON said there was no way the DM could have seen anything happen from her vantage point in the kitchen. Nobody complained about CNA 2 being rude or rough with residents. After speaking with CNA 2, nobody else saw anything and the DON let the Administrator know of her findings. Resident E could be very aggressive and there were times when CNA 2 could have been on the receiving end of Resident E fighting or resisting care. The Administrator was responsible for reporting alleged incidents of abuse to the state. That was why she called him right after the DM made the allegation of abuse. If the Administrator was unavailable to report an incident of abuse, the DON would contact a corporate consultant. She could not recall if she had collected written statements from the DM, CNA 2, or CNA 3.During an interview with CNA 2 on 12/10/25 at 10:55 a.m., she indicated she was called into the DON's office because the DM had reported to the DON an allegation of CNA 2 being abusive to a resident. On 11/3/25, during lunch service, she was passing drinks when Resident E grabbed another resident's drink. CNA 2 took the drink from Resident E and said, You can't have that, it is someone else's drink. CNA 2 told the DON to pull camera footage to see what happened. CNA 2 had never hit or pinched a resident. The DM complained about CNAs all the time. CNA 2 was usually one of them. For some reason, the DM just did not like CNA 2.An untitled document, dated 11/3/25 and provided by the Administrator on 12/10/25 at 3:15 p.m., indicated the entire IDT was present and called the Administrator, due to being out of the facility. During that phone call, the DM said she wanted to see the cameras because she was unsure about the behavior towards Resident E, and another aide (CNA 3) was present. When CNA 2 was loud with Resident E, the DM made the comment I'm not sure it happened, but I can see CNA 2 doing that. Immediately, while still on the phone, the DON went and got CNA 3 for a statement. CNA 3 stated that no such thing happened while she was in the dining room. CNA 3 stated that she was speaking to Resident E. Resident is a cue whom, while attempting to grab an item from the table, reached to scratch CNA 2, who backed away from the scratch and stated, 'We don't scratch (resident's name).' Then the Administrator and DON called CNA 2, who was confused as to what was said, stated that while she had told Resident E not to scratch, her level of speaking was appropriate and suggested we speak to CNA 3 who had already been interviewed. Assessments were completed for Resident E and the SSD noted no red marks to face or arms. At that time, the Administrator, DON, and SSD felt that the statement from the DM was not reason to pursue further action. The document was signed by the Administrator, DON, ADON, and SSD.During an interview with the Administrator on 12/10/25 at 3:15 p.m., he indicated the 11/3/25, untitled statement was written on 12/10/25 at 12:10 p.m.A current facility policy, titled Abuse Prevention Program, provided by the Administrator on 12/10/25 at 10:47 a.m., indicated the following: . It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party.IV. Identification - Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator. The Administrator is the Abuse Coordinator.If you suspect abuse - Separate the alleged perpetrator and assure all residents safety, notify a Supervisor/Nurse Immediately, notify the Administrator and Director of Nursing, or the person in charge of the facility by page (to summon them to the area) or by telephone, complete the documentation of the incident in the EMR under the Risk Management section, DO NOT LEAVE the building until above is completed, the Administrator or designee utilizing the Incident Reporting System (IRS) will immediately notify the Department of Health by the online system or per the direction given by the Department of Health.V. Investigation - All incidents will be documented, whether or not abuse occurred, was alleged or suspected, any incident or allegation involving abuse or mistreatment will result in an abuse investigation, for any incident involving suspicion of abuse, neglect, or mistreatment, the Administrator or person appointed by the Administrator will gather further facts prior to making a determination to conduct an abuse investigation, once the Administrator designee determines that there is a reasonable cause for suspecting abuse, the Administrator designee will investigate the allegation and obtain a copy of any documentation relative to the incident. the Charge Nurse must complete an incident report and obtain a written, signed and dated statement from the person reporting the incident, a completed copy of the incident report and written statements from the witnesses, if any, will be provided to the Administrator within twenty-four (24) hours of the occurrence of such incident.VI. The facility will take steps to prevent mistreatment while the investigation is underway, residents and visitors are protected from any retaliation or possible harm, staff members who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation, prosecution, or disciplinary action against the employee.Cross reference F610.This citation relates to Intake 2671909. 3.1-28(c)

Based on interview and record review, the facility failed to investigate an allegation of staff to resident abuse and failed to implement the facility policy to protect residents following an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident E)Findings include:An anonymous allegation of staff to resident verbal abuse involving Resident E was received by the Indiana Department of Health on 11/14/25. During an interview with the Dietary Manager (DM), on 12/8/25 at 12:59 p.m., she indicated, on 11/3/25, she observed CNA 2 become aggressive with Resident E during lunch. Resident E was sitting at her dining table when CNA 2 placed a drink for another resident on the table. When Resident E and CNA 2 reached for the drink at the same time, Resident E scratched the CNA's hand. CNA 2 grabbed both Resident E's wrists and in a very loud voice said, Don't scratch me!. The DM indicated she went to the DON's office to report the incident. She was later told, by the Administrator, there were no findings regarding the incident. The DM asked the Administrator if he needed her written statement and he said he did not need one.During an interview with the Administrator on 12/8/25 at 1:24 p.m., he indicated there had been no report(s) of abuse from staff in the past 60 days and no grievances were filed during that time.During an interview with the Administrator on 12/8/25 at 3:16 p.m., he indicated he was ill the week of the alleged incident. Resident E required cues or reminders to eat. CNA 3 first brought the incident to his attention on an unknown date. CNA 3 heard the DM talking about something happening during lunch service. He did an investigation but had no findings. The Administrator indicated the DM was not a reliable witness. Approximately two weeks before the 11/3/25 incident, during an interdisciplinary team meeting (IDT), the DM had told him she wanted CNA 2 fired or she would walk that day. The DM and CNA 2 had a history outside of working at the facility. The Administrator did not think the 11/3/25 incident was reportable. He talked to CNA 2, who told him she said We don't scratch like that, honey when Resident E tried to scratch her. He had no complaints from residents regarding CNA 2. He did have complaints from other staff members regarding CNA 2. He had not heard about hands being put on Resident E until the next IDT meeting. The DM had tried to do her own investigation and reported the incident to the DON while he was out sick. He later went to the DM and told her that at no point should she ever be doing her own investigation. If she truly thought she witnessed abuse, she would have called the police. The Administrator indicated he should have reported the allegation of abuse to IDOH.During an interview with the DON on 12/8/25 at 4:05 p.m., she indicated she was in the Social Services Director's (SSD) office when the DM entered and said she had tried to check the cameras because she saw CNA 2 grab Resident E by the face. The DM wanted to report the incident to the Administrator. The DON contacted the Administrator at home. After the DM left the office, CNA 3 reported the DM was slamming things in the kitchen, saying CNA 2 grabbed Resident E by the face. CNA 3 did not see or hear anything during the lunch service. CNA 2 was interviewed and was completely confused about the allegation of abuse. CNA 2 described the incident where Resident E tried to take a drink and tried to scratch the CNA. CNA 2 pulled away and said No, we don't scratch. The DON said there was no way the DM could have seen anything happen from her vantage point in the kitchen. Nobody complained about CNA 2 being rude or rough with residents. After speaking with CNA 2, nobody else saw anything and the DON let the Administrator know of her findings. Resident E could be very aggressive and there were times when CNA 2 could have been on the receiving end of Resident E fighting or resisting care. The Administrator was responsible for reporting alleged incidents of abuse to the state. That was why she called him right after the DM made the allegation of abuse. If the Administrator was unavailable to report an incident of abuse, the DON would contact a corporate consultant. She could not recall if she had collected written statements from the DM, CNA 2, or CNA 3.Resident E's clinical record was reviewed on 12/10/25 at 9:50 a.m. Diagnoses included dementia and major depressive disorder.Current physician's orders included behavior monitoring every shift for restlessness, nervousness, mood disturbances (8/7/25), memantine 10 mg give one tablet by mouth every morning and at bedtime for dementia (11/2/23), and sertraline 100 mg give one table in the morning for depression (3/7/25).A quarterly Minimum Data Set (MDS) assessment, dated 9/17/25, indicated Resident E was severely cognitively impaired, did not experience hallucinations or delusions, and displayed no physical or verbal symptoms towards others during the assessment period.A care plan, initiated 11/17/25, indicated Resident E displayed behavioral symptoms related to dementia which included restlessness, nervousness, and mood disturbances. Interventions included administering psycho-active medications as ordered, recording behavioral symptoms of verbal/physical aggression and inappropriate behaviors, intervene when any inappropriate behavior was observed, and use creative refocusing to alter behavioral patterns.An untitled document, dated 11/3/25 and provided by the Administrator on 12/10/25 at 3:15 p.m., indicated the entire IDT was present and called the Administrator, due to being out of the facility. During that phone call, the DM said she wanted to see the cameras because she was unsure about the behavior towards Resident E, and another aide (CNA 3) was present. When CNA 2 was loud with Resident E, the DM made the comment I'm not sure it happened, but I can see CNA 2 doing that. Immediately, while still on the phone, the DON went and got CNA 3 for a statement. CNA 3 stated that no such thing happened while she was in the dining room. CNA 3 stated that she was speaking to Resident E. Resident is a cue whom, while attempting to grab an item from the table, reached to scratch CNA 2, who backed away from the scratch and stated, 'We don't scratch (resident's name).' Then the Administrator and DON called CNA 2, who was confused as to what was said, stated that while she had told Resident E not to scratch, her level of speaking was appropriate and suggested we speak to CNA 3 who had already been interviewed. Assessments were completed for Resident E and the SSD noted no red marks to face or arms. At that time, the Administrator, DON, and SSD felt that the statement from the DM was not reason to pursue further action. The document was signed by the Administrator, DON, ADON, and SSD.During an interview with the Administrator on 12/10/25 at 3:15 p.m., he indicated the 11/3/25, untitled statement was written on 12/10/25 at 12:10 p.m.A current facility policy, titled Abuse Prevention Program, provided by the Administrator on 12/10/25 at 10:47 a.m., indicated the following: . It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party.IV. Identification - Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator. The Administrator is the Abuse Coordinator.If you suspect abuse - Separate the alleged perpetrator and assure all residents safety, notify a Supervisor/Nurse Immediately, notify the Administrator and Director of Nursing, or the person in charge of the facility by page (to summon them to the area) or by telephone, complete the documentation of the incident in the EMR under the Risk Management section, DO NOT LEAVE the building until above is completed, the Administrator or designee utilizing the Incident Reporting System (IRS) will immediately notify the Department of Health by the online system or per the direction given by the Department of Health.V. Investigation - All incidents will be documented, whether or not abuse occurred, was alleged or suspected, any incident or allegation involving abuse or mistreatment will result in an abuse investigation, for any incident involving suspicion of abuse, neglect, or mistreatment, the Administrator or person appointed by the Administrator will gather further facts prior to making a determination to conduct an abuse investigation, once the Administrator designee determines that there is a reasonable cause for suspecting abuse, the Administrator designee will investigate the allegation and obtain a copy of any documentation relative to the incident. the Charge Nurse must complete an incident report and obtain a written, signed and dated statement from the person reporting the incident, a completed copy of the incident report and written statements from the witnesses, if any, will be provided to the Administrator within twenty-four (24) hours of the occurrence of such incident.VI. The facility will take steps to prevent mistreatment while the investigation is underway, residents and visitors are protected from any retaliation or possible harm, staff members who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation, prosecution, or disciplinary action against the employee.This citation relates to Intake 2671909. 3.1-28(c)

Based on interview and record review, the facility failed to ensure the Dietary Manager completed the required education to meet the qualifications for a Dietary Manager. This deficiency had the potential to impact 56 of 56 residents who received meals from the facility kitchen. Findings include: During an interview on 5/18/25 at 9:49 a.m., the Dietary Manager indicated she did not have a certification qualifying her to act as Dietary Manager. She was hired in December of 2024 and had received no training at that time, or since. During an interview with the Administrator on 5/20/25 at 11:48 a.m., he indicated he was aware the Dietary Manager was not certified to act as Dietary Manager. During an interview with the Regional Director of Operations on 5/20/25 at 12:07 p.m., he indicated he was aware the Dietary Manager was not certified to act as Dietary Manager. He planned to enroll her in an appropriate training program to get her certification. He was aware she had been employed as the Dietary Manager since December of 2024. A current facility policy, dated 11/3/17, titled Food & Nutrition Department Staffing, provided by the Administrator on 5/22/25 at 10:57 a.m., indicated the following: .The facility will maintain sufficient and competent qualified staff to meet the residents needs .to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services .The facility will employ a Qualified Food Service Director per regulatory requirements Cross reference F804. Cross reference F812. 3.1-20(e)

Based on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions related to kitchen equipment, utensil storage, food storage, and chemical storage. This deficient practice had the potential to affect 56 of 56 residents who received food from the facility kitchen. Findings include: During a kitchen observation on 5/18/25 at 9:49 a.m., accompanied by the Dietary Manager, the following was observed: Next to the front service window, an open container of brown sugar was on the countertop with a scoop (including the handle) laying inside the brown sugar. The microwave had splatters of eggs and other unidentifiable foods on the bottom, three inside walls, and inside the door. The many food splatters varied in size and were dry and thick in appearance. The upper cabinets to the left of the service window contained different colored splatters on the outsides of the doors. Splatter sizes ranged from the size of a dime to the size of a quarter. Under the cabinets, a pair of discarded kitchen gloves lay on the countertop along with three empty coffee packets. The floor beneath the cabinets and countertop was covered with corn flakes, about the size of a floor mat. The toaster had a thin layer of crumbs on the spill tray, with crumbs on the countertop beneath the toaster. There were scissors laying in the crumbs. There was an uncovered container of melted butter on top of the toaster. The front of the stainless-steel refrigerator had thick, finger sized, sticky prints covering the areas above, below, and beside the handles. Inside the refrigerator was a roast beef (identified by the Dietary Manager) in a zip lock bag dated 5/5/25. The Manager removed the meat and threw it away. The top utensil drawer on the single sink station, containing spatulas and tongs, had crumbs and nickel-sized drips of an unidentifiable, brown substance on the bottom. The bottom utensil drawer contained measuring utensils with crumbs and a piece of torn paper on the bottom. There was an open 25-pound bag of panko breadcrumbs sitting on a rolling bin underneath the counter where the food processor was located. In the dry storage area, to the left of the entrance, two containers of bleach and approximately six boxes of sanitizer and floor cleaner sat on the floor beneath two electrical panels. During an observation on 5/19/25 at 11:39 a.m., a kitchen staff member emptied a large can of green beans into a stainless-steel container in preparation for heating. The lid of the green beans was not completely removed. As she shook the can to empty the green beans, the inside and outside of the lid touched the green beans repeatedly. The Dietary Manager indicated the lid should have been removed completely and the staff member had not been trained properly. During an observation on 5/19/25 at 11:45 a.m., the chemicals in the dry storage area remained in their same position beneath the electrical panels. During an observation and interview on 5/21/25 at 9:34 a.m., the Regional Director of Operations indicated the chemicals should be stored properly in the janitor's closet. He pointed to the closet approximately 4 to 5 feet from where the chemicals sat. He planned to train the staff on proper kitchen cleaning and storage of chemicals. A current facility policy, dated 3/25/12, titled Cleaning & Sanitation, provided by the Administrator on 5/22/25 at 10:47 a.m., indicated the following: .The Food and Nutrition Director will develop, implement, and monitor schedules for cleaning, sanitizing, and maintenance and keep record for 1 year .To ensure the food service department is maintained according to state and federal regulations and is a clean, sanitary, and safe environment at all times .1. The Food Service Director develops, implements, and monitors a cleaning schedule to include all areas of the kitchen and equipment. 2. Food Service employees are trained in proper use, cleaning, and maintaining all equipment. 3. Cleaning schedules designate cleaning for each position and are posted in an accessible area A current facility policy, dated 3/25/12, titled Food Storage, provided by the Administrator on 5/22/25 at 10:57 a.m., indicated the following: .Food is stored and prepared in a clean, safe, sanitary manner that will comply with state and federal guidelines .to minimize contamination and bacteria .1. Food storage areas are clean, organized, and free of dirt .4. Containers for bulk items (flour, sugar, etc.) are leak proof, non-absorbent, sanitary, NSF approved and have tight fitting lids . 5. All food not in original containers are to be labeled and dated and stored in NSF approved containers A current facility policy, dated 3/25/12, titled Safe Food Handling Practices, provided by the Administrator on 5/22/25 at 10:57 a.m., indicated the following: .All food is purchased, store, prepared, and distributed in a clean, safe, sanitary manner promoting safe food handling and compliance with state and federal guidelines .To minimize contamination and bacteria while providing nutritious meals .6. All working surfaces and equipment are clean and sanitized after each use 3.1-21(i)(3)

Based on observation, interview, and record review the facility failed to ensure meals were palatable for 17 of 31 residents reviewed for palatable meals. (Residents 3, 4, 5, 9, 17, 19, 23, 25, 33, 34, 36, 40, 49, 50, 51, 108, and 109) Finding includes: During an interview, on 5/18/25 at 11:04 a.m., the Resident 109's representative indicated the food at the facility was terrible. The resident's representative had talked with the Administrator and sent a letter to the vice president of the company. The food was worse than terrible. The roll yesterday was as hard as a rock. He could bounce it off the floor. The residents were served some kind of soup yesterday and were unable to tell what it was supposed to be. The food was cold, did not look good, and tasted terrible. He sent back the resident's breakfast three days in a row because it was cold and looked terrible. Sometimes, there was very little on the plate. One time, there was just a hot dog on the plate. He kept hearing everyone's hands were tied when trying to make the food more pleasing During an interview, on 5/18/25 at 11:13 a.m., Resident 36 indicated the food sucked and looked disgusting. The food either had no taste or had too much spice. The facility served lentil soup last evening. It had no flavor and did not look good. The plates looked like slop. The residents complained, but nothing changed. The food was always cold. During an interview, on 5/18/25 at 2:24 p.m., Resident 40 indicated the food was not good at all. The food was cold, did not taste good, and looked nasty. During an interview, on 5/18/25 at 3:11 p.m., Resident 49 indicated she often went back to her room to eat snacks and food provided by her family because the facility's food was not good. During an interview, on 5/19/25 at 9:56 a.m., Resident 3 indicated the food was awful. During an interview, on 5/19/25 at 10:11 a.m., Resident 108 indicated the taste of the food varied and depended on who the cook was. The food taste had really slipped and did not taste good at all. Sometimes it was warm when served, and sometimes it was cold. She often had her family bring in food for her. During an interview, on 5/19/25 at 11:26 a.m., Resident 50 indicated most of the food was cold when he got it. Yesterday, the facility had served lentil soup, so he had his wife bring him something later from a restaurant. During an interview, on 5/19/25 at 12:17 p.m., Resident 25 indicated sometimes the food did not taste good. The quantity was not good either. A sandwich and some fruit was all she got for supper sometimes. The food was cold by the time she got her tray in her room. The staff warmed it up if she wanted. She had eaten sausage gravy this morning, and it was the first time it was hot. The nurse had gotten it before others started eating and brought it to her since she had an appointment in the morning. When she got soup, the soup bowls were maybe half filled. One night, she had a piece of pizza so small it fit in a bowl, and half of a dessert dish of fruit. The last month, the food had gotten worse. During an interview, on 5/19/25 at 12:39 p.m., Resident 9 indicated she had been taking notes about the food and the various issues with it. On 5/9/25, she received her supper at 6:20 p.m., although dinner was supposed to be served at 5:00 p.m. On 5/12/25, she received minestrone soup for dinner, which was only half a bowl. She had to fill up on snacks because the dinner was not enough food. On 5/13/25, for lunch, she received very little of the pudding; the dish was not even filled halfway up. On 5/14/25, for lunch she had a small portion of goulash and a very hard roll, which she called a hockey puck. For dinner, she had cold French fries and a carrot and raisin salad that was bad. On 5/15/25, for dinner she received one taco with lettuce, tomato, a little meat, and a cookie. She felt it was very little food to receive. During an observation, on 5/19/25 at 5:14 p.m., drinks passed to the residents contained very little ice. During an observation, on 5/19/25 at 5:29 p.m., CNA 12 indicated to the residents the meat loaf, which was on the menu, was made with turkey. During an observation, on 5/19/25 at 5:36 p.m., pudding portions were not consistent. One resident received a full dish of pudding; another resident had requested pudding and received a dish less than half filled. During an interview, on 5/19/25 at 6:06 p.m., Resident 9 indicated the meal was warm but not hot tonight. The biscuit was only the size of a silver dollar. During an interview, on 5/19/25 at 6:08 p.m., Resident 49 indicated she did not like the meat loaf. She ate one bite. On 5/19/25 at 6:29 p.m., a test tray was observed. The meat loaf was grayish in color with lots of ketchup on the top,and the flavor was displeasing. The mashed potatoes and gravy were not flavorful. The cranberry juice was watered down and lacked flavor. Facility grievances provided by the Administrator on 5/20/25 were reviewed and indicated the following: Resident 33, on an undated grievance, indicated the food was lousy, lousy, lousy. The food was poorly cooked and was not provided enough food to fill her up. Resident 23, on a grievance dated 12/2/24, indicated the cream of wheat was too thick, and the pancakes were too thick. Resident 109's representative, on a grievance dated 2/27/25, indicated the resident only received two chicken wings and was supposed to get four. He also received applesauce instead of the apple pie on the menu. Resident 109's representative, on a grievance dated 4/29/25, indicated the supper ticket listed hamburger on a bun, but the resident received a bologna sandwich. The French fries were not cooked through. The meals were usually not warm and had to be sent back to be heated. Resident 5, on a grievance dated 4/29/25, indicated the French fries were not cooked through. There were not enough hamburgers to serve everyone, so some people got bologna instead. Resident 51, on a grievance dated 4/30/25, indicated the evening meal was a chicken pot pie and crushed pineapple. The food served made her feel like older people did not matter. Resident 40, on a grievance dated 4/30/25, indicated the food tasted like s**t. Resident 49, on a grievance dated 4/30/25, indicated the French fries were never done. The meat loaf tasted like a big chunk of hamburger with no seasoning. Resident 17, on a grievance dated 4/30/25, indicated he received a bowl of crap for dinner. He ate two bags of fried cheese puffs and some crushed pineapple. He had another meal that was egg salad sandwiches and was still hungry after he ate. Resident 4, on a grievance dated 4/30/25, indicated the food was terrible. She wondered why the facility couldn't get someone who could cook. Resident 19, on a grievance dated 4/30/25, indicated the food was not very good and needed improvement. He could not eat his dinner on 4/30/25. Resident 3, on a grievance dated 4/30/25, indicated the food was terrible and looked bad - messy. Resident 25, on a grievance dated 4/30/25, indicated she received a bowl with a two-inch piece of pizza and a bowl of pear cubes. She was glad she had some chicken strips in her refrigerator she had gotten when she was out of the facility the day before. The meals were bad. Resident 9, on a grievance dated 4/30/25, indicated the supper portion of potpie was very small. She only took three bites and that was all there was. She often received cornbread without butter and chili without chili seasoning. A review of the Resident Council minutes, provided by the Social Services Director (SSD) on 5/20/25, indicated in the meeting on 4/9/25 the residents had complained that the supper was getting later and later, the baked potatoes were served with no butter and no sour cream. In the meeting, on 5/7/25, the residents' complaints about the food were still an issue including the not getting bread when on the menu, the hamburger was not good, and the salad lettuce was brown. During an interview, on 5/20/25 at 10:59 a.m., the Administrator indicated he was working with the resident on the food complaints. There was a food committee developed to discuss the residents food concerns. During an interview, on 5/20/25 at 12:07 p.m., the Regional Director of Operations for the contracted company supplying the facility dining services indicated he had spoken with the Resident Council and had received good feedback. He knew residents were dissatisfied with the portions and the temperatures of the food. There were some new dietary staff members, and he was making sure they were getting educated. The company tried to customize the menu from facility to facility. For example, he was taking the lentil soup and the turkey loaf off the menu. Anonymous interviews were conducted during the survey as follows: Interviewee B indicated the food had been sucking. The portion sizes were inconsistent. Interviewee C indicated the food was more often worse than good. Interviewee D indicated she would not eat the food and the portions were small. Interviewee E indicated she had talked to the Administrator about the food. The food was not good. Interviewee F indicated the food was subpar in temperatures, portion sizes, presentation, and taste. A facility policy, revised on 3/7/25, provided by the Administrator on 5/22/25 at 3:35 p.m., titled Meal Service - Palatability and Nutritive Value, indicated the following: .Food will be prepared, held, and served in a manner that maintains its nutritive value and palatability Cross reference F801. 3.1-21(a)(2)

Based on observation, record review, and interview, the facility failed to provide a dignified dining experience for 2 of 20 residents observed during meal service in the main dining room. (Residents 22, 45) Findings include: 1. During an observation, on 5/19/25 at 11:54 a.m., Resident 22 sat in a wheelchair at the dining table. Her chair was low in comparison to the table height and put the resident's chin roughly four inches from the top of the table. On 5/19/25 at 12:30 p.m., Resident 22 was sitting very low in a wheelchair. The resident's chin was level with the tabletop. Resident 22 indicated it was difficult for her to eat. On 5/19/25 at 6:06 p.m., Resident 22 sat in a wheelchair at the dining table. She was eating while hunched over and leaning to the right. On 5/21/25 at 8:09 a.m., Resident 22 sat in her wheelchair at the dining table. Her chin was level with the tabletop. Resident 22's clinical record was reviewed on 5/21/25 at 8:55 a.m. Diagnoses included dementia, osteoarthritis, and heart failure. Current orders included a regular diet and may use her personal cup during meals. A 2/19/25, annual, Minimum Data Set (MDS) indicated the resident was cognitively intact. She required setup or clean up assistance with eating. A current care plan, dated 5/20/20, and revised on 9/30/24, indicated the resident needed supervision assistance with eating/drinking. The interventions included required assistance during meals with tray set-up and eating as needed. 2. During an observation, on 5/19/25 at 5:25 p.m., Resident 45 was sitting at the dining table. The resident was low in relation to the table, with her chin roughly four inches above the tabletop. Resident 45 had to reach upward to grab her drink. While drinking, Resident 45's coffee cup was halfway below the tabletop, then she reached back up and placed the cup back on the table. On 5/19/25 at 5:42 p.m., Resident 45 continued to sit low at the dining table. Her chin was the same height as the tabletop. Resident 45 had to reach up to grab her coffee cup. While drinking, the coffee cup was halfway below the top of the table. On 5/21/25 at 7:34 a.m., Resident 45 was sitting at the table. She was leaning forward while resting her eyes. Her chin was below the tabletop. When Resident 45 took a drink from her coffee mug, the bottom of the mug was below the tabletop. On 5/21/25 at 8:05 a.m., Resident 45 was eating her meal. Her chin was below her plate. Her bottom lip touched the plate when she took a bite of her food. During an interview, on 5/21/25 at 8:10 a.m., CNAs 14, 15, and 16 each indicated they didn't feel it was a problem for either Resident 22 nor 45 to eat with their chin close to the tabletops. They were unsure if the tables could be lowered. Neither resident had ever complained of the table being too high. On 5/21/25 at 8:19 a.m., Resident 45's representative indicated the resident had always sat low to the table since she was admitted to the facility over a month ago. On 5/21/25 at 8:27 a.m., the ADON indicated neither resident had ever complained about the height of the table. She never thought about the height of the table as both residents ate well. She would ask maintenance if they could lower the tables. Resident 45's clinical record was reviewed on 5/21/25 at 9:00 a.m. Her diagnoses included altered mental status, dysphagia (difficulty swallowing), epilepsy (seizures), and adult failure to thrive. Current orders include mechanical soft diet, ground meat texture, and thin liquids. A 3/28/25, significant change, Minimum Data Set (MDS) indicated the resident was cognitively intact. She required setup or clean up assistance with eating. A current care plan, 1/4/25, revised on 5/22/25, indicated the resident needed supervision assistance with eating/drinking. The interventions included required assistance during meals with tray set-up and eating as needed. During meals, place the food on which the resident should be concentrating on in front. Ensure resident is close enough to the table to reach food/drink properly. A current policy, titled Guidelines to ensure reasonable accommodation of needs, provided by the Administrator on 5/22/25 at 10:57 a.m., indicated the following: .Residents needs and preferences will be honored a much as possible considering each resident's circumstances and overall health status and safety for themselves and others 3.1-3(t) 3.1-3(v)(1)

Based on interview and record review, the facility failed to provide notification of Medicare non-coverage for 2 of 3 residents reviewed for Beneficiary Protection Notifications. (Residents 49, 14) Findings include: On 5/19/25 at 2:00 p.m., the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Forms were reviewed and indicated the following: 1. Resident 49 admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day for Part A services was 2/19/25. The resident remained in the facility. The clinical record lacked Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). 2. Resident 14 admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day for Part A services was 4/25/25. The resident remained in the facility. The clinical record lacked Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). During an interview, on 5/19/25 at 2:31 p.m., the Business Office Manager indicated she notified the resident and/or their representative what their private pay amount would be for their room. She had never given any residents an ABN form before. A current policy, titled Detailed Explanation of Non-coverage, provided by the Administrator on 5/22/25 at 10:57 a.m., indicated the following: .The notice explains why your provider and/or health plan decided Medicare coverage for you current services should end Detailed explanation of why your services are no longer covered, and the Medicare coverage rules used to make this decision . 3.1-4(f)(2) 3.1-4(f)(3)

Based on observation and interview, the facility failed to provide clean equipment for 2 of 19 residents reviewed for wheelchair cleanliness. (Residents 22 and 34) Findings include: 1. During an observation, on 5/19/25 at 12:30 p.m., Resident 22's outer left panel of her wheelchair was smeared with a dark substance. During an interview, on 5/19/25 at 6:38 p.m., CNA 11 and CNA 12 indicated third shift CNAs deep cleaned the resident wheelchairs, but it was really every staff member's responsibility. During an observation, on 5/21/25 at 8:16 a.m., Resident 22's wheelchair had honey colored streak marks down the outside panels of her wheelchair. A dark reddish colored substance was smeared over the outer panels of her wheelchair. During an interview, on 5/21/25 at 10:04 a.m., LPN 4 indicated third shift CNAs were responsible for cleaning resident wheelchairs. There was a CNA book at the nurse's station that had the cleaning schedule for resident wheelchairs. Resident 22's wheelchair was scheduled for deep cleanings every Wednesday night. During an observation, on 5/21/25 at 10:13 a.m., Resident 22's wheelchair had a reddish brown substance smeared all over the outer sides of her wheelchair panels. 2. During an observation, on 5/18/25 at 10:21 a.m., Resident 34's wheelchair had a nickel-sized dark brown substance on the right arm pad of her wheelchair. The left side of her seat had a buildup of food particles and stains. On 5/20/25 at 10:39 a.m., Resident 34 was propelling herself down the hallway. The nickel-sized brown spot on the right arm pad of her wheelchair remained. The left side of her seat had a buildup of food particles and stains. On 5/21/25 at 8:33 a.m., Resident 34's wheelchair still had the nickel-sized brown spot on the right arm pad of her wheelchair. The left side of her seat had a buildup of food particles and stains. During an observation with the ADON, on 5/22/25 at 9:24 a.m., Resident 34's wheelchair had a nickel-sized dark brown substance on the right arm of her wheelchair. On the left side, down the post of the wheelchair, had unidentifiable streaks. There was a nickel sized crumb like substance on her right foot peg. The left side of her seat had a buildup of food particles and stains. Resident 22's wheelchair had a reddish brown food substance smeared all over the outer left and right wheelchair panels. The ADON indicated Resident 22's wheelchair should have been deep cleaned the night prior. A current policy, titled Guidelines for cleaning DME (Durable Medical Equipment) Wheelchairs/Mechanical Lifts/ Stand up lifts/ shower chairs/ bedside commodes/ walkers/other , provided by the Administrator, on 5/22/25 at 10:57 a.m., indicated the following: .It is policy of the facility to ensure that DME is clean and in good repair 5-1.5(e)

Based on observation, record review, and interview, the facility failed to implement fall precautions and update care plan interventions following falls for 1 of 2 residents reviewed for accidents. (Resident 41) Findings include: Resident 41's clinical record was reviewed on 5/20/25 at 9:57 a.m. Diagnoses included syncope (fainting) and collapse, repeated falls, chronic kidney disease, and protein-calorie malnutrition. An annual Minimum Data Set (MDS) assessment, dated 2/19/25, indicated Resident 41 was severely cognitively impaired, used a walker and/or wheelchair to ambulate, required supervision when eating, maximum assistance for toileting and showering, was frequently incontinent of both bladder and bowel, had repeated falls, and a history of syncope and collapse. Current orders included padded side rails related to seizure precautions (5/19/25), check wander alert bracelet placement (8/21/24), check bed/chair alarm placement every shift for frequent falls (8/15/24), and acetaminophen 650 mg by mouth every four hours as needed for pain/discomfort (11/2/23). A current care plan, initiated on 5/26/23, indicated the resident required extensive assistance with eating/drinking, bed mobility, and toileting related to cognition deficits, weakness, unsteady gait, and the use of assistive devices. Interventions included an assessment of mobility and level of functioning at least quarterly, encourage and assist to toilet and/or check and change upon rising before and after meals, before laying down at night, and as needed (7/29/24). A current care plan, initiated on 5/26/23, indicated the resident needed extensive assistance with transfers related to weakness, unsteady gait, and the use of assistive devices. Interventions included provide assistance with sit to stand, surface to surface, and balance support. See nurse aide assignment sheet for details on transfer assist as needed and use gait belt for transfers. A current care plan, initiated on 5/22/23, indicated the resident was at risk for falls due to her condition and risk factors of an unsteady gait, with or without assistive devices, use of assistive devices for mobility (walker and wheelchair), weakness, confusion/forgetfulness, and syncope (fainting). Interventions included a bed/chair alarm (4/23/25), call light within reach (5/22/23), do not leave in the bathroom unattended (4/10/25), keep locked wheelchair beside the resident (5/24/23), non-skid strips to front of recliner (7/15/24), pommel cushion to wheel chair (3/21/25), a reminder sign to be hung in room to remind resident to ask for assistance from staff (3/4/24), and staff to toilet resident upon waking, before and after meals, and before laying down for the night (7/25/24). An interdisciplinary team (IDT) general note, dated 12/23/25 at 11:40 a.m., indicated the team reviewed a fall from 12/21/25 at 6:32 a.m. A nurse heard the resident's alarm going off and found Resident 41 in another resident's room on the floor. The resident was assessed, and a new red area was found on the center of her back. No other injuries were noted. The care plan lacked the addition of new interventions after the fall on 12/21/25. An incident note, dated 3/20/25 at 10:19 p.m., indicated staff entered another resident's room and found Resident 41 on the floor in front of her wheelchair. The resident was alert and confused as per her baseline. She had a red area to her back, approximately 10 centimeters (cm) length x 5 cm width in size. No other injuries were notes. The resident's care plan was updated on 3/21/25 to include a pommel cushion to her wheelchair. An IDT progress note, dated 4/11/25 at 4:17 p.m., indicated the team reviewed the resident's fall on 4/10/25 around 6:15 a.m. Resident 41's bed alarm was alerting, and the third shift nurse went to assist the resident to the toilet. The nurse left the resident in the restroom on the toilet to speak to another staff member. Staff normally are to stay with the resident while on the toilet and assist her safely back to her bed/chair due to the resident's dementia and risk of falls. The resident was found on the floor in front of the bathroom, on her right side. No injuries were noted. The staff member was educated about not leaving the resident alone on the toilet. An incident note, dated 4/13/25 at 1:54 p.m., indicated staff heard the resident's alarm going off and found her sitting on the floor in front of her wheelchair. No injuries were noted. The care plan lacked the addition of new intervention(s) after the fall on 4/13/25. An Interdisciplinary Team (IDT) progress note, dated 5/19/25 at 1:35 p.m., indicated Resident 41 had an unwitnessed fall on 5/19/25 around 5:10 a.m. She was found on the floor by her bed, laying on her left side, with her blankets wrapped around her body. She was able to move all her extremities. Neurological checks were initiated, no injuries were noted, and the resident had no complaints of pain or discomfort. The care plan lacked the addition of new interventions after the fall on 5/19/25. During an observation on 5/20/25 at 3:08 p.m., the skid strips in front of the resident's recliner consisted of two squares, each smaller than a sticky-note, approximately 12 inches apart. There was no signage in the room to remind the resident to ask for assistance to ambulate (as indicated on the care plan intervention dated 3/4/24). During an interview with CNA 13 on 5/21/25 at 2:08 p.m., she indicated there was supposed to be a sign in the resident's room to remind her to ask for assistance when getting up from her bed or chair. She thought the non-skid strips were supposed to be bigger than the small squares in front of the resident's recliner. During an interview with CNA 5 on 5/21/25 at 2:10 p.m., she indicated Resident 41 required extensive assistance to ambulate. The squares on the floor should be strips. During an interview with the Assistant Director of Nursing (ADON on 5/22/25 at 2:48 p.m., she indicated a new intervention should be added each time a resident had a fall. The CNA sheet would be updated, and staff would be told about any new interventions during shift changes. During an interview with CNA 25 on 5/22/25 at 2:50 p.m., she indicated aides used care plan sheets to find out about any new interventions for residents. During an interview with the MDS Coordinator on 5/22/25 at 2:52 p.m., she indicated care plans were updated often. New interventions should be put into place after every fall. A current, undated facility policy titled Guidelines for Incidents/Accidents/Falls, provided by the Administrator on 5/22/25 at 10:57 a.m., indicated the following: .15. Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place 3.1-35(e)

Based on observation, record review, and interview, the facility failed to implement interventions to prevent and promote the healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 109) Finding includes: During an observation, on 5/19/25 at 9:12 a.m., Resident 109 rested in his bed on his back. During a continuous observation, beginning on 5/20/25 at 2:26 p.m., the resident was lying in his bed on his back. Moon boots (designed to prevent or reduce the risk of pressure injuries) set in a chair beside his bed. At 2:33 p.m., the resident turned on his call light. LPN 4 immediately entered the resident's room, talked with him, then exited his room. At 2:37 p.m., the resident's moon boots remained set on the bedside chair. At 2:42 p.m., the resident turned on his call light. At 2:46 p.m., CNA 5 entered the resident's room. She indicated the resident was asleep. The moon boots remained set on the bedside chair. At 3:26 p.m., the resident was lying in his bed on his back, and the moon boots remained set on the bedside chair. During an observation, on 5/20/25 at 4:07 p.m., the resident was lying on his back in bed. The moon boots remained set on the bedside chair. During an observation, on 5/20/25 at 4:12 p.m., LPN 4 entered the resident's room. She uncovered his feet. He had slipper socks on his feet, and his heels were not floated. She indicated the resident should have his moon boots on while in bed. He did not have them on. During an interview, on 5/20/25 at 4:14 p.m., LPN 4 indicated the resident had an order to wear his moon boots while he was in bed. The order was signed off every shift by nursing staff. During an interview, on 5/21/25 at 9:29 a.m., Resident 109's representative indicated the resident often lay on his back for three to four hours while the resident representative visited and was not repositioned. The staff put on the resident's moon boots about half the time while the resident was in bed. The resident had sores on his back, bottom, and heel. Resident 109's clinical record was reviewed on 5/21/25 at 10:27 a.m. Diagnoses included acute respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, chronic kidney disease, anemia, protein-calorie malnutrition, weakness, and fracture of other parts of the pelvis. Current orders included moon boots on while in bed and offload heels every shift (4/2/25), pressure relieving mattress to bed, hydrophilic wound dressing external paste - apply to bilateral buttocks topically every shift for wound care - cleanse, pat dry, apply paste until area resolved (5/16/25), and left heel - cleanse with Dakin's solution (a topical antiseptic) and apply hydrocolloid dressing (a type of wound dressing that creates a moist wound environment, absorbs wound drainage, and can remain in place for several days in a row) every three days (5/16/25). A significant change Minimum Data Set (MDS) assessment, dated 5/7/25 indicated the resident was severely cognitively impaired. He exhibited no behaviors. He had a functional limitation in the range of motion of one lower extremity. He was dependent on the staff for putting on and taking off footwear. He required substantial/maximal staff assistance with toileting hygiene, showering/bathing, upper and lower body dressing, and transfers. He required partial/moderate staff assistance with rolling right and left in bed. He had an indwelling catheter and was occasionally incontinent of bowels. The resident had one stage 3 pressure injury (full-thickness skin loss) that was not present on admission. A current care plan, initiated on 2/18/25, indicated the resident was at risk for skin breakdown related to chronic renal disease, chronic heart disease, edema, and thin/fragile skin. Interventions included assist to toilet and/or check and change frequently (2/18/25), provide peri care as needed (2/18/25), and remind or assist to turn at least every two hours (2/18/25). A current care plan, initiated on 3/26/25 and revised on 4/29/25, indicated the resident had developed a pressure injury to his left heel related to impaired/decreased mobility and decreased functional ability. Interventions included float heels off bed (3/26/25). A 3/21/25 Weekly Wound Evaluation indicated the resident had a suspected deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) to his left heel that was 4 centimeters (cm) in length and 3.5 cm in width and black in color. The treatment ordered was to cleanse the area with soap and water, pat dry, and apply povidone iodine. The area was identified on 3/21/25. Current preventative interventions included heel boots. A 3/25/25 Weekly Wound Evaluation indicated the resident had a suspected deep tissue injury to his left heel that was 1 cm in length and 1 cm in width and black in color. The treatment ordered to the area was to cleanse the area with povidone iodine and leave open to air. Current preventative interventions included heel boots. A 4/8/25 Weekly Wound Evaluation indicated the resident had an unstageable pressure injury (obscured full-thickness skin and tissue loss) to his left heel that was 0.8 cm in length and 0.7 cm in width and black in color. The treatment ordered to the area was to cleanse the area with povidone iodine, leave open to air, and offload with moon boot. Current preventative interventions included heel boots. The wound was improving without complications. A 4/15/25 Weekly Wound Evaluation indicated the resident had a stage 3 pressure injury to his left heel that was 0.7 cm in length, 0.6 cm in width, and 0.2 cm in depth. The wound was red with 50% epithelial tissue (cells migrate from wound edge to cover the wound surface) and 50% granulation tissue (new connective tissue and tiny blood vessels that form on the surface of a wound during the healing process). The treatment ordered was to cleanse the area with Dakin's solution, apply calcium alginate (a wound care product made from brown seaweed) and then apply bordered gauze to the wound every other day. Current preventative interventions included heel boots. The wound was improving without complications. A 5/13/25 Weekly Wound Evaluation indicated the resident had a stage 3 pressure injury to his left heel that was 0.2 cm in length, 0.3 cm in width, and 0.0 cm in depth. The wound was red with 100% epithelial tissue. The treatment ordered was to cleanse the area with Dakin's solution and apply hydrocolloid to the wound every three days. Current preventative interventions included heel boots. The wound was improving without complications. During an observation, on 5/22/25 at 10:06 a.m., the resident was lying on his back in bed. His moon boots were set on the chest of drawers. During an observation, on 5/22/25 at 10:46 a.m., CNA 5 indicated when a resident had heel boots, the boots should be applied while he was in bed. She pulled back the covers. The resident wore slipper socks, no moon boots, and his heels were not floated. During a continuous observation, beginning 5/22/25 at 11:22 a.m., RN 7, after applying a gown and gloves, pulled up the resident's shirt in the back. The area to the resident's back was healed. RN 7 removed the resident's brief. The resident had pasty brown feces on his buttocks. She provided incontinence care. The resident's buttocks were reddened with a pea sized open area with less than a grain of sugar sized depth near the coccyx area. She applied hydrophilic paste to the buttocks as ordered. She indicated the wound nurse practitioner (NP) had called the area to the buttocks gluteal dermatosis (skin abnormality that isn't inflamed) and utilized the paste for the buttocks since dressings would become soiled easily with incontinence. She removed the moon boot to the left heel to observe the unwrinkled, hydrocolloid dressing that was adhered to the resident's left heel. She indicated the resident had the dressing changed by the wound NP two days ago and was not due to be changed until tomorrow. Throughout the incontinence care and paste application, LPN 8 assisted with holding the resident on his left side. During an interview, on 5/22/25 at 11:37 a.m., LPN 8 indicated the resident should have his moon boots on while he was in bed. During an interview, on 5/22/25 at 2:54 p.m., the DON indicated the resident should wear his moon boots while in bed unless he had refused. If he refused, the refusal should be documented in the resident's record. A review of the resident's clinical record, on 5/22/25 at 2:57 p.m., indicated a lack of documentation of the resident's refusal to allow moon boots to be placed on his feet. An undated facility policy, provided by the Administrator on 5/22/25 at 3:13 p.m., titled Preventative Skin Care, indicated the following: .It is the intent of the facility that the facility provide preventative skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well groomed, and free from pressure sores .Heels up or specialty ordered therapeutic boots may be used to protect heels on those residents identified to be high risk 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to implement seizure precautions for 1 of 2 residents reviewed for accidents. (Resident 41) Findings include: Resident 41's clinical record was reviewed on 5/20/25 at 9:57 a.m. Diagnoses included syncope (fainting) and collapse, repeated falls, chronic kidney disease, and protein-calorie malnutrition. An annual Minimum Data Set (MDS) assessment, dated 2/19/25, indicated Resident 41 was severely cognitively impaired, used a walker and/or wheelchair to ambulate, required supervision when eating, maximum assistance for toileting and showering, was frequently incontinent of both bladder and bowel, had a history of repeated falls, and a history of syncope and collapse. An Interdisciplinary Team (IDT) progress note, dated 5/19/25 at 1:35 p.m., indicated Resident 41 had an unwitnessed fall that morning around 5:10 a.m. She was found on the floor by her bed, laying on her left side, with her blankets wrapped around her body. She was able to move all her extremities. Neurological checks were initiated, no injuries were noted, and the resident had no complaints of pain or discomfort. A general progress note, dated 5/19/25 at 1:35 p.m., indicated Resident 41 had an episode in the dining room at 12:30 p.m. She started jerking and convulsing, her eyes were open and rolled back in her head. Her skin color was gray. Staff stayed with the resident for the duration of the seizure. The seizure lasted approximately 45 seconds to one minute. Afterwards, the resident was alert. She was taken to her room where staff continued to monitor her. A current order, dated 5/19/25, indicated the resident required an assistive device which included two, one-half padded side rails on her bed as a seizure precaution. A current care plan, initiated on 5/19/25, indicated Resident 41 had a need for an assistive bed rail on her bed related to seizure precautions. Interventions included a bed rail screen annually and as needed, ensure proper body alignment in bed, and ensure the resident was not placed too close to either side of her bed. The resident was to be instructed on the use of her call light, reminded to call for assist with transfers, and notify the Physician of any change in condition. A current care plan, initiated on 5/19/25, indicated Resident 41 had a diagnosis of seizure/tremor and was at risk for injury. Interventions included the administration of medications as ordered, monitor pertinent labs, and notify the Physician if seizure activity increased. Side rails were to be padded as needed and the onset, duration, and description of any seizure/tremor activity was to be recorded. During an observation on 5/20/25 at 10:25 a.m., Resident 41's side rail to the outside of her bed was padded with a gray pool noodle. It was approximately the length of two rulers and covered the center of the bed rail, exposing some of the bedrail at the head of the bed and the bottom of the rail. The inside bed rail, against the wall, was up and had not been padded. During an interview with CNA 5 on 5/21/25 at 2:10 p.m., she indicated she did not know if there should be padding on both rails for seizure precautions. During an interview, on 5/21/25 at 2:18 p.m., CNA 5 indicated both rails should be padded. During an interview on 5/21/25 at 2:51 p.m., the DON indicated the maintenance person had not known how to install pads to side rails because it was uncommon for the facility to use seizure precautions. A current, undated facility policy, titled Seizure Precautions Guidelines for Care and provided by the Administrator on 4/22/25 at 4:20 p.m., indicated the following: .It is the policy of this facility to protect the resident from injury during a seizure and to evaluate and document observations prior to, during, and after a seizure The policy lacked instructions for side rail pad application. 3.1-45(a)(2)

Based on record review and interview, the facility failed to implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program activities to prevent repeat deficiencies identified during a revisit to the annual survey. Finding includes: Review of the Summary Statement of Deficiencies (2567), for the facility's last annual Recertification and Licensure Survey completed on 5/22/25, indicated the facility had deficiencies related sanitary conditions related to kitchen equipment and food storage (F812). During an observation, on 6/24/25 at 9:02 a.m., accompanied by the Dietary Manager, the facility kitchen was found to be maintained in an unsanitary condition related to food storage and equipment maintenance. During an interview, the Dietary Manager indicated she was unable to provide audit tools for cleaning or cleaning schedules for the kitchen. Review the facility's plan of correction (2567), signed by the Administrator on 6/12/25, indicated the facility's F812 Food Safety Audit Tool will be completed five times per week for four weeks, then three times per week for four weeks, then weekly for four months for kitchen and equipment cleanliness and food storage. During an interview, on 6/24/25 at 10:00 a.m., the Administrator indicated kitchen audit logs had been completed and were in the facility's Plan of Correction (POC) binder. Review of a food storage audit indicated kitchen equipment was clean, food was stored, and no follow up was required initialed by the Administrator on June 9, 2025- June 13, 2025 and June 20, 2025- June 23, 2025. During an interview, on 6/24/25 at 2:27 p.m., the Administrator indicated the facility's QAPI program had a dietary section. The facility was reviewing cleanliness, food tray audits, and weekly sanitation. One random hall cart tray was temperature checked. During an interview, on 6/24/25 at 2:57 p.m., the Regional Nurse Consultant indicated the facility's plan of correction had not been ran through the facility's QAPI program, as the facility's compliance date was June 9, 2025. A current facility policy, dated 3/9/22, titled Quality Assurance/Performance Improvement Program, provided by the Administrator on 6/24/25 at 3:38 p.m., indicated the following: .Policy: It is the intent of this facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systemically monitor, evaluate, and improve the quality and appropriateness of resident care. 6. The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes Cross reference F812. 3.1-52(b)(2)

Based on observation, interview, and record review, the facility failed to consistently implement facility policy for enhanced barrier precautions for staff to identify those residents requiring enhanced barrier precautions for 1 of 3 residents reviewed for enhanced barrier precautions. (Resident 21) Finding includes: During an observation, on 5/19/25 at 9:15 a.m., Resident 21 lay on his bed on top of the blankets looking at a phone. A heel boot was lying on the floor beside the bed. No signage for transmission-based precautions was on his door During an observation, on 5/20/25 at 9:49 a.m., Resident 21 sat in his wheelchair in his room with a heel boot on his right foot. No signage for transmission-based precautions was on his door. During an observation, on 5/21/25 at 9:19 a.m., Resident 21 sat in his wheelchair in his room. He had a heel boot on his right foot. No signage for transmission-based precautions was on his door. Resident 21's clinical record was reviewed on 5/20/25 at 3:26 p.m. Diagnoses included chronic diastolic (congestive) heart failure, peripheral vascular disease, multiple myeloma, and protein calorie deficit. Current orders included enhanced barrier precautions related to his wound with personal protective equipment (PPE) outside door, bin in room for disposal, and sign on door every shift (5/8/25) and cleanse wound to right foot with Dakin's solution, pat dry, apply calcium alginate with silver, and cover with bordered foam dressing every other day until resolved (5/14/25). A 2/26/25 admission Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. He required partial/moderate staff assistance for rolling left and right in bed. He required substantial/maximal staff assistance with toileting, showering/bathing, upper/lower body dressing, and transfers. He was dependent on staff for putting on and taking off footwear. A care plan, initiated on 5/8/25, indicated the resident had developed an arterial wound to his right lateral foot. A care plan, initiated on 5/18/25, indicated the resident was on enhanced barrier precautions related to wounds or a skin opening requiring a dressing. Interventions included set up isolation per facility protocol and follow enhanced barrier precautions (5/18/25). A Wound Assessment Report, dated 5/13/25, indicated the resident had an arterial wound to his right later foot with a length of 1.0 centimeters (cm), a width of 1.0 cm, and a depth of 0.2 cm. During an interview, on 5/22/25 at 11:44 a.m., CNA 16 indicated she knew which residents were on enhanced barrier precautions and required PPE by the signs on the doors. They also had a PPE cart beside their door or across the hall in front of their door. She knew what PPE was required for the resident by the signs on the doors. She walked down the hall and pointed to all the doors with signs on them as residents who required enhanced barrier precautions. She indicated Resident 21 was not on any transmission-based precautions. He did not have a sign on his door. She thought the enhanced barrier precautions were also listed on the CNA assignment sheets. She looked at the CNA assignment sheets and indicated transmission-based precautions were not on the assignment sheets for anyone. During an interview, on 5/22/25 at 11:48 a.m., the Infection Preventionist (IP) indicated she had not put the enhanced barrier precautions sign on the door. The resident had been recently added to the enhanced barrier precautions list. During an interview, on 5/22/25 at 11:50 a.m., CNA 18 indicated she knew the resident required PPE when doing care because he had a wound, but he did not have a sign on his door. During an observation, on 5/22/25 at 11:57 a.m., the Housekeeping Supervisor placed bins in the room for disposal of PPE/trash/laundry. The resident did not have the facility bins that were utilized for the enhanced barrier precautions in his room prior to this placement. During an interview, on 5/22/25 at 2:52 p.m., the DON indicated the resident should have had the EBP signage on his door as ordered. A facility policy, revised 12/2022, provided by the Administrator on 5/22/25 at 3:13 p.m., titled ENHANCED BARRIER PRECATIONS-(EBP), indicated the following: .Procedure .3) Ensure that proper signage is posted on the resident's room door instructing those who plan to enter the room to check first at the Nurses' Station for education/instructions .5) Ensure that proper receptacles are in place to collect discarded EBP in the resident's room 3.1-18(a)

Based on observation and interview, the facility failed to maintain appropriate infection control practices during urinary catheter care for 1 of 1 residents reviewed for Enhanced Barrier Precautions. (Resident D) Findings include: Resident D's clinical record was reviewed on 3/11/25 at 2:10 p.m. Diagnoses included aftercare following joint replacement surgery, weakness, congestive heart failure, and chronic kidney disease. Current physician orders included, but were not limited to, catheter care every shift and ensure catheter drainage bag is below the waist and covered, change catheter as needed for leakage or dislodgement. Change catheter drainage bag at the time of catheter change. During a catheter care observation for Resident D, on 3/12/25 at 9:25 a.m., CNA 2 performed hand hygiene with soap and water before donning gloves. CNA 2 failed to don a gown before starting Resident D's catheter care. Resident D had EBP signage displayed on the door. During an interview, at the time of observation, CNA 2 indicated she failed to put on a gown before providing Resident D's catheter care. During an interview, on 3/12/25 at 10:40 a.m., the ADON indicated staff members were required to wear gown, gloves, goggles, and a mask before performing catheter care on residents who required Enhanced Barrier Precaution. Residents who required Enhanced Barrier Precaution had signage displayed on their doors. A copy of the facility's Enhanced Barrier Precaution sign was provided on 3/12/25 at 9:45 a.m., by the Administrator. The EBP sign indicated everyone must clean their hands before entering and leaving the resident's room. Providers and staff must also wear gloves and gown for the following high contact resident care activities: Dressing, bathing/showering, transferring, changing linen, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care. A current facility policy, titled Catheters, provided by the Administrator on 3/12/25 at 9:45 a.m., indicated the following: .4. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and facility policy and procedure with adherence to infection prevention and control techniques This citation relates to Complaint IN00452389. 16.2-5-12(a)

Based on observation, interview, and record review, the facility failed to provide palatable food to 23 residents in the main dining room during meal service. Findings include: During an interview, on 3/20/24 at 10:34 a.m., Resident 19 indicated the meat was dry and it took a while for everyone to be served. During an interview, on 3/20/24 at 10:48 a.m., Resident 12 indicated the meat was hard at times and the food was usually cold when she ate in her room. During a meal observation, on 3/20/24 at 12:18 p.m., CNA 6 was unable to cut a resident's brisket with a butter knife. She retrieved a different knife from the kitchen to cut the meat. During a meal observation, on 3/20/24 at 12:19 p.m., CNA 6 had difficulty cutting a piece of brisket for another resident. During an observation, on 3/20/24 at 12:21 p.m., Resident 16 carried her plate to the kitchen window and requested a salad as she indicated her food was inedible. During an interview, on 3/20/24 at 12:33 p.m., Resident 16 indicated the food was always terrible and usually inedible. She was unable to eat the meat, so she requested a chef salad. The salad consisted of eggs and lettuce. A test tray was obtained on 3/20/24 at 12:44 p.m. The brisket was dark brown in appearance. It cut easily and was flavorful, but dry. The green beans were mushy and lacked flavor. During an interview, on 3/20/24 at 1:05 p.m., CNA 16 indicated the food was terrible, and she had to retrieve a sharper knife to cut the brisket. Review of the facility grievance binder was completed on 3/20/24 at 2:15 p.m. and indicated the following: Resident 47 filed a grievance on 2/14/24 stating the meat was always cold. The response did not address concerns about cold meat. Resident 16 filed a grievance on 12/19/23 stating the meat was dry, the baked potato was hard, and the pasta was clumpy. The response included the option of having gravy with the meat and starting to cook the meat in broth. During an interview, on 3/21/24 at 1:12 p.m., the Regional Nurse Consultant indicated it was difficult to provide perfectly cooked food daily. A policy on general preparation and cooking practices was provided on 3/21/24 at 1:30 p.m. by the Administrator. Review of the policy indicated the policy did not address meat preparation or serving palatable food. 3.1-21(a)(2) This citation relates to Complaint IN00427042.

Based on observation and interview, the facility failed to maintain infection control practices while serving food to 23 residents in the main dining room, in accordance with facility policy for meal service. Findings include: During a meal observation, on 3/20/24 at 12:18 p.m., CNA 5 pulled bread from the plastic wrapper with her bare hands on two separate occasions. Both residents had eaten the bread that was touched during the meal observation. During an interview, on 3/20/24 at 12:35 p.m., CNA 5 indicated she removed bread from the wrapper with her bare hands when she should have used a glove. A current undated facility policy titled Policy and Procedure Meal Service, provided by the Administrator on 3/21/24 at 1:45 p.m., indicated the following.there is no bare hand contact with ready to eat foods 3.1-21(i)(3) This citation relates to Complaint IN00427042.

Based on observation, interview, and record review the facility failed to ensure residents were assessed to determine ability to self-administer medications prior to self-administering for 2 of 3 residents observed during random observations. (Resident E and Resident D) Findings include: 1. During an interview with Resident E, on 1/24/24 at 11:10 a.m., there was a clear bag with several boxes of medication in it and a medication bottle next to the bag located on his overbed table, next to his bed. He indicated the bag contained his eye drops that he administered to himself. He had one eye drop that he put in his eye four times a day, three eye drops twice a day, and one eye drop once a day. He identified the drops by the color of the lids on the bottles. There were drops that he had to wait 10 minutes before putting in the next drop and asking the nurses to run back and forth to administer them was ridiculous. Resident E's clinical record was reviewed on 1/24/24 at 11:49 a.m. Diagnoses included type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema and unspecified glaucoma. His current medications included latanoprost ophthalmic solution (treat glaucoma) 0.005 % one drop in both eyes in the evening, atropine sulfate ophthalmic solution (treat glaucoma) 1% one drop in left eye every morning and at bedtime, brinzolamide-brimonidine tartrate ophthalmic suspension (treat glaucoma) 1-0.2% one drop in right eye every morning and at bedtime, timolol maleate ophthalmic solution (treat glaucoma) 0.5% one drop in right eye every morning and at bedtime, prednisolone acetate ophthalmic suspension (treat glaucoma) 1% one drop in left eye four times a day and fluticasone propionate suspension (treat allergies) 50 mcg one spray in each nostril every morning and at bedtime. A significant change, Minimum Data Set (MDS) assessment, dated 11/7/23, indicated he was cognitively intact. His clinical record lacked a self-administration assessment. During an interview with LPN 15, on 1/24/24 at 11:56 a.m., she indicated Resident E insisted on giving himself his eye drops, seemed he had to wait for 5 minutes between the drops. They normally gave him the eye drops and he would let them know when he was done. They probably should had completed a self-administration assessment on him, because he didn't have one. She didn't know why he had his medications in his room, as he normally would let them know when he was done with them. 2. During an interview with Resident D, on 1/24/24 at 11:00 a.m., she indicated she was doing well, other than a kidney infection. The nurses gave her some cream that she put on her vagina at night because it was sore. On the shelf of her mirror in the bathroom, a medicine cup was observed with a white creamy substance in it. She indicated that was the cream the nurses gave her, so she could apply it to her vagina. Resident D's clinical record was reviewed on 1/24/23 at 11:03 a.m. Diagnoses included chronic kidney disease and other Alzheimer's disease. Her current medications included estradiol vaginal cream (hormone replacement) 0.1 mg/gm (milligram/gram) apply one application to outer vaginal area in the evening. A quarterly MDS assessment, dated 12/20/23, indicated she was moderately cognitively impaired. Her clinical record lacked a self-administration assessment. During an interview with RN 8, on 1/25/24 at 10:18 a.m., the vaginal cream remained in Resident D's bathroom. RN 8 indicated she normally let Resident D administer the cream herself because that was her preference, but stayed in the bathroom with her when she applied it. The cream should not be left in the bathroom. An undated, current facility policy, titled Medication Self Administration, provided by the DON, on 1/25/24 at 2:49 p.m., indicated the following: .Policy: 1. Residents who request to self-administer drugs will be assessed at the time of admission or thereafter to determine if the practice is safe based on the results of the Resident Assessment-Self-administration Tool. 2. The assessment results will be discussed with the attending physician and an order obtained to self-administer if appropriate This citation relates to Complaint IN00422953. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision of a resident with a known risk for falls for 1 of 1 residents reviewed for falls with major injury. This deficient practice resulted in the resident sustaining a wrist fracture during a subsequent fall (Resident 44). Findings include: On 1/29/18 at 9:08 a.m., Resident 44 was in her room, sitting in her wheelchair. She was wearing a sling and had a wrapped splint to her left arm. Her left hand was observed to have purple bruising to the top of her left hand. On 2/1/18 at 9:47 a.m., she was sitting in her wheelchair in the doorway of her bathroom. The ADON asked her if she needed assistance and she indicated yes, she needed to go to the bathroom. On 2/2/18 at 9:35 a.m., she was sitting in her wheelchair, propelling herself slowly with her feet toward her bathroom. As she moved the wheelchair, her call light, which was attached to her wheelchair, pulled from the wall, causing the call light to come on. At 9:36 a.m., LPN 34 entered the room, where Resident 44 had entered the bathroom with her wheelchair. After assisting the resident, LPN 34 entered the hallway and indicated to the ADON that the resident had pulled the call light from the wall, had gone into the bathroom herself, and was now using the bathroom. At 9:43 a.m., CNA 35 entered the room to answer the bathroom call light. Review of the clinical record began on 1/30/18 at 10:42 a.m. [DIAGNOSES REDACTED]. She had current orders for, but not limited to, splint to left wrist and sling to left arm at all times, ice to left wrist every 20 minutes as needed for swelling, low mattress with raised edge, [MEDICATION NAME] (for blood pressure and heart failure) 3.125 mg twice daily, and [MEDICATION NAME] (water pill)1 mg once daily, and [MEDICATION NAME] (for gout) 100 mg once daily. A 12/29/17, quarterly MDS indicated she was moderately cognitively impaired and required extensive assistance for mobility, ADLs, transfers, and ambulation. She was not steady during transfers and was only able to stabilize with staff assistance. She was frequently incontinent of urine and continent of bowel, and was not on a toileting program. She had a current care plan problem of needing extensive assistance with ADLs, including toileting, due to weakness. She had a current care plan for risk for falls due to, but not limited to, weakness, use of assistive devices, and forgetfulness. A 10/30/17 Admission Assessment indicated she had arrived for admission to the facility at 1:29 p.m. Interventions, such as non-skid socks, were in place due to her being at risk for falls. A 10/30/17 Occurrence Assessment indicated she had fallen in her bathroom at 9:40 p.m. She had been noted in a sitting position on the floor with her legs extended in front of her. Her left leg was slightly turned inward and she was not able to move it. A Hospital Progress Note, dated 11/5/17, indicated she had required surgery to repair a fracture to the neck of her left femur ([MEDICAL CONDITION]). An 11/5/17 Admission Assessment indicated she had been admitted back to the facility from the hospital and was at risk for falls. An 11/8/17 Occurrence Assessment indicated she had been found sitting on the floor with her legs extended out. She had been trying to get into her recliner and could not find her call light. An 11/9/17 Occurrence Assessment indicated she had two new skin tears observed at 12:27 p.m., to the front of her left lower leg, each measuring 1 centimeter (cm) long x 1 cm wide. A 1/20/18 Occurrence Assessment indicated she had fallen at 2:00 p.m. and was noted to be on the floor on her left side, resting on her left elbow. She stated she was trying to stand up, the floor was too slick, and she felt like she had broken her left wrist and elbow. She returned from the emergency room with a [DIAGNOSES REDACTED]. A 12/28/17, physician assistant note indicated she was being discharged from therapies and had made some progress, but had not returned to previous level of function and had not been cleared to transfer without assistance. During an interview, on 2/1/18 at 9:56 a.m., the ADON indicated the resident transferred with the assistance of one staff member. During an interview, on 2/1/18 at 2:08 p.m., CNA 30 indicated the resident required the assistance of one person with a gait belt for transfers, was continent of bowel and bladder, and would use the call light to alert staff. She indicated she did not walk, but could propel her wheelchair at times. During an interview, on 2/1/18 at 2:49 p.m., the DON indicated the resident was not able to transfer herself without assistance and could not walk. She indicated the resident had not been assessed as a fall risk at the time of admission to the facility. During an interview, on 2/2/18 at 9:49 a.m., CNA 39 indicated the resident was usually continent of urine and would sneak at times and transfer herself to the toilet . She indicated the staff tried to have her be the first one assisted to toilet before and after meals, but they couldn't always get to her in time. Review of a CNA assignment sheet, provided by the DON on 1/29/18 at 10:15 a.m., indicated she was confused, needed assistance of one person for ADLs, and was listed as .FALL RISK- don't leave alone in bathroom The document indicated she needed the assistance of 2 persons and a gait belt for transfers. Review of a policy, titled Fall Management Procedure, dated 4/13/16 and provided by the Administrator on 2/2/18 at 2:44 p.m., indicated the purpose of the policy was to assess all residents for risk factors that may contribute to falling and to provide planned interventions. The procedures included, but were not limited to, the care plan team would review risk factors and determine if further assessment is indicated and would determine which interventions were appropriate. 3.1-45(a)

Based on record review and interview, the facility failed to ensure licensed nursing staff assessed thoroughly and visually observed two surgical wounds with staples for seven days, resulting in the resident being readmitted to the hospital for irrigation and debridement of the wounds for 1 of 3 residents with surgical wounds in a sample of 4. This involved 7 of 10 licensed nurses who cared for the resident between 12/7/10 and 12/15/10 (Resident B and LPN #1, LPN#2, LPN#3, LPN#4, LPN#5, RN#6, LPN#7, LPN#8, LPN#9, and LPN#10). Findings include: 1. Resident B's closed clinical record was reviewed on 01/20/11 at 2:30 P.M. Resident B's [DIAGNOSES REDACTED]. Resident B's admission orders F/U (follow up) with (name of orthopedic surgeon group) on 12/14/10." There was an additional order for "Moniter (sic) surgical incisions to (L) (left) ankle q. (every) shift for s/s (signs/symptoms) infection & pain until healed." There were initials on the MAR (Medication Administrator record), dated December 2010, for the order "Moniter (sic) surgical incisions to (L) (left) ankle q. (every) shift for s/s (signs/symptoms) infection & pain until healed" indicating this had been done as ordered. Resident B's admission assessment, dated 12/7/10 at 8:40 P.M., indicated Resident B was assessed as having "no [MEDICAL CONDITION] in her legs or ankles." She was assessed as having had a recent fracture with a "splint in place." She was assessed as "left ankle fracture, has surgical incisions, no tretaments (sic) at this time." Her surgical incision was assessed with [REDACTED]. Clean and dry. Drainage present." with a comment of "left ankle has 2 incisions, surrounding areas red & purple in color, swollen, skin flaky, small amount of brown drainage noted. 1. left side of ankle 10.5 cm (centimeters) X 0.2 cm 13 staples intact. 2. right side of ankle 6 cm x 0.2 cm 7 staples." There were check marks by the following: "Wound(s) potentially related to pressure, vascular insufficiency, diabetic [MEDICAL CONDITION], severe burns" and "Bruises." This assessment was signed by LPN #1. Resident B's assessment, dated 12/8/10 at 2:44 A.M., indicated Resident B was assessed as having "3+ Deep pitting, indentation remains for a short time, legs/feet look swollen (may last > (greater than) 1 min) [MEDICAL CONDITION] in her feet/lower legs/abdomen." She was assessed as having a "(L) ankle FX (fracture) with a "splint in place. staff encourages resident to elevat (sic) ext (extremity) on pillows while in bed." The assessment for the "Surgical incision had check marks by the following: "Sutures/staples in place. Clean and dry. Drainage present." with a comment of "Scant amount of brown drainage noted. 1. left side of ankle has staples intact. 2. right side of ankle has 7 staples." 3.... If dressing in place and not removed this shift note that. The area on the assessment was blank. This assessment was signed by LPN #2. Resident B's assessment, dated 12/8/10 at 12:01 P.M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly [MEDICAL CONDITION] in her feet/lower legs/abdomen." She was assessed as having a "(L) ankle repair with a "splint covered with gauze et ACE wrap. There was no additional assessment of the ankle wound. This assessment was signed by LPN #3. Resident B's assessment, dated 12/8/10 at 5:56 P.M., indicated Resident B was assessed as having "3+ Deep pitting, indentation remains for a short time, legs/feet look swollen (may last > (greater than) 1 min) [MEDICAL CONDITION] in her feet/lower legs/abdomen." She was assessed as having a "FX (fracture) to Left ankle" with a device present. The assessment for "Surgical incision had check marks by the following: "Sutures/staples in place. Clean and dry. Drainage present." with a comment of "Scant amount of brown drainage noted. 1. left side of ankle has 13 staples intact. 2. right side of ankle has 7 staples." 3.... If dressing in place and not removed this shift note that. The area on the assessment was blank. This assessment was signed by LPN # 4. Resident B's assessment, dated 12/9/10 at 12:52 A. M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly in her feet/lower legs/abdomen." She was assessed as having a "Left ankle Fx repair" with a device present. The assessment for the "Surgical incision had check marks by the following: "Sutures/staples in place. Drainage present." with a comment of "Sm (small) amount of brown drainage noted. 1. left side of ankle has 13 staples intact. 2. right side of ankle has 7 staples. drsg (dressing) clean dry and intact at this time." 3.... If dressing in place and not removed this shift note that. The area on the assessment was blank. This assessment was signed by LPN #5. Resident B's assessment, dated 12/9/10 at 12:23 P.M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly, [MEDICAL CONDITION] in her feet/lower legs/abdomen." She was assessed as having a fracture to the "Lt (left) ankle" with a device present. The assessment for the "Integumentary system" was "dressing intact, unable to assess ankle at this time." This assessment was signed by LPN #3. Resident B's assessment, dated 12/9/10 at 4:51 P. M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly in her feet/lower legs/abdomen." The assessment for the "Surgical incision" had check marks by the following: "Sutures/staples in place. Clean and dry." with a comment of "Left ankle. Small amount of brown drainage noted. 1. left side of ankle has 13 staples intact. 2. right side of ankle has 7 staples. dressing clean, dry, and intact at this time. no s/s (signs/symptoms) infection" 3.... If dressing in place and not removed this shift note that. The area on the assessment was blank. This assessment was signed by LPN #1. Resident B's assessment, dated 12/10/10 at 1:38 A. M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly in her feet/lower legs/abdomen." The assessment of the "Musculoskeletal assessment" had a notation of "splint on Left ankle, gauze and ace bandage wrap area." The assessment for the "Surgical incision" had check marks by the following: "Sutures/staples in place. Clean and dry." with a comment of "Left ankle. Small amount of brown drainage noted. 1. left side of ankle has 13 Sutures (According to the admission assessment, there were staples in the suture line.) intact. 2. right side of ankle has 7 sutures dressing clean, dry, et intact at this time. no s/s (signs/symptoms) infection." 3.... If dressing in place and not removed this shift note that. The area on the assessment was blank. This assessment was signed by LPN #2. Resident B's assessment, dated 12/10/10 at 9:48 A. M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly in her feet/lower legs/abdomen." The assessment of the "Musculoskeletal assessment" had a notation of "Sm (small) amount of bloody drainage noted. Left side of ankle has 13 Sutures intact. Right side of ankle has 7 Sutures intact. Dressing clean dry and intact at this time, no s/s infection." 3.... If dressing in place and not removed this shift note that. The area on the assessment was blank. This assessment was signed by RN #6. Resident B's assessment, dated 12/10/10 at 6:44 P. M., indicated Resident B was assessed as having "1+ Mild pitting, slight indentation, no perceptible swelling that disappears rapidly" in her feet/lower legs/abdomen." The assessment of the "Musculoskeletal assessment" had a notation of "Left ankle fracture. Splint in place." The assessment of the "Integumentary system assessment" had checkmarks for "Sutures/staples in place" and "Clean and dry." There were no additional comments on the condition of the 2 surgical wounds. This assessment was signed by LPN #1. Resident B's assessment, dated 12/11/10 at 2:24 A. M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly in her feet/lower legs/abdomen." The assessment of the "Musculoskeletal assessment" had a notation of "Left ankle fracture. Splint on Left ankle, gauze and ace bandage wrap area." The assessment for the "Surgical incision" had check marks by the following: "Sutures/staples in place." with a comment of "Left ankle. Small amount of brown drainage noted. 1. left side of ankle has 13 Sutures intact. 2. right side of ankle has 7 sutures dressing clean, dry, et intact at this time. no s/s (signs/symptoms) infection.... If dressing in place and not removed this shift note that." The area on the assessment was blank. This assessment was signed by LPN #5. Resident B's assessment, dated 12/12/10 at 12:14 A. M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly in her feet/lower legs/abdomen." The assessment for the "Surgical incision" had check marks by the following: "Sutures/staples in place" and "Clean and dry." with a comment of "Left side of ankle has 13 Sutures intact. Right side of ankle has 7 sutures dressing clean, dry, and intact no s/s (signs/symptoms) infection.... If dressing in place and not removed this shift note that." The area on the assessment was blank. This assessment was signed by LPN #7. Resident B's assessment, dated 12/12/10 at 4:28 P. M., indicated Resident B was assessed as having "2+ Moderate pitting, indentation subsides rapidly in her feet/lower legs/abdomen." The assessment of the "Musculoskeletal assessment" had a notation of "Left ankle fracture." with "Splint to left lower extremity." The assessment for the "Surgical incision" had check marks by the following: "Sutures/staples in place" and "Clean and dry" with a comment of "Left side of ankle has 13 Sutures intact. 2. right side of ankle has 7 Sutures dressing clean, dry, and intact no s/s (signs/symptoms) infection.... If dressing in place and not removed this shift note that." The area on the assessment was blank. This assessment was signed by LPN #7. Resident B's assessment, dated 12/13/10 at 10:42 A.M., indicated Resident B was assessed as having "3+ Deep pitting, indentation remains for a short time, legs/feet look swollen (may last > (greater than) 1 min) [MEDICAL CONDITION] in her feet/lower legs/abdomen." She was assessed as having a fracture to "Lt ankle" with a device present which was a "splint covered with ACE wrap." The assessment for the "Surgical incision" was blank. This assessment signature did not print. Resident B's assessment dated [DATE] at 9:42 A.M., indicated Resident B was assessed as having "3+ Deep pitting, indentation remains for a short time, legs/feet look swollen (may last > (greater than) 1 min) [MEDICAL CONDITION] in her feet/lower legs/abdomen." She was assessed as having a fracture to "Lt ankle" with a device present which was a "splint covered with guaze and ACE wrap." The assessment for the "Surgical incision" was blank. This assessment was signed by LPN #3. Review of the care plans, dated 12/08/10, indicated the following: "Focus Fracture: left ankle - At risk for complications." The interventions included, but were not limited to, "Administer treatments as ordered.... Monitor and medicated for discomfort as needed...." "Focus - Risk for infection Left ankle X 2 incisions." The interventions included, but were not limited to, ".... Assess incision daily during treatment.... Notify M.D. of any changes that may indicate infection or not healing properly (i.e. increased redness , warmth, drainage, increased pain, dehiscence).... Follow up with orthopedic surgeon and (sic) scheduled." "Focus - Actual skin Alteration.... Surgical incision X 2 to left ankle noted on admission 12/7/10." The interventions included, but were not limited to, "....Monitor for s/s of infection & notify MD as needed...." The progress notes indicated on 12/15/10 at 9:10 A.M., Resident B was transported to the orthopedic's office for a follow-up visit for her fractured ankle. The progress notes indicated on 12/15/10 at 1:38 P.M., Resident B was admitted to the hospital directly from the orthopedic's office. Review of the "History and Physical," dated 12/15/2010, from the hospital indicated "REASON FOR ADMISSION: Infected left ankle, status [REDACTED]. She was seen by my partner in the office today, (name), found to have purulence from both medial and lateral incisions....IMPRESSION: Infected hardware and incision, status [REDACTED]. PLAN: At this point, she needs irrigation and debridement, possible hardware removal versus replacement.... She is a high risk for medical complications [REDACTED]. She will require admission to the hospital, intravenous antibiotics, and likely repeat irrigation and drainage at future dates." Review of the "Discharge Summary," dated 12/23/2010, from the hospital indicated "She was admitted to the hospital on [DATE], where she did undergo a successful irrigation and debridement of her right lower extremity...." The facility provided their investigation of the care of Resident B, which they had completed, after Resident B's son had called the facility on 1/6/2011, asking for a copy of her chart. During the investigation, all staff involved in the care of Resident B were suspended. The facility concluded: "Licensed nurses conducted assessments which they thought were appropriated given the fact that the resident was in an immobilizer/cast due to a severe fracture which the nurses considered to be unstable.... Some nurses visually assessed the sutures, and all nurses assessed in their own way for signs and symptoms of infection. This would include checking for drainage on ace wrap of immobilizer/cast, pedal pulses, circulation, sensation and movement of the toes, temperature, [MEDICAL CONDITION], checking exposed foot including toes and above the immobilizer/cast...." The facility provided a copy of the "Standards for the competent practice of registered and licensed practical nursing" as part of their investigation of the care of Resident B. This document indicated "Rule 3 ....Know and utilize the nursing process in planning, implementing, and evaluating health services and nursing care to the individual patient or client.... Assess the health status of the patient/client, in conjunction with other members of the health care team, for analysis and identification of health goals...." Review of the facility interview notes indicated the "2. Nurses assessed leg and foot and toes. They looked at gauze/dressing for drainage, potential infection and pain. Nurses did not feel they could remove case/immobilizer, as in the past they could not similar cast/immobilizers until after the orthopedic visit. 3. 12/10/10 09:48 Assessment (LPN #10) (This assessment is signed by RN #6) stated on assessment there was bloody drainage. However, she stated she should have stated the blood was on ace wrap. She did change the ace wrap and applied a new one. There was no blood on the gauze or near incision.... 4. 12/10/10 (LPN #2) documentation brown drainage on her assessment. However, she used her initial assessment from 12.8.10 and after she assessed resident, she noticed no brown drainage on 12/10/10. However, she did change her documentation from 12/10/10 to reflect no drainage noted. Facility did not make any changes in assessments in order to reflect changes in assessment. (sic). 5. (LPN #2) stated that she learned during report that resident had brown drainage on gauze. However, she did not document information was given to her per last nurse, as she never saw brown drainage on 12/8/10...." During an interview with the Administrator on 1/21/2011 at 1:13 P.M., he indicated the only nurses who looked at the resident's incision lines were the admitting nurse (LPN #1) and another nurse (LPN #8), who she had look at the incisions at the same time she (LPN #1) looked at them. He indicated the same admitting nurse (LPN #1), with a second nurse (LPN #9), looked at the incision lines on the second day Resident B was in the facility. He indicated no other nurses had looked at the incision lines, they had only looked at the dressing covering the incision lines. This federal tag relates to complaint IN 727. 3.1-37(a)

Based on record review and interview, the facility failed to ensure staff administered the correct medications as ordered by the physician for 2 of 2 residents reviewed related to medication errors in a sample of 3 resident reviewed related to medication administration. (Residents A and B). This deficient practice resulted in Resident A experiencing a drop in blood pressure and temperature, and a change in skin color to the lips. The changes in the resident's condition required transfer to the emergency room for evaluation, including multiple test procedures, and further assessment at the facility, including during normal hours of sleep. (Residents A and B). Findings included: 1. Resident A's clinical record was reviewed on 11/8/10 at 9:15 A.M. Resident A's [DIAGNOSES REDACTED]. Resident A's Nurses' Notes indicated: 10/30/10 7:14 P.M., "B/P (blood pressure) 126/62, P (pulse) 70, R (respiratory rate) 20, T (temperature) 98.0...." 11/3/10 9:06 A.M. "v/s o2 (oxygen saturation) 93%, RA (room air) p (pulse) 66 resp (respiratory rate) 18, (blood pressure) 90/56, temp 95.8/ax (axillary) res (resident) noted to be slow to respond when asked questions. lungs clear. resp even et (and) non labored. skin warm, dry et pale. res lips noted to be blue. boso (bowel sounds) active x 4. abd soft et non tender. res eye are pinpoint et non reactive to light. res noted to have had a fall on 10/30/19 (sic) in room ... stated to have hit head. when asked if res was in pain he would answer yes et placed hand on head. updated Dr. (name) on above. n.o. (new order) rec'd (received) per Dr. (name) to send res to ER (emergency room ) to eval et tx." 11/3/10 9:51 A.M. "Notified Dr. (name), Dr. (name), Dr. (name) of resident receiving all daily medications for 11-3-10 and transfer to ER...." The emergency room notes dated 11/03/10 indicated Resident A's blood pressure was 107/40, pulse was 67, respiratory rate was 16, temperature was 97.3, and oxygen saturation was 95% on room air and 98% on oxygen therapy at 9:55 A.M. Resident A complained of "hurting all over" and he had a history of [REDACTED]. During his stay in the ER, Resident A had a CT (computerized tomography) scan of his head, spine, abdomen, and pelvis. All of these scans indicated the resident had no acute trauma or fractures. He had identified changes, but none were acute. Resident A had his blood and urine tested with some abnormal values, but none that were treated. The CT scan of the abdomen indicated there was fecal matter in the colon. The ER discharge noted the resident had constipation and Mag [MEDICATION NAME] (a laxative) was ordered for the resident. Resident A's Nurses' Notes indicated: 11/3/10 5:17 P.M., "N.O. (new order) rec'd (received) per Dr. (name) 1. increase fluids, 2. v/s (vital signs) q (every) 4 hrs (hours) for 24 hrs, 3. hold all meds today except mag [MEDICATION NAME], resume normal meds tomorrow 11-4-10." 11/4/10 1:34 A.M., "VS (vital signs) @ 12 mn (midnight) 106/78, 70, 24, 97.8 ax (axillary), 93% ORA (on room air), .... easily aroused to name, alert and oriented times 3...." Review of the MAR (medication administration record) for November 2010 indicated the resident received the following medications on 11/8/10 at 8:00 A.M.: Fluticansone Spray (corticosteroid) 50 mcg (micrograms) inhale 1 spray in each nostril [MEDICATION NAME] (stomach acid reduction) 150 mg. [MEDICATION NAME] Sodium (stool softener) 100 mg. Questran (lipid lowering agent) 1 scoop in 8 ounces of water [MEDICATION NAME] (antihypertensive) 6.25 mg. [MEDICATION NAME] (pain reliever) 325 mg. 2 tablets (650 mg) Carbo/Levo (antiparkinsonian) 25/100 (3 1/2 tabs for a total of 37.5/150 mg.) Vitamin D 1000 units (vitamin) Aspirin 81 mg. (pain medication used to prevent blood clots) Daily vite w/iron (vitamin) [MEDICATION NAME] Mono (antihypertensive) 30 mg. tab ER Therapeutic Tab-M (vitamins) [MEDICATION NAME] (antidepressant)10 mg. Review of the medication error forms on 11/8/10 at 11:30 A.M. indicated Resident A had received the following medications in error at 7:30 A.M.: Poly-Iron 150 mg. (milligrams) which was scheduled for noon. [MEDICATION NAME] (Klonopin) 0.25 mg.which was scheduled for 8 P.M. [MEDICATION NAME] 6.25 mg. which was scheduled for 8 P.M. Carbo/Levo 25/100 (3 1/2 tabs for a total of 37.5/150 mg.) which was scheduled for noon [MEDICATION NAME] 1 mg. which was scheduled for bedtime [MEDICATION NAME] 150 mg. which was scheduled for 8 P.M. This meant Resident A received double doses of the [MEDICATION NAME] (causes dizziness, fatigue, depression, headache, [MEDICAL CONDITION], constipation), Carbo/Levo (causes depression, dizziness, [MEDICAL CONDITION], blurred vision, and constipation), [MEDICATION NAME] (causes fatigue, drowsiness, and depression), [MEDICATION NAME] (causes dizziness, headache, drowsiness, [MEDICAL CONDITION], and blurred vision), and [MEDICATION NAME] (causes headache and constipation). Review of the statements dated 11/4/10, made by the two nurses who made the medication errors, indicated neither of them normally passed medications, as one was the MDS (Minimum Data Set) nurse and the other was the ADoN (Assistant Director of Nurses). Both of the nurses were filling in for a nurse who had called and said she would not be at work on 11/3/10. The MDS nurse was taking the medications out of the medication cart, and the ADON was passing the medications to the residents at 7:30 A.M. The ADoN wrote, "At approximately 9:30 a.m. (name) reported that (Resident A) was not responding very well, had pin point pupils, and was gray around his mouth. I thought to myself 'I hope we didn't mess up any of his meds (medications).' I went to the med cart and looked at his meds and noticed that he only had a few packages left for the day in the drawer. I looked through the brown bag (destruction bag) and noticed the wrappers were in for med times after 8 am." The facility had instituted a new medication pass company in which each medication was packaged in its own packet with the resident's name, the date, and the medication. These were on a roll and would be opened individually for each medication pass. The MDS nurse wrote "I have never passed meds with the new pharmacy. I was struggling to with (sic) finding each med, looking at the dates on the package and then looking at the med sheet.... (ADoN) was notified by the desk nurse that (Resident A) was non responsive (ADoN) asked me if we might have messed up his meds....looked in the med drawer and noticed that there were only a few packages left of meds for the day in (Resident A)'s drawer.... I must have missed looking at the MAR indicated [REDACTED]." During an interview with the ADoN and the MDS nurse on 11/09/10 at 10:05 A.M., they both indicated the same information as was in their statements. The MDS nurse indicated they were in a hurry because they normally helped to feed residents in the dining room and were trying to get to the dining room to help. The MDS nurse indicated she did not know why she had stopped pouring the pills, but she did realize the time on the individual packets she was opening was not 8:00 A.M., but was for a later time the same day. She indicated she thought she was doing it right, but she was in a hurry. They indicated they had checked all of the papers in the destruction bag and no other resident received extra or wrong medications. Both of the nurses knew they should not have had one nurse set up the medications and another nurse give the medications. During an interview with the DoN (Director of Nurses) on 11/8/10 at 10:45 A.M., she indicated there were two nurses passing medications for a nurse who had called in and not come to work that day. She indicated one nurse set up the medications and the other nurse gave the medications. She indicated both of the nurses knew they should not have had one nurse set up the medications and another nurse give the medications. 2. Resident B's clinical record was reviewed on 11/8/10 at 12:30 P.M. Resident B's [DIAGNOSES REDACTED]. Resident B's nurses' notes lacked a notation of a medication error on 10/28/10. Resident B's October 2010 MAR (medication administration record) had an order for [REDACTED]. "[MEDICATION NAME] 120 mg. (milligrams). Give 1 tab (tablet) by mouth daily at 6 PM." The October 2010 medication record indicated Resident B received [MEDICATION NAME] 120 mg at 6 P.M. on 10/28/10. The clinical record had an order for [REDACTED]." dated 10/29/10. Review of a Medication Error report dated 10/28/10 indicated, "2 doses of [MEDICATION NAME] given @ 6 pm (sic) on 10-28-10; Dr. gave order to hold 90 mg 6 AM dose on 10-29-10 et to give 60 mg. @ 6AM on 10/29/10." The resident's vital signs were stable and were taken for the 3 shifts after the medication error. During an interview with the DoN on 11/8/10 at 11:00 A.M., she indicated the medication error had been made by a QMA (qualified medication aide). She indicated she did not know why the QMA had given the resident a double dose of the medication. She indicated there was a bottle of tablets in the medication cart besides the packets of medications for the resident. She indicated this had occurred very close to the switch over to the individual packets with medications and the medication cart still had the bottle of tablets, but the bottle had been removed after the medication error. This federal tag relates to Complaint IN 980. 3.1-25(b)(9) 3.1-48(c)(2)