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

Based on interview and record review, the facility failed to ensure showers were provided to 1 of 2 residents requiring assistance from facility staff. (Resident F).Findings include:In a confidential interview on 3/12/26, the interviewee alleged Resident F had not received showers per his preference and care plan. He was to receive 2 showers per week with moderate assistance from staff.On 3/16/26 at 11:09 A.M., Resident F's record was reviewed. Diagnoses included a history of strokes.A quarterly Minimum Data Set (MDS) assessment, dated 1/26/26, indicated Resident F was cognitively intact, had no behaviors or rejection of care, and required moderate assistance from staff for transferring in/out of the shower and moderate assistance with bathing.Care plans, revised on 2/9/26, indicated Resident F required assistance with activities of daily living (ADL) to maintain his current level of functioning. Staff were to provide assistance with all ADL's as required by his dependent needs such as transferring and bathing. The care plans indicated he had specific daily preferences important to him, including choosing a shower or bath.A master shower schedule indicated the resident was to receive a shower, 2 times per week, on Wednesday and Saturday in the evening.A Documentation Survey Report, dated February 2026, indicated Resident F received a shower on 2/18/26 and 2/25/26. He was given a complete bed bath on 2/19/26. Scheduled showers were not provided on 2/4, 2/7, 2/11, 2/14, 2/21, or 2/28/26.A Documentation Survey Report, dated March 2026, indicated Resident F was given showers on 3/5 (Thursday) and 3/11/26. Scheduled showers were not provided on 3/7/26 or 3/14/26.On 3/16/26 at 2:50 P.M., the Director of Nursing (DON) was interviewed. She indicated Resident F was scheduled to receive 2 showers per week, on Wednesday and Saturday evenings. According to Documentation Survey Reports for February and March 2026, the resident had not received his showers as scheduled, 2 times per week. The DON indicated it was the facility policy to provide care according to resident's preference of shower or bath, at least 2 times per week, on assigned days. She indicated there was a shower schedule available at each nurse's station. The shower schedule indicated assigned showers for certain days and shifts, for each resident and were to be followed.This Citation relates to Intake 2798019.410 IAC 16.2-3.1-38(3)(b)(2)

Based on interview and record review, the facility failed to ensure timely assessments following a change in condition were completed for 1 of 3 residents reviewed (Resident D). Findings include:A report by Adult Protective Services, alleged Resident D had become ill on 2/20/26 but had been sent to dialysis as scheduled. At the dialysis center, the nurse stopped Resident D's dialysis treatment early and called the facility to come pick her up. The dialysis center nurse, allegedly spoke with a nurse at the facility and indicated the resident needed to be seen by the doctor or nurse practitioner (NP) to rule out an infection (sepsis). The resident was sent to the hospital on 2/22/26 where she had emergency surgery for a necrotic (dead) bowel and sepsis.On 3/12/26 at 11:36 A.M., Resident D's record was reviewed. Diagnoses included end-stage renal disease with dependence on dialysis and dementia.A quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated Resident D could usually make herself understood and usually understood others. She had severely impaired cognition and no behavior symptoms affecting her care. She required moderate to maximum assistance with her activities of daily living. She denied having acute or chronic pain. The resident was prescribed anti-coagulant medication taken daily to thin her blood.Current care plans, dated 8/7/2025, indicated Resident D had kidney disease requiring dialysis. Staff were to ensure she got to her dialysis appointments 3 times per week, on Monday, Wednesday, and Friday from 8:00 a.m.-noon. The resident could be resistant to care related to swallowing medications and removing the pressure dressing on her dialysis access port. She had the potential for pain and staff were to observe for signs/symptoms of pain, provide medications for pain as ordered, and notify the doctor of uncontrolled pain.A dialysis communication form, dated 2/20/26 at unknown time, indicated assessment of post-dialysis treatment was completed by the dialysis center Registered Nurse (RN) 2. The assessment indicated Resident D required extra fluids during her treatment to keep her systolic (top number) blood pressure >100. RN 2 indicated the resident needed to be seen by the nurse or doctor to rule out sepsis.Progress notes, on 2/20/26, did not indicate the resident had returned from dialysis early. She had not been assessed for signs of sepsis and the doctor had not been notified of the dialysis center's concern for sepsis.A Medication Administration Record (MAR), dated 2/20/26 at 6:40 p.m., indicated Resident D had been given extra strength Tylenol-2 tablets by mouth for complaints of abdominal pain, not responsive to repositioning. A change in condition form (SBAR), dated 2/20/26 at 6:45 p.m., indicated the NP was notified Resident D was complaining of abdominal pain and tenderness. An order was given to obtain a STAT abdominal x-ray. If symptoms persisted, the resident was to be sent to the hospital. A progress note, dated 2/20/26 at 7:23 p.m., indicated Resident D was repeatedly calling out, complaining of abdominal pain, and stating she could hardly breathe. Her respirations were unlabored and even. She had been given Tylenol at 6:40 p.m. but continued to complain of pain. Her abdomen was rounded and soft to touch. The resident complained of tenderness in her right upper abdomen. Her bowel sounds were normal and she'd had a bowel movement that morning. The resident's family was notified of the resident's pain and they indicated the resident had a history of liver and bowel conditions. The family member was agreeable to transfer the resident to the hospital if necessary.A progress note dated 2/20/26 at 10:36 p.m., indicated the NP was notified of the residents abdominal x-ray results completed at 8:10 p.m. The abdominal x-ray showed no acute abdominal issues such as obstruction. Resident D was last observed at 9:35 p.m. and had been sleeping but easily arousable. She had no yelling out, moaning, or facial grimacing to indicate continued pain. The NP gave orders to monitor the resident closely and send to the hospital if she developed fever or worsening pain.A follow-up condition change progress note dated 2/21/26 at 2:31 a.m., indicated Resident D had been resting in bed with no complaints of stomach pain. There were no further assessments completed or progress notes written after 2/21/26 at 2:31 a.m. until 2/22/26 at 7:42 a.m.A change in condition (SBAR) form, dated 2/22/26 at 7:42 a.m., indicated Resident D had severe abdominal pain. The resident was yelling out with increased pain in her lower abdomen and severe pain in her right lower abdomen. Orders were given to send the resident to the hospital for evaluation and treatment.On 3/12/26 at 2:30 P.M., Licensed Practical Nurse (LPN) 4 was interviewed. She indicated she had worked the evening shift on 2/20/26 and observed Resident D in severe abdominal pain. She had not been told in report from 1st shift, the resident's dialysis treatment had been stopped early due to her not feeling well. LPN 4 checked on the resident around 6:00 p.m. after she had refused supper and was complaining of abdominal pain. LPN 4 tried re-positioning her in bed without relief. She assessed the resident, administered Tylenol per orders and notified the NP of the resident's condition. She observed the resident appearing to sleep around 9:30 p.m. and had called the NP to report results of the STAT abdominal x-ray. When asked, LPN 4 indicated she had not seen the communication form from dialysis as the resident attended treatments on the day shift. Upon return to the facility from dialysis, day shift nurses would check the resident's vital signs and pressure bandage, review dialysis communication forms found in the dialysis book which went with the resident to/from dialysis, and follow the forms instructions.On 3/16/26 at 9:27 A.M., RN 2 was interviewed. He indicated on 2/20/26, during Resident D's dialysis treatment, her blood pressure dropped more than usual. She was given extra fluids to keep her systolic blood pressure up to a safe level. He indicated the resident had been more restless than usual, was agitated and wanted to leave. RN 2 indicated concern the resident was developing sepsis due to her unusual blood pressure drop. He called the facility and spoke with the unit manager-LPN 6. He reported to LPN 6, Resident D was more restless and agitated than usual, had wanted to stop dialysis early, had low blood pressure, concerns for developing sepsis, and need for nurse or doctor assessment of her condition.On 3/16/26 at 12:38 P.M., the Director of Nursing (DON) was interviewed. She indicated LPN 6 should have reviewed the dialysis form, performed an assessment of the resident's condition upon return, and notified the NP or doctor of dialysis staff concerns. The DON indicated residents assessed as having an acute change in condition, were to be assessed for 72 hours following to ensure the acute change had not worsened or had resolved. On 3/16/26 at 1:30 P.M., the Administrator and Regional Nurse Consultant (RNC) were interviewed. The RNC indicated when an acute change in condition form (SBAR) was opened and completed, the form would trigger follow up assessments to be completed every shift for 72 hours. The Administrator indicated the follow up assessments triggered by the SBAR, would be found in the nurse progress notes. The Administrator nor RNC were able to locate follow up assessments in the resident's record but indicated the assessments should have been completed.On 3/16/26 at 3:28 P.M., LPN 8 indicated she had worked on Saturday, 2/21/26 during the day with Resident D. She indicated being told in report, the resident had stopped her dialysis treatment early on Friday 2/20/26 due to complaints of being sick and nauseous. Staff reported to her, the resident hadn't been eating well for the past few days due to decrease in appetite. LPN 8 indicated she had not performed an assessment on the resident because there had been no further reports of abdominal pain and the abdominal x-ray done the night before had been negative. There were no follow-up assessments completed following the change in condition (SBAR) started on 2/20/26 when Resident D complained of abdominal pain and refused 2 meals. The resident was sent to the hospital on 2/22/26 for severe abdominal pain.This Citation relates to Intake 2798019.410 IAC 16.2-3.1-37

Based on observation, record review, and interview, the facility failed to store food under sanitary conditions related to foods not tightly sealed and outdated foods, for 1 of 1 kitchen observed. This issue had the potential to affect 83 of 83 residents who received food from this kitchen. Findings include: On [DATE] at 9:39 A.M., a kitchen tour was conducted with [NAME] 2. The following was observed in the walk-in cooler: - An opened bag of sausage gravy with a use by date of [DATE]. - An opened container of ketchup with no use by date. - An opened bag of tomato soup with a use by date of [DATE]. - An opened bag of lettuce not sealed tightly. - An opened bag of shredded cheddar cheese not sealed tightly. - An opened bag of lettuce with a use by date of [DATE]. - An opened box of hot dogs not sealed tightly. The following was observed in the walk-in freezer: - An opened bag beef of patties not sealed tightly. - An opened bag of green beans not sealed tightly. During an interview on [DATE] at 9:51 A.M., [NAME] 2 indicated the bags that were not sealed tightly should have been and the expired foods should have been thrown out. On [DATE] at 12:00 P.M., the Regional Director of Clinical Services provided a policy titled, Food Safety and Sanitation, dated ,d+[DATE] and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The facility will show safe food handling and storage of dry foods and supplies. Opened products will be labeled and stored in tightly covered containers. Foods in the refrigerator will be covered, labeled, and dated. Foods will be used by its use by date, frozen or discarded 3XXX,d+[DATE](i)(3)

Based on observation, interview and record review the facility failed to follow a Physicians order to hold a hypotensive medication (Resident 24), failed to keep a complete hospice binder (Resident 55), failed to follow physician's orders regarding hypertensive medication (Resident 6), failed to provide recommended emollient for skin (Resident 39), and failed to provide sliding scale insulin for 2 day for a resident with diabetes mellitus (Resident 331). Finding includes: 1. The record for Resident 24 was reviewed on 3/12/2025 at 9:43 A.M. Diagnoses included but were not limited to: pulmonary hypertension, orthostatic hypotension, obesity, congestive heart failure, and anxiety. Physician Orders included but were not limited to: carvedilol 3.125 milligrams (mg) daily, torsemide 10 mg daily, and midodrine 5 mg three times a day, hold for systolic blood pressure (SBP) greater than 120. The Medication Administration Record MAR for January 2025 indicated that Resident 24 had a SBP greater than 120 and the medication midodrine was administered 42 times. The MAR for February 2025 indicated that Resident 24 had a SBP greater than 120 and the medication midodrine was administered 28 times. The MAR for March 2025 indicated that Resident 24 had a SBP greater than 120 and the medication midodrine was administered 7 times. During an interview on 3/12/2025 at 2:34 P.M., Regional Nurse indicated on the days with SBP greater than 120, the midodrine should not have been administered. During an interview on 3/13/2025 at 10:41 A.M., LPN 7 indicated if Resident 24's SBP was greater than 120 the facility staff should not have administered the medication. 49994 2. A record review was completed for Resident 55 on 3/13/2025 at 11:32 A.M. Diagnoses included, but were not limited to: senile degeneration of the brain and dementia. A Quarterly MDS (Minimum Data Set) assessment, dated 2/10/2025 indicated Resident 55's cognition was significantly impaired. A significant changed MDS was completed on 1/26/2025 indicating the resident was receiving hospice services. A Physician's Order, dated 1/15/2025 indicated hospice was to evaluate and treat the resident per family request. A Physician's Order, dated 1/17/2025 indicated Resident 55 was accepted to (name of hospice) and was a DNR (do not resuscitate). A current Care Plan, revised on 1/20/2025 indicated Resident 55 elected hospice services and was to be followed by hospice care (name of hospice). Interventions included, but were not limited to: Staff nurses will contact hospice with information that affects resident care. On 3/13/2025 at 1:35 P.M., a review of Resident 55's hospice book was completed. The resident's hospice book lacked documentation of the resident's medications, physician's orders, a signed DNR and any communication between the facility and (name of hospice). During an interview on 3/13/2025 at 1:38 P.M., the DON indicated the resident's hospice book should have had a copy of the resident's signed DNR, current orders, medications and any communication between the facility and (name of hospice). On 3/13/2025 at 2:16 P.M., the DON provided a policy titled, Guidelines for Palliative Care- Hospice Care, dated 10/9/2024 and indicated it was the policy currently being used by the facility. The policy indicated, : What must a LTC facility do as their part for partnering with the hospice provider? D. A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the residents are addressed and met 24 hours per day 3. A record review was completed for Resident 6 on 3/11/2025 at 1:09 P.M. Diagnoses included, but were not limited to: atrial fibrillation, coronary atherosclerosis and hypertension. A Physician's Order indicated Resident 6 was to receive Triamterene and Hydrochlorothiazide 37.5-25 mg (milligram) tablet by mouth, one time a day for hypertension. The medication was to be held if the resident's systolic blood pressure was below 110 mmHg (millimeters per mercury). A review of Resident 6's MAR (medication administration record) indicated the Triamterene and Hydrochlorothiazide 37.5-25 mg tablet was documented as given on the following dates, when the resident's blood pressure was outside the recommended parameter: - on 11/21/2024 the resident's blood pressure was 100/50 mmHg. - on 11/22/2024 the resident's blood pressure was 102/54 mmHg. - on 12/11/2024 the resident's blood pressure was 97/53 mmHg. - on 12/22/2024 the resident's blood pressure was 108/62 mmHg. - on 1/4/2025 the resident's blood pressure was 102/60 mmHg. - on 1/21/2025 the resident's blood pressure was 88/58 mmHg. - on 2/1/2025 the resident's blood pressure was 91/52 mmHg. - on 2/16/2025 the resident's blood pressure was 105/58 mmHg. During an interview on 3/12/2025 at 1:53 P.M., the DON indicated the resident's medication should have been held on the days her blood pressure was outside the recommended parameters. On 3/12/2025 at 1:09 P.M., the DON provided a policy titled, Guidelines for Physician Orders- Following Physician Orders, dated 6/18/2023 and indicated it was the policy currently being used by the facility. The policy indicated, .4. All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received 45120 4. During an interview, on 3/10/2025 at 11:09 A.M., Resident 30 indicated she had very dry skin. A record review for Resident 30 was completed, on 3/13/2025 at 9:17 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 and hemiplegia. A Quarterly Minimum Data Set (MDS) assessment, dated 1/11/2025, indicated Resident 30 had moderate cognitive impairment and impaired range of motion to the upper and lower extremities on one side of her body. A Nurse Practitioner Skin and Wound Progress Note, dated 2/28/2025 at 9:26 A.M., indicated Resident 30's skin was dry, flaky and atrophied and was observed to have dry skin generalized to her entire body. An emollient skin application as needed for dry and/or atrophic skin was recommended by the nurse practitioner.However, there were no orders for an emollient to be provided to Resident 30 for her dry skin. A Care Plan, initiated 5/10/2025 and revised on 8/13/2024, indicated Resident 30 was at risk for additional areas of skin breakdown. The goal included, but was not limited to: Resident 30 would be provided with preventative measures to avoid skin breakdown. Interventions included, but were not limited to: monitor skin daily during care and notify the physician and family of any change in skin integrity. During an interview, on 3/14/2025 at 10:14 A.M., the Director of Nursing (DON), indicated Resident 30 should have had an order for an emollient if recommended by the nurse practitioner. During an interview, on 3/14/2025 at 11:19 A.M., the Regional Director of Clinical Services indicated the emollient for Resident 20 would have been ordered as needed if an issue of her skin arose. A policy was provided, on 3/14/2025 at 1:00 P.M., by the Director of Nursing. The policy titled, Guidelines for Preventative Skin Care, indicated, .Procedure: 1) Appropriate skin care is provided by staff each shift and/or as necessary 4. During an interview, on 3/10/2025 at 11:41 A.M., Resident 331 indicated the meals provided by the facility were high in carbohydrates and her blood sugars had been running high since her admission to the facility. A record review for Resident 331 was completed on 3/12/2025 at 10:03 A.M. Diagnoses included, but were not limited to: pathological fracture of left femur, malignant neoplasm of liver and lower lobe of left bronchus, secondary malignant neoplasm of bone and diabetes mellitus type 2. Resident 331 admitted to the facility on [DATE]. The Admission MDS assessment had not yet been completed and was still in progress. Hospital discharge instructions, dated 3/7/2025, indicated the following order: Insulin Lispro 100 units per milliliter Solution Sliding Scale subcutaneously as ordered as needed for serum glucose, see parameters: 140-160 give 1 unit; 161-180 give 2 units; 181-200 give 3 units; 201-220 give 4 units; 221-240 give 5 units; 241-280 give 6 units; 281-320 give 7 units; 321-360 give 8 units; 361-400 give 9 units; Above 400 give 10 units. A Physician's Order, dated 3/7/2025 and discontinued 3/7/2025 by a pharmacy interchange order, indicated the following order was to be implemented for the interchange: Insulin Lispro 100 units per milliliter Solution inject as per sliding scale subcutaneously four times a day for diabetes: if 140-160 give 1 unit; 161-180 give 2 units; 181-200 give 3 units; 201-220 give 4 units; 221-240 give 5 units; 241-280 give 6 units; 281-320 give 7 units; 321-360 give 8 units; 361-400 give 9 units; Above 400 give 10 units. The Physician's Orders for Resident 331, from the pharmacy interchange order, was dated 3/10/2025 and indicated the following: Insulin Lispro 100 units per milliliter Solution inject as per sliding scale subcutaneously four times a day for diabetes: if 140-160 give 1 unit; 161-180 give 2 units; 181-200 give 3 units; 201-220 give 4 units; 221-240 give 5 units; 241-280 give 6 units; 281-320 give 7 units; 321-360 give 8 units; 361-399 give 9 units and notify MD if over 350; 400-500 give 10 units and notify MD. A review of the Medication administration record indicated Resident 331 received Lispro sliding scale insulin on the following dates between 3/7/2025 and 3/10/2025. -3/7/2025 at 4:30 P.M. -3/10/2025 at 7:30 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M. Resident 331 did not receive any sliding scale insulin on 3/8/2025 or on 3/9/2025. A Care Plan, initiated 3/10/2025, indicated Resident 331 had a diagnosis of diabetes mellitus type 2 with the risk of hypo/hyperglycemia. Interventions included, but were not limited to: administer medications and insulins per order. During an interview, on 3/14/2025 at 11:28 A.M., the Regional Director of Clinical Services indicated the pharmacy had issued a therapeutic interchange of the sliding scale insulin on 3/7/2025 and the sliding scale insulin order was not signed by the nursing department and implemented until 3/10/2025. She indicated Resident 331 had missed two days of the sliding scale insulin ordered. On 3/12/2025 at 1:09 P.M., the DON provided a policy titled, Guidelines for Physician Orders- Following Physician Orders, dated 6/18/2023 and indicated it was the policy currently being used by the facility. The policy indicated : . It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care . 4. All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received 3.1-37(a)

Based on observation and interview, the facility failed to ensure recipes were followed when preparing pureed meals. This deficient practice had the opportunity to affect 4 of 4 residents who received pureed meals from the kitchen. Finding includes: During an observation of the preparation of pureed meals on 3/10/2025 at 11:41 A.M., [NAME] 2 added 4 scoops of cauliflower and an unmeasured amount of water to the mixer. She indicated she used a #8 (1/2 cup) scoop for the cauliflower and added as much water as she needed to get the correct consistency. [NAME] 2 did not use a recipe for the pureed cauliflower. During an observation of the main dining on 3/10/2025 at 12:29 P.M., Resident 14 received a pureed meal. The resident's pureed meal was watery in appearance and all of the individual food items ran together. During an observation of the preparation pureed meals on 3/13/2025 at 11:06 A.M., [NAME] 2 indicated she was preparing nine servings of mixed vegetables. [NAME] 2 added the vegetables to the mixer with an unknown measured amount of water and began mixing. [NAME] 2 added more water to the mixer and continued mixing. [NAME] 2 did not use a recipe to make the mixed vegetables. The pureed vegetables appeared very thin. She indicated she would add some thickener to the mixture prior to serving if the mixed vegetables appeared too thin after placing onto the steam table. During an interview on 3/13/2025 at 11:16 A.M., [NAME] 2 indicated she should have used a recipe when preparing the pureed meals. On 3/13/2025 at 2:05 P.M., the DON provided a policy titled, Pureed Diet, date 6/2023 and indicated it was the policy currently being used by the facility. The policy indicated .Foods are thickened if necessary to achieve a pudding or mashed potato consistency using commercial food thickeners or food items like mashed potato flakes. At times, it may be necessary to add liquid instead of thickening the food. Liquids used include: gravies, broth, juices or milk. Water is not used since it causes flavor loss then resulting in poor intake. Food characteristics: Can be piped, layered, or molded; appears softly formed on the plate. Shows some very slow movement under gravity but cannot be poured. Falls off spoon in single spoonful when tilted and continues to hold shape on plate 1.3-20(i)(1)

Based on observation, interview and record review, the facility failed to ensure staff members followed general infection control practices regarding enhanced barrier precautions (EBP) (CNA 10 & DON) and failed to ensure an infection prevention and control program was established and maintained. Findings included: 1. During an observation on 3/11/2025 at 9:27 A.M., CNA 10 was observed in Resident 14's room without wearing a gown. There was an EBP sign on the resident's door. During an interview on 3/11/2025 at 9:33 A.M., CNA 10 indicated she was gathering the residents trash and making the resident's bed. She indicated she should have had on a gown while in the resident's room. 2. During an observation on 3/12/2025 at 1:44 P.M., the DON was observed walking into a residents room who was on EBP precautions without wearing a gown. There was an EBP sign on the resident's door. During an interview on 3/13/2025 at 1:48 P.M., the DON indicated she went into the resident's room to help the resident off the toilet. She indicated she also provided perineal care prior to placing the resident in bed. She indicated she was wearing gloves but was not wearing a gown while providing care to the resident. She indicated she should have been wearing a gown. 52118 3. During an observation, on 3/10/2025 at 3:05 P.M., CNA 3 was observed providing toileting assistance for Resident 3, who had multiple skin tears. CNA 3 donned (applied) gloves but did not don a gown. Resident 3's room door did not have a Enhanced Barrier Precautions (EBP) sign on the door. During an interview, on 3/10/2025 at 3:15 P.M., CNA 3 indicated she was aware of Resident 3's multiple skin tears, but she did not know Resident 3 was on Enhanced Barrier Precautions. The record for Resident 3 was reviewed on 3/11/2025 at 9:15 A.M. A current Physician's Order, dated 8/3/24, indicated Enhanced Barrier Precautions due to skin tears. During an interview on 3/11/25 9:30 A.M., Nurse 9 indicated she thought the resident had a sign on her door due to her skin tears. Per Centers for Disease Control (CDC), the EBP sign directs providers and staff to gown and wear gloves during high-contact care, including toileting and transfering of residents with skin wounds that require dressings. 51598 4. A record review for Resident 17 was completed on 3/11/2025 at 1:26 P.M. Diagnoses included but were not limited to: Chronic Hepatitis C, carrier of carbapenum resistant Acinetobacter baumannii (CRAB), and chronic kidney disease stage 3. Physician Orders dated 1/19/2024 indicated Resident 17 was on contact precautions. A current Care Plan for Resident 17 indicated he was on contact precautions related to CRAB (a multidrug resistant infection). A sign was observed on Resident 17's door indicating staff were to apply gloves and gown before entering the room, were to perform all care while wearing gloves and gown, and dispose of linen and trash in designated receptacles. During an observation on 3/10/2025 at 10:25 A.M., a housekeeper was observed in Resident 17's room carrying a trash bag but not wearing gloves or a gown. During an observation on 3/10/2025 at 10:33 A.M., a CNA was observed making Resident 17's bed without wearing gloves or a gown. During an observation on 3/12/2025 at 9:05 A.M., a CNA was observed entering Resident 17's room without wearing gloves or a gown. During an interview on 3/11/2025 at 2:03 P.M., CNA 11 indicated that staff should have worn a gown and gloves when entering Resident 17's room. CNA 11 also indicated she should have been wearing a gown and gloves when she was making his bed. 38845 5. On 3/14/2025 at 1:06 P.M., a review of the infection log book indicated the last documentation for tracking and trending resident infections had been completed in December 2024. The book lacked the documentation to show resident infections had been monitored since December 2024. During an interview, on 3/14/2025 at 1:10 P.M., the Director of Nursing indicated the policies were reviewed annually and there had been tracking and trending done in 12/2024. She indicated there was nothing documented more recently for this year, and it should have been done. On 3/13/2025 at 2:35 P.M., the Regional Nurse provided the policy titled, Guidelines for Enhanced Barrier Precautions: An extension of Personal Protective Equipment, dated 12/2022 and indicated it was the policy currently being used by the facility. The policy indicated . Policy: It is the policy of the facility to ensure that additional and appropriate PPE (Personal Protective Equipment) is utilized, when indicated, to prevent the spread of Multi-drug resistant Organisms also known as MDRO's On 3/14/2025 at 1:45 P.M., the Director of Nursing provided the policy titled, Guidelines for Infection Prevention and Control, dated 8/17/2023, and indicated the policy was the one currently used by the facility. The policy indicated . Surveillance: A surveillance system designed to do the following will be maintained: Identify possible communicable diseases or infections before they can spread to other persons in the facility. Ensure that any communicable diseased are identified and reported timely and to the required parties/agencies. Ensure that standard and transmission-based precautions are followed in an effort to prevent the spread of infection 3.1-18(a) 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure a resident's choice of Advance Directive was documented consistently in the medical record and staff were aware of the resident's choice for 1 of 1 residents reviewed for Advance Directives (Resident 31). Findings include: During a record review for Resident 31, completed on 3/11/25 at 9:22 A.M., the following conflicting information regarding the resident's advance directives/code status was noted: the face sheet indicated the resident was a Do Not Resuscitate (DNR). However, the physician's orders included orders indicating the resident was a DNR and a Full Code (initiate life sustaining measures, such as chest compressions if heart stops). A Indiana Physician Orders for Scope of Treatment (POST) form dated and signed on 2/20/2025 for Resident 31, indicated the resident wanted to be a full code. The current Care Plan for Resident 31, dated 3/4/2025, indicated a code status of DNR. During an interview, on 3/11/2025 at 1:11 P.M., LPN 8 indicated a resident's code status located on the face sheet and if it was not listed on the face sheet, facility staff were to look in the resident's physician's orders or documents. LPN 8 confirmed the code status for Resident 31 on the face sheet, physician orders, and POST were conflicting and did not match. During an interview, on 03/11/25 1:17 P.M., the DON indicated Resident 31 had recently changed her code status. The DON indicated the code status should have been updated and confirmed the clinical record did not match Resident 31's current code status. A current facility policy was provided by the Regional Nurse, on 3/13/2025 at 2:35 P.M. The policy titled, Advanced Directives Policy and Procedure indicated the facility provides residents the right to accept or refuse treatment and formulate advanced directives . 3.1-4 (f) (5)

Based on record review and interview, the facility failed to provide urostomy care and required urostomy supplies for 1 of 3 residents reviewed for urinary devices. (Resident B) Finding includes: A record review for Resident B was completed on 3/11/2025 at 10:19 A.M. Diagnoses included, but were not limited to: chronic kidney disease stage 2, anal fissure, other artificial openings of urinary tract and dementia. A Medicare 5-day Minimum Data Set (MDS) assessment, dated 2/15/2025, indicated Resident B's cognitive status was not able to be assessed and he had a urostomy. The medical record did not have any physician orders related to a urostomy or the care of the urostomy. An Internal Medicine History and Physical, provided by the hospital from the 2/9/2025 admission, indicated Resident B had a past medical history of a malignant neoplasm of the posterior wall of the urinary bladder and a cystectomy that occurred on 6/3/2019. An Admission/Re-Admission Screener Assessment, on 2/12/2025 at 5:00 P.M., indicated Resident B was continent of his bladder. A Bowel and Bladder Incontinence Screener Assessment, on 2/13/2025 at 9:06 P.M., indicated Resident B voided appropriately without incontinence. Daily Skilled Nursing Notes, from 2/14/2025 through 2/16/2025, indicated the following urinary descriptions: -2/14/2025 at 2:42 A.M., Urinary: Continent. -2/14/2025 at 10:18 A.M., Urinary: Continent/Incontinent. -2/16/2025 at 5:23 A.M., Urinary: Continent -2/16/2025 at 11:27 A.M., Urinary: Continent, Resident has a urostomy. A document titled, I Would Like to Know , indicated a concern from family regarding, .Urostomy bag leaked and he sat in urine all night, Facility should have the necessary supplies on hand for the resident. His significant other is bringing in supplies A document titled, Internal review of 'I Would Like to Know ' Form [QA Tool], dated 2/14/2025, indicated the following: urostomy site and bag examined and a small amount of urine was on the chux pad (disposable, absorbent bed pad) under Resident B's back. A new bag and wafer were replaced by the Assistant Director of Nursing on 2/14/2025. The Marketing Director was to request urostomy supplies to be sent by the hospital for urostomy maintenance. When Resident B arrived, no urostomy supplies were sent to the facility. The family provided the needed urostomy supplies the following day. A Customer Service Progress Note, on 2/14/2025 at 1:00 P.M., indicated a discussion of urostomy supplies was conducted with Resident B and his wife. The information from the urostomy supplies (bags and wafers) the wife provided was taken so the facility could order the supplies needed to take care of the urostomy. Resident B requested a larger urinary drainage bag for overnight use. Resident B's wife brought in a larger drainage bag and a small tubing adaptor. The nursing staff reinforced the urostomy wafer and there had been no more leaking reported. A Nursing Progress Note, on 2/14/2025 at 10:34 P.M., indicated Resident B's wife had reported a leak was present with Resident B's urostomy. An assessment was completed and Resident B was dry with no leak noted. Resident B's daughter was at the bedside and requested the urostomy bag be changed. The nurse indicated dinner was being served soon and the nurse would change the urostomy bag after dinner so Resident B could lay down. Resident B's wife was statisfied with the plan and reassured resident B's daughter. The urostomy bag was changed after dinner. A Social Service Note, on 2/15/2025 at 1:00 P.M., indicated the Social Service Director called the family to discuss the urostomy. The Social Service Director had been in the building and had discovered the urostomy had been replaced and was working properly. A General Progress Note, on 2/16/2025 at 10:00 A.M., indicated Resident B's daughter stated, We are taking him home. A Care Plan, initiated on 2/14/2025 and revised on 2/14/2025, indicated Resident B had urinary incontinence related to physically or mentally unawareness of the need to void. The care plan, nor any other care plans, addressed Resident B's urostomy. During an interview, on 03/14/2025 at 10:02 A.M., the Director of Nursing indicated Resident B was admitted to the facility on a Thursday (2/13/2025). She indicated the Marketing Director was to request that the hospital send urostomy supplies or was to arrange for the family to bring supplies until the facility could order the needed supplies for the urostomy. She indicated the supplies did not come from the hospital nor was the family made aware of the need to bring urostomy supplies. She indicated Resident B's family complained of Resident B lying in urine and that the CNA working had been reluctant to provide urostomy care per Resident B's complaints. She indicated the Assistant Director of Nursing had checked Resident B on Friday (2/14/2025) morning for leakage from the urostomy bag and had applied a new urostomy bag. The facility had also brought in an indwelling catheter bag to connect to the urostomy bag, so the urostomy bag did not need to be drained every two hours. A policy was provided, on 3/11/2025 at 1:48 P.M., by the Director of Nursing. The policy titled, Urostomy, indicated, .A urostomy is similar to a fecal ostomy, but it is an artificial opening for the urinary system and the passing of urine to the outside of the abdominal wall through an artificial created hole called a stoma .A urostomy patient has no voluntary control of urine, and a pouch system must be used and emptied regularly. Many patients empty their urostomy bag every 2 to 4 hours .the pouch should be emptied when it is 1/3 full. The pouch may also be attached to a drainage bag for overnight drainage This citation relates to complaint IN00453772. 3.1-47(a)(3)

Based on observation, record review and interview, the facility failed to provide non-invasive mechanical ventilation equipment for 1 of 3 residents and failed to properly store respiratory treatment for 1 of 3 residents reviewed for respiratory services. (Resident 333 & 16) Findings include: 1. During an observation on 3/10/2025 at 10:02 A.M., Bi-Pap (bi-level positive airway pressure) equipment was observed in Resident 333's room on a table by the door of her room. When Resident 333 was questioned about the Bi-Pap equipment, she indicated she had been admitted to the facility a week ago and was not sure why she had the Bi-Pap equipment in her room. During an observation, on 3/11/2025 at 9:26 A.M., 3/12/2025 at 9:32 A.M. and 3/13/2025 at 9:12 A.M., Bi-Pap equipment was observed on a table by Resident 333's door in a plastic bag. A record review for Resident 333 was completed on 3/12/2025 at 9:33 A.M. Diagnoses included, but were not limited to: acute respiratory failure with hypoxia, rib fracture, panic disorder and emphysema. The Admission Minimum Data Set (MDS) assessment .had not been completed yet. A Physician's Order for Resident 333, dated 3/5/2025, indicated to apply the Bi-Pap mask as ordered while sleeping and remove while awake for sleep apnea. The order indicated an inspiratory positive airway pressure setting of 10 cm H2O (centimeters of water) and expiratory positive airway pressure setting of 6 cm H2O. There was no baseline care plan related to Resident 333's diagnosis of obstructive sleep apnea or the use of the Bi-Pap machine. During an interview, on 3/13/2025 at 9:12 A.M., Resident 333 indicated she had not worn the Bi-Pap mask since before admission to the facility. She indicated the Bi-Pap mask had not been offered to her for use. During an interview, on 3/14/2025 at 10:12 A.M., the Director of Nursing (DON) indicated Resident 333 should have been wearing her Bi-Pap equipment, unless she had declined. The DON indicated any declination of wearing the Bi-Pap would have been documented. There was no documentation regarding any refusals to wear the Bi-Pap in Resident 333's record. 2. During an observation, on 3/10/2025 at 10:50 A.M., 3/12/2025 at 1:18 P.M., 3/13/2025 at 2:14 P.M. and 3/14/2025 at 9:34 P.M., Resident 16's C-Pap (continuous positive airway pressure) mask was stored uncovered in the top drawer of her bedside table. A record review for Resident 16 was completed on 3/12/2025 at 1:15 P.M. Diagnoses included, but were not limited to: Parkinson's disease, shortness of breath and obstructive sleep apnea. A Quarterly MDS assessment, dated 2/25/2025, indicated Resident 16 was cognitively intact and used non-invasive mechanical ventilation (C-Pap). A Physician's Order, dated 8/16/2024, indicated Resident 16 to wear the C-Pap at bedtime and during naps for sleep apnea. A Care Plan initiated, on 5/13/2024, indicated Resident 16 was at risk for altered sleep/respiratory function related to obstructive sleep apnea. During an interview, on 3/14/2025 at 10:13 A.M., the DON indicated the C-Pap mask should have been stored in a dated respiratory bag when the mask was not in use. A policy was provided, on 3/14/2025 at 1:00 P.M., by the DON. The policy titled, Bi-Level Therapy, indicated, .Bi-level therapy is used to treat patients with obstructive sleep apnea who have difficulty tolerating CPAP. The goals of this therapy include: improved ventilation, improve quality of sleep, decrease hospitalization s, improve cognitive function, improve oxygen saturations during sleep, decrease work of breathing, and improve lung compliance. BiLevel machines are set with two pressures, Inspiratory and Expiratory A policy was provided, on 3/14/2025 at 1:00 P.M., by the DON. The policy titled, CPAP Therapy, indicated, .Continuous Positive Airway Pressure is used to treat obstructive sleep apnea. The goals of this therapy include; improve ventilation, improve quality of sleep, decrease hospitalization s, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve lung compliance 3.1-47(a)(6)

Based on record review and interview the facility failed to assess a dialysis fistula for 1 of 2 residents reviewed for dialysis. (Resident 24) Findings include: A record review for Resident 24 was completed on 3/12/2025 at 9:43 A.M. Diagnoses included but were not limited to: chronic kidney disease stage 4 and fistula left wrist. A current care plan indicated Resident 24 was at risk for the dialysis fistula to become non-functioning. The interventions included but were not limited to: all fistulas will be assessed every shift and as needed for the bruit and thrill, if absent notify the doctor. The record for Resident 24, did not include a Physician's Order to assess the fistula. During an interview on 3/12/2025 at 2:34 P.M., Regional Nurse indicated the fistula should have been assessed and documented every shift. During an interview on 3/12/2025 at 2:39 P.M., LPM 6 indicated there was not an order for facility staff to assess the fistula and there was no documentation staff had been assessing the fistula. A current facility policy was provided by the Regional Nurse, on 3/13/2025 at 3:35 P.M. The policy titled, Guidelines for Post Hemodialysis Care, indicated . a licensed nurse should palpate the fistula daily for bruit/thrill and each shift the site should be assessed. 3.1-37(a)

Based on record review and interview, the facility failed to attempt a gradual dose reduction (GDR) for a resident's whose last GDR was completed on 11/17/2023, for 1 of 5 residents reviewed for unnecessary medications. (Resident 22) Finding includes: The record for Resident 22 was reviewed on 3/12/2025 at 1:32 P.M. Diagnoses included, but were not limited to Alzheimer's disease, anxiety, mood disorder and hypertension. Current Physician Orders, dated 11/17/2023, included Ativan (Lorazepam) an (antianxiety) 0.5 mg (milligrams) 1 tablet two times a day for anxiety. A current Care Plan, initiated on 1/18/2021 and revised on 11/17/2023, indicated Resident 61 expresses/or exhibits restlessness, and nervousness and has a diagnosis of dementia. Interventions included, but were not limited to: monitor quarterly for Medication GDR for psychoactive medication through pharmacy consultant. A current Care Plan, initiated on 4/11/2022 and revised on 2/1/2023, indicated the resident displayed mood issues as exhibited by: excessive nervousness, restlessness, slapping at staff or yelling at staff during care. Interventions included, but were not limited to: Administer antianxiety medication as ordered. Monitor quarterly for Medication GDR for psychoactive medication through pharmacy consultant and psych services. A Consultant Pharmacy Note, dated 2/22/2025 at 2:31 P.M., indicated a Medical Record Review (MRR) was completed - Recommendation Made. Please route recommendation to appropriate prescriber: due for GDR for the following medications: Lorazepam 0.5 mg BID Due for GDR attempt. Recommend the following options: 1). condition stable - Will attempt dose reduction of the following: Lorazepam 0.5 mg in AM and 0.25 mg in PM for anxiety. 2). Another agent to GDR- please describe below. All areas of the Pharmacy Recommendation were blank and had no response from the NP. A Psychotropic Medication Note To Physician/Prescriber, dated 2/22/2025, indicated As a reminder, Per CMS Guidelines, this patient is due for a GDR for the following medication(s) to ensure that he/she is using the lowest possible effective/optimal dose. Lorazepam 0.5 mg BID (twice a day) due for GDR attempt. A Nurse Practitioner Progress Note, dated 3/10/2025, indicated recent medication adjustments have improved her behavior, reducing her anxiety and disturbances in the pod. Is currently on Ativan (Lorazepam) 0.5 mg BID for anxiety, which has effectively decreased episodes of screaming, crying and other behaviors. Med changes since last visit: none documented. There was no indicatation the Nurse Practioner had considered the Pharmacist's recommendation to attempt a Gradual Dose reduction and no documentation the reduction attempt was contra-indicated. During an interview, on 3/12/2025 at 2:06 P.M., CNA 5 indicated the resident had behaviors where she would get mad if 2 staff went in to transfer her. She would get mad at the one who was doing the care and would not be mad at the other one who was there. CNA 5 indicated Resident 61 had gotten anxious when the facility had tried to change her where she would pull away. During an interview, on 3/14/2025 at 1:00 P.M., the Regional Nurse indicated the behaviors were documented on the Medication Administration Record (MAR) and in the nurses notes. The last documented behaviors/anxiety issues for Resident 22 included: Nursing Progress Note, on 10/14/2024 at 4:28 A.M., indicated the resident resisted care during the night. CNA's had attempted to change resident but she kept on resisting. Nursing Progress Note, on 10/14/2024 at 4:28 A.M., indicated the resident had been combative with night care- hitting, pinching, with 2 caregivers assisting with her care. During an interview, on 3/14/2025 at 1:05 P.M., the Director of Nursing indicated she did not see any indication for the antianxiety medication to be decreased. On 3/13/2025 at 1:45 P.M., the Director of Nursing provided the policy titled, Guidelines for use of Unnecessary Drugs to Include Chemical Restraints, undated, and indicated the policy was the one currently used by the facility. The policy indicated .Intent: It is the intent of this facility to ensure that any use of unnecessary meds, to include unnecessary psychoactive medications is prohibited . When a medication is indicated to treat a medical symptom- the facility must use the least restrictive alternative; for the least amount of time; provide ongoing re-evaluation of the need to the medication . Each resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is defined as one that is used in excessive dose or duration, without adequate monitoring, without adequate indications for use . Residents who use psychotropic drugs will receive gradual dose reductions 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to ensure medications were stored appropriately, had resident labels, and medication carts were were free of loose pills for 2 of 3 medication carts observed. (Peach Pod & Maple Pod) Findings include: 1. During a medication storage observation, on [DATE] at 10:44 A.M., with LPN 4 on the Peach medication cart, the following was observed: - An opened and undated bottled of Zinc Caps and Vit. C with no resident identifiers - An opened and undated vial of Lantus insulin. - An opened and undated Lispro insulin pen. - An opened and undated vial of Lantus insulin. - An opened bottle of betadine for a discharged resident. - A tube of neopsporin ointment with no resident identifiers. - An opened and undated bottle of ammonium lactate lotion with the resident label torn off. - One (1) loose white pill. - Four (4) opened and undated containers of [NAME] lax. - An opened and undated bottle of Tussin cough syrup. During an interview, on [DATE] at 10:57 A.M., LPN 4 indicated the medications should have been label and dated when opened. 2. During a medication storage observation, on [DATE] at 10:59 A.M., with RN 13 on the ICF Maple medication cart, the following was observed: - An unlabeled Flutisone Propionate inhaler. - An unopened bottle of timolol eye drops with no resident identifiers. - An opened and undated vial of Humalog insulin. - Two (2) boxes of assure prism solution that had expired on [DATE] and [DATE]. - Two (2) containers of Aquaphor (skin lotion) for a resident who had been expired and 1 container with no label. - An opened and undated bottle of maxi Tussin cough syrup. - Four (4) opened and undated bottles of Miralax. During an interview, on [DATE] at 11:09 A.M., RN 13 indicated the medications should have been labeled and dated when opened. On [DATE] at 1:45 P.M., the Director of Nursing provided the policy titled, Medication Storage in the Facility, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated . Medications and biological's are stored safely, securely, and properly following manufacture or supplier recommendations . 14. Outdated, contaminated, or deteriorated drugs and those in containers .will be immediately withdrawn from stock by the facility. 15. Medication storage areas are kept clean A policy for dating and labeling medications was requested, but were not provided prior to the survey exit. 3XXX,d+[DATE](j) 3XXX,d+[DATE](o)

Based on record review and interview, the facility failed to obtain a physician ordered lab for 1 of 1 residents reviewed for laboratory services. (Resident 61) Finding includes: The record for Resident 61 was reviewed on 3/12/2025 at 10:15 A.M. Diagnoses included, but were not limited to epilepsy, depression, hypertension, atrial fibrillation, hernia and cardiomegaly. A Nursing Progress Note, dated 2/8/2025 at 11:10 P.M., indicated the resident complained of abdominal pain where a hernia was protruding. The Nurse Practitioner was notified and an order to send the resident to the hospital was received. Resident 61 was hospitalized from 2/8/2025 to 2/13/2025. The Post Acute Transfer Order sheet, date 2/13/2025, indicated Resident 61 was to have laboratory draws (blood draws) consisting of CBC (complete blood count) and a Renal Panel test in 1 week. There was no documentation of the laboratory blood draws being completed and/or the results. During an interview, on 3/12/2025 at 11:50 A.M., the Director of Nursing indicated the lab orders should have been completed. 3.1-49(a)

Based on record review and interview, the facility failed to ensure a notice of discharge was provided in writing, discharge planning was completed, and a resident's discharge was safe with continuity of care ensured for 1 of 3 residents reviewed for discharge. (Resident E) This deficient practice resulted in an unsafe discharge when the resident was transferred to a hospital waiting area without admission arrangements and no way to obtain nutrition through enteral feedings. The resident voiced feeling of hopelessness and felt others wanted him to die. The immediate jeopardy began on 12/24/24 when the facility discharged Resident E to a hospital waiting area. The Administrator and Regional Administrator were notified of the immediate jeopardy at 3:58 P.M. on 1/6/25. The immediate jeopardy was removed on 1/7/25, but the noncompliance remained at the lower scope and severity level of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy Finding includes: The clinical record for Resident E was reviewed on 1/5/25 at 2:00 P.M. Resident E was admitted to the facility on [DATE] from an acute care facility following surgical repair of necrotizing pancreatitis. The resident's diagnoses included, but were not limited to, status post (s/p) perforation of the esophagus, acute pancreatitis with uninfected necrosis, gastroesophageal reflux disease with esophagitis, fistula of the stomach and duodenum, and gastrostomy placement. The resident had a gastrostomy/jejunostomy tube (a GJ tube - combination of a tube placed in the stomach and a tube placed in the jejunum that is secured with a balloon or plastic bumper in the stomach and a plastic disc around the outside of the body.) The resident was admitted with physician orders for enteral tube feedings and nothing by mouth (NPO) except diet soda and medications. The acute care transfer documentation indicated the plan was for the resident to receive nutrition via an enteral tube feeding in the extended care facility until a gastrointestinal surgical consult was completed in four weeks. The resident was to have a Computerized Tomography (CT) scan performed in two weeks. The surgical note indicated in January, the resident's condition was to be reevaluated, a cholecystectomy performed, surgical repair of the resident's intestinal system performed and the G/J tube removed. The Admission Minimum Data Set (MDS) assessment, completed on 11/30/24, indicated the resident was admitted for short stay rehabilitation from an acute care facility. The assessment indicated the resident was cognitively intact, had not displayed any mood issues or behaviors during the assessment period, was dependent on staff for feeding due to requiring enteral feedings, utilized a walker and/or wheelchair for mobility needs, required moderate staff assistance for lower body dressing, applying footwear, and bathing needs, received physical and occupational therapy and did not require an active discharge plan. An Admission Care plan meeting note, completed on 11/29/24 at 11:01 A.M., indicated the resident attended the meeting and both sisters had participated via telephone. The resident was working with therapy to evaluate his ability to perform his own Activities of Daily Living (ADL) needs and the discharge goal was for the resident to discharge to an assisted living group home setting. There were no recommendations documented as a result of the care plan meeting. There was no further follow-up with discharge planning. A Discharge care plan for Resident E, dated 12/16/24 with a target date of 2/28/25, indicated the resident's goal was to discharge from the facility after a short-term stay. The focus indicated the resident planned to return home with a family member. The goals were for the resident to actively participate in therapy, as shown by his attendance and cooperation, and to have a safe discharge home. The only intervention listed for the plan was to assist the resident and family with discharge planning. A care plan, dated as revised on 12/5/24, indicated the resident was at risk for nutritional status deficit related to nothing by mouth (NPO) status and tube feeding for nutritional support. Interventions included, but were not limited to, tube feedings and flushes per the physician orders, monitor weights and laboratory values. During an interview, on 1/7/25 at 3:00 P.M., Employee 23 indicated the resident had been discharged from therapy services on 12/6/24, and the resident had remained at the facility. There were no nursing and/or social service progress notes regarding discharge needs until a Social Service Note, dated 12/23/24 at 2:35 P.M., indicated the Social Service Director (SSD) spoke with the resident and, via a phone call with one of the resident's sisters, informed the resident and his sister that the facility had nothing to skill the resident on, so he needed to leave because his insurance would not pay his bill. The resident informed the SSD he would be living on the streets. His sister was asked to come to the facility the following day for some training and the discharge. The resident's sister indicated she was going to call the State and bring them with her. Social Service Notes, dated 12/24/24 at 10:17 A.M. and 12/24/2024 at 4:21 P.M., indicated the SSD attempted to leave messages for both sisters regarding the resident's discharge time. A Social Service Note, dated 12/24/24 at 2:25 P.M., indicated one of the resident's sisters had left a phone message that the resident was to be transported to the local hospital because she refused to take him in. A follow-up entry from the SSD, dated 12/24/24 at 2:19 P.M., indicated the resident wanted to go to the local hospital to speak with his doctors and then he planned to get a bus ticket out of the state to go to his sister's. There was no documentation in the record that indicated the resident had any prior communication about wanting to discharge until he was informed he would have to leave. There was no documentation in the record to indicate the SSD or any other staff attempted to provide any written notice of discharge, services for discharge planning, or services to ensure continuity of care to the resident or family. The physician's orders for Resident E lacked an order to discharge the resident from the facility. During an interview on 1/6/25 at 3:36 P.M., the Medical Director indicated he had not been notified nor had any record of ordering a discharge for Resident E. A Nursing Progress Note, dated 12/24/24 at 4:12 P.M., indicated the resident was transported by the facility transporter to the local hospital as requested by the resident. However, a Nursing Progress Note, dated 12/24/24 at 4:14 P.M., indicated the resident was discharged to home. A Resident Discharge Summary, completed on 12/24/24 by the Director of Nursing (DON), indicated Resident E was discharged to Home/Community accompanied by his family - sister/family to drive him home. The resident was given discharge instructions and discharged with all of his personal belongings but declined education on his gastronomy tube. The resident was quoted as stating I am going to be dropped off at [name of local hospital] and they will take it [gastronomy tube] out for me. No community resources were listed and 'None Needed was marked. Additional comments on the form were as follows, Resident is discharging because we can no longer skill his services. He has no forwarding address so home health cannot be scheduled. A Nursing Progress Note, dated 12/24/24 at 6:10 P.M., indicated the facility received a phone call from a nearby community police department. They informed the facility that Resident E was at the local hospital and claimed he had been kicked out of the long-term care facility and they had dumped him off at the hospital. The facility nurse documented she had corrected the officer and informed him the resident was discharged from the facility because his insurance had cut him off and his sister had refused to come get him. She indicated the resident had requested to go to the local hospital because of his feeding tube. A (Name of Hospital) admission note indicated the resident arrived at the hospital on 12/24/24 at 4:38 P.M. for feeding tube issue. The emergency room (ER) note indicated the resident presented with complaints, .they discharged me from the [name of facility] rehab [rehabilitation] today and I have no place to go .I have this feeding tube in place and I am forced to be outside tonight, it could freeze and freeze my internal organs .I need to be readmitted . The note indicated the resident was evaluated and, .differential diagnostic consideration include social situation of him being homeless tonight on Christmas Eve. Unfortunately, my care coordinators have left for the day as it is after 5 p.m The case was discussed with the house supervisor and there was no medical need for an inpatient stay. He was safe to discharge. A (Name of Hospital) ER note, dated 12/25/24, indicated the resident presented to the ER with his sister. The resident had a history of complex medical history necrotizing pancreatitis with J tube feedings. He complained of feeling depressed due to his current situation, as he was unhoused. He was discharged from a nursing home two days ago. The sister indicated she had been calling everyone to try to get help. The resident indicated he was tube dependent and had not had any feedings for the past two days and was discharged without any equipment. The note indicated, .Patient is feeling hopeless because he feels like everyone in the state of Indiana wants him to crawl in a ditch and die .Patient is feeling depressed and hopeless like he would be better off dead .I do not feel comfortable discharging him home because he has no way to get nutrition The (facility name) was contacted and indicated the resident was transported to the ER yesterday because he had no home, and family would not pick him up. He was not prescribed any feedings and there were no definite arrangements that staff were aware of and they would fax the discharge summary. A (Name of Hospital) Discharge Note indicated the resident arrived at the hospital on 12/25/24 at 4:27 P.M., after making suicidal statements. The documentation indicated the resident had been in the acute care facility for a prolonged stay, was discharged to the long-term care facility with tube feedings to be continued, and a GI (gastro-intestinal) physician follow-up to have occurred in January 2025. The note indicated the resident was discharged from the long-term care facility but was homeless with nothing set up for his tube feedings. The note indicated he was unable to go to any of the homeless shelters in the area due to the tube feeding, and so he had presented to the emergency department feeling hopeless. The emergency room note indicated the resident was not able to take in nutrition orally and had complex social issues. The resident was evaluated in the emergency room by psychiatry due to the suicidal comments he had made and deemed not actively suicidal, but just feeling hopeless due to his situation. The resident was admitted to the acute care facility with diagnoses including, but not limited to, cellulitis of the lower extremities with antibiotic therapy ordered and continued need for jejunal nocturnal (night) tube feedings for nutritional needs. On admission, he also had bilateral lower extremity deep vein thrombosis (a condition that occurs when a blood clot forms in a vein deep inside a part of the body) and was treated with heparin (a blood thinner). The resident was discharged from the hospital on 1/3/25. During a confidential telephone interview, on 1/5/2025 at 11:30 A.M., the interviewee indicated the resident and his family members were informed on 12/23/24 that the resident's insurance had cut him and would not pay the bill for the resident to stay at the facility. The complainant indicated the resident was not given any prior notice and/or documentation regarding an impending discharge. During an interview with the SSD, on 1/5/25 at 4:10 P.M., she indicated during the Admission Care Plan Meeting, the resident's sisters had informed her the discharge goal was for the resident to go to a group home setting. She indicated she had informed the sisters that the resident did not have any qualifying diagnoses for a group home admission and the process to admit someone to a group home took up to six months to complete. She indicated the plan was for the resident to discharge to his sister's home but when she notified them on 12/23/24 of the resident's need to be discharged on [DATE], both sisters indicated he could not stay with them. She indicated the resident asked to be discharged to the hospital because his car was there. The SSD indicated she told the resident and his sisters he had to leave because he had been discharged from therapy services and the facility had no skilled service for him. When asked about his payor source or if there was a letter from the resident's insurance of his notice of eligibility change, the SSD indicated she did not pay attention to resident's payor sources and she was not aware of any cut letters (from Resident E's insurance) or any NOMNC (Notice of Medicare/Medicaid Non-Coverage form) being provided for Resident E. When asked if the resident was given a written 30-day discharge notice, the SSD indicated she was not familiar with the form. When asked if the local hospital had been informed of Resident E's desire to be taken to the hospital and if any paperwork had been faxed to the local hospital, the SSD indicated nursing would have taken care of those types of things and she was unsure if any communication had been given to the local hospital regarding Resident E. When asked if there were any more discharge planning notes or documentation for Resident E, the SSD indicated the only notes were the ones provided in the electronic record progress notes. During an interview, on 1/6/25 at 11:00 A.M., the DON indicated she had completed the discharge forms and instructions for Resident E on 12/24/24. She thought the resident was being discharged due to an insurance thing, as rehabilitation-wise, the facility had nothing to skill him on. The DON had attempted to teach him how to use his PEG tube, but he refused all teaching and refused to take any tube feeding with him because he was going straight to the hospital to have the tube removed. When asked if the hospital was notified of his desire to go to the hospital, and a interfacility transfer set up with the hospital, the DON stated No, he was being discharged to the hospital parking lot because that was where his car was located. The DON indicated she had sent his prescriptions for medication to a local pharmacy, but the resident told her he was probably not going to go get his medications because he did not have any money for them. She indicated she had sent a three-day supply of medications with him and gave him instructions for the medications. The DON indicated usually the SSD and the Assistant Director of Nursing (ADON) completed discharge planning for residents and she was unsure what planning had been completed for Resident E prior to his discharge from the facility. The week of his discharge, the ADON was on vacation and the DON was not sure what planning the SSD had documented. During an interview, on 1/6/25 at 2:39 P.M., the Administrator indicated the resident was admitted for short-term rehabilitation to home. She understood home was to his sister's home in Michigan, as the resident was homeless otherwise. The Administrator thought the plan to discharge the resident to his sister's home in Michigan was documented on 12/4/24, but there was no documentation of this plan in the social service or nursing progress notes. The Administrator indicated the resident needed to discharge because he had been discharged from therapy services and the facility was not able to skill him for just his gastronomy tube. She then indicated that the resident desired to discharge from the facility before the holidays to spend them with his family. However, there was no social service and/or nursing progress note to support the resident's desire to discharge from the facility on 12/24/24 or any notes leading up to the holidays documenting the resident and/or his family's desire for him to be discharged prior to the holidays. The Administrator indicated the resident's sister in Texas had left a phone message insisting the resident be discharged to the local hospital. However, on 1/6/24 at 4:01 P.M., the Administrator had played part of the audible recorded phone message and the resident's sister clearly stated neither she nor her sister were able to take care of the resident, he was homeless, and she was very upset the facility was kicking him out before Christmas. During an interview with the facility transportation staff member, Employee 41, on 1/6/25 at 4:00 P.M., she indicated she had dropped Resident E off by himself at the main entrance to the local hospital and he had walked into the hospital carrying his suitcase. She was not aware of any paperwork sent to the hospital. During an interview with the Regional Administrator, on 1/6/25, she indicated that since the resident was discharged to the hospital, the discharge was safe. During an interview, on 1/7/25 at 12:40 P.M., the interviewee indicated her brother, herself and their other sister were informed on 12/23/24 that the resident needed to discharge because his insurance would not continue to pay. She indicated neither the family nor the resident were given any prior notice and offered any assistance in finding a place of discharge. The facility was informed that neither their sister nor her could get him due to living out of state. He was taken to the hospital and dropped off. None of them knew what else they could do. The resident was seen in theER on [DATE] and was discharged . She indicated the security guard at the hospital was so upset that the resident had no place to go, the security guard bought him a one-night stay at a local hotel. The family did not see the resident until 12/25/24, when he was taken back to the hospital by the family. He was subsequently admitted to the hospital on 12/25/24. She indicated this had been a horrible ordeal for her brother. He was currently in the hospital again with life threatening concerns. Resident E's government-provided insurance eligibility forms indicated Resident E was approved for long-term care skilled care through 12/26/24. The approval dates were given for short-term time periods and Resident E's stay had been approved from his admission through 12/26/24 at the time of his discharge on 12/24/24. The facility policy and procedure, titled Transfer and Discharge Policy and Procedure provided by the Administrator as current on 1/6/25 at 9:05 A.M., included the following: 2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/responsible party. 3. The written notice will include the following: a. A statement that the resident has the right to appeal the section to State Department of Health including a current phone number of the Department, b. The name, address and telephone number of the State Long Term Care Ombudsman, .d. A state that, if the resident may appeal the transfer or discharge to the Department of Health within 10 days of being notified of the transfer/discharge 4. The resident may remain in the facility pending an appeal determination or 34 days if the department agrees that the transfer is appropriate .6. The facility will provide provisions for continuity of care and in non-emergency situations a care plan meeting will be held with the appropriate parties to determine a relocation plan . Discharge to Home or lower level of care where resident or family will be administering the resident's medications . 2. The attending physician is required to write a discharge order. Telephone orders are acceptable .Discharge Against Medical Advice 1. When the resident wishes to go home or the resident's family/Responsible Party wishes to take the resident home and the attending physician refuses to give a discharge order a 'Discharge Against Medical Advice' form must be signed by the resident or the resident's representative and placed in the health record. 2. No transfer form completed . 4. The facility should determine the need to contact the appropriate State agencies if the resident's safety is a concern .Emergency Transfer: 1. Obtain physician order for transfer. If the attending physician is not available in an emergency, contact the alternate physician. 2. If the alternate physician is not available, contact the Medical Director. 3. If the Medical Director is not available, contact the Director of Nursing .5. Call ambulance for transfer. 6. Explain transfer and reason to the resident and/or representative, if applicable send the original State Transfer/Discharge/Bed hold notice with the resident and/or representative or person(s) responsible for care. Place the facility copy in the health record. 7. Complete the Resident Transfer for make 2 copies of any portion of the heath record necessary for care of resident (E.g. Physician's Orders, History & Physical, chest x-ray, Immunization information, any pertinent lab work, etc) 8. Send original of transfer form and portions of health record that was copies with the resident, attach the second copy of the portions of the health record to the facility copy of the transfer form. Give the third copy of the transfer form to the DON The immediate jeopardy that began on 12/24/24 was removed on 1/7/25, after the facility completed a complete audit of all discharges in the last three months and educated all licensed nursing staff, the Administrator and social service staff on the transfer discharge policy. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the facility needed to ensure the education was effective by auditing discharges and following up on staff education with further education for the SSD. This citation relates to Complaint IN00448438. 3.1-12(a)(3) 3.1-12(a)(4) 3.1-12(a)(5)(B) 3.1-12(a)(6)(A) 3.1-12(a)(7) 3.1-12(a)(18) 3.1-12(a)(19) 3.1-12(a)(20) 3.1-12(a)(21) 3.1-12(a)(22)

Based on observation, interview and record review, the facility failed to ensure hot food and cold liquids were served and maintained in a sanitary and safe manner related to staff touching food and other items both with the same gloved hands during meal service and not keeping room tray meal cart food at the proper serving temperature during two random food service observations. (Main Kitchen and ICF/Maple Unit) This had the potential to affect all residents who received food and drinks from the kitchen. Findings include: 1. During dinner service on 1/3/25 at 5:30 P.M. - 5:33 P.M., the following was observed from the entrance to kitchen: The Dietary Manager (DM) and Dietary Aide 28 were in the kitchen wearing blue gloves which covered their hands. The DM took one gloved hand, grabbed a plate and removed a piece of fish from the steamer pan with her other gloved hand. Then, with the same hand, scooped up a serving of carrots with a ladle and continued down the steamer with the same gloved hands, touching each ladle. The DM placed the plate on a tray and took it to an open counter, which she touched with her gloved hand, to be picked up by a facility staff member who served the tray to a resident. Dietary Aide #28 followed behind the DM and was observed taking his blue gloved hand, grabbing a plate and removing a piece of fish from the steam pan with his gloved hand, then placing the fish on a plate. He then added the carrots and on down the steamer touching the ladle handles with the same gloved hands, and placed the plate on a tray to be distributed to a resident. As Dietary Aide 28 returned to the steam table, the DM repeated the same process with the same gloved hands, as did Dietary Aide 28 again. On 1/3/25 at 5:34 P.M., the DM indicated she had placed a set of tongs in the pan of fish and should have used the tongs to remove the fish from the pan instead of her gloved hands. On 1/7/25 at 10:38 A.M., the Administrator provided a form titled, Glove and Hand Washing Procedures, dated 2017 and indicated the policy was the one currently used by the facility. The policy indicated .7. Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, other non-food contact surface, such as door handles and equipment 2. On 1/5/25 at 1:02 P.M., the meal cart arrived to the ICF/Maple unit with approximately 5 trays. The Dietary Manager had accompanied the cart to the unit. A tray was taken from the cart and the following temperatures of the food, were recorded: Italian Sausage - 116 degrees Pasta - 149 degrees Fruit punch drink - 56 degrees After the Dietary Manager checked the temperatures, the sausage was tasted and was not palatable for consumption, as it tasted uncooked. During an interview, on 1/5/25 at 1:07 P.M., the Dietary Manager indicated the sausage had not maintained a proper temperature and the punch was too warm, as it should be served cold. The Dietary Manager indicated the kitchen only had 10 plate warmers and there were more residents who ate in their rooms than the facility had plate warmers for use. The facility had 5 resident units in the facility. On 1/6/25 at 9:25 A.M., the Administrator provided a form titled, Resource: Minimum Cooking Food Temperatures and Holding Times, dated 2017, and indicated the policy was the one currently used by the facility. The policy indicated Pork or Beef minimum temperature was 145 degrees.8. Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be a 120 degrees or greater to promote palatability for the resident This citation relates to Complaints IN00450476, IN00450474, IN00449158 and IN00448896. 3.1-21(a)(2)

Based on record review and interview, the facility failed to ensure a notice of discharge was provided, in writing, prior to a facility-initiated discharge for 1 of 3 residents reviewed for discharge. (Resident E) Finding includes: The clinical record for Resident E was reviewed on 1/5/25 at 2:00 P.M. Resident E was admitted to the facility on [DATE] from an acute care facility following surgical repair of necrotizing pancreatitis. The resident's diagnoses, included, but were not limited to, status post (s/p) perforation of the esophagus, acute pancreatitis with uninfected necrosis, gastroesophageal reflux disease with esophagitis, fistula of the stomach and duodenum, and gastrostomy placement. The resident was admitted with physician's orders for enteral tube feedings and nothing by mouth (NPO) except diet soda and medications. The acute care transfer documentation indicated the plan was for the resident to receive nutrition via an enteral tube feeding in the extended care facility until a gastrointestinal surgical consult was completed in four weeks. The resident was to have a Computerized Tomography (CT) scan performed in two weeks. The surgical note indicated in January, the resident's condition was to be reevaluated, a cholecystectomy performed, surgical repair of the resident's intestinal system performed and the G/J tube removed. The Admission Minimum Data Set (MDS) assessment, completed on 11/30/24, indicated the resident was admitted for short stay rehabilitation from an acute care facility. An Admission care plan meeting note, completed on 11/29/24 at 11:01 A.M., indicated the resident had attended the meeting and both sisters had participated via telephone. The resident was working with therapy to evaluate his ability to perform his own Activities of Daily Living (ADL) needs and the discharge goal was for the resident to discharge to an assisted living group home setting. There were no recommendations documented as a result of the care plan meeting and no follow-up for discharge planning. A Discharge Care Plan, dated 12/16/24 with a target date of 2/28/25, indicated the resident's goal was to discharge from the facility after short-term stay. The focus indicated the resident planned to return home with a family member. The goals were for the resident to actively participate in therapy, as shown by his attendance and cooperation, and to have a safe discharge home. The only intervention listed for the plan was to assist the resident and family with discharge planning. There was no documentation in the clinical record for discharge planning. There were no nursing and/or social service progress notes regarding discharge needs until a Social Service Note, dated 12/23/24 at 2:35 P.M., indicated the Social Service Director (SSD) spoke with the resident and, via a phone call with one of the resident's sisters, informed the resident and his sister that the facility had nothing to skill the resident on, so he needed to leave because his insurance would not pay his bill. The resident informed the SSD he would be living on the streets. His sister was asked to come to the facility the following day for some training and the discharge. The resident's sister indicated she was going to call the State and bring them with her. A Social Service note, dated 12/24/24 at 2:25 P.M., indicated one of the resident's sisters had left a phone message that the resident was to be transported to the local hospital because she refused to take him in. A follow-up entry from the SSD, dated 12/24/2024 at 2:19 P.M., indicated the resident wanted to go to the local hospital to speak with his doctors and then he planned to get a bus ticket out of the state to go to his sister's house. A Nursing Progress Note, dated 12/24/24 at 4:12 P.M., indicated the resident was transported by the facility transporter to the local hospital as requested by the resident. However, a Nursing Progress Note, dated 12/24/24 at 4:14 P.M., indicated the resident was discharged to home. A Resident Discharge Summary, completed on 12/24/24 by the Director of Nursing (DON), indicated Resident E was discharged to Home/Community accompanied by his family - sister/family to drive him home. The resident was given discharge instructions and discharged with all of his personal belongings but declined education on his gastronomy tube. The resident was quoted as stating I am going to be dropped off at [name of local hospital] and they will take it [gastronomy tube] out for me. No community resources were listed and 'None Needed was marked. Additional comments on the form were as follows, Resident is discharging because we can no longer skill his services. He has no forwarding address so home health cannot be scheduled. The resident signed form section indicated a Bed Hold Policy was provided but there was no signed copy of the form located in the clinical record. The physician's orders for Resident E lacked an order to discharge the resident from the facility. There was no documentation in the record to indicate the SSD or any other staff attempted to provide any prior written notice of discharge. Resident E's government-provided insurance eligibility forms indicated Resident E was approved for long-term care skilled care through 12/26/24. The approval dates were given for short-term time periods and Resident E's stay had been approved from his admission through 12/26/24 at the time of his discharge on 12/24/24. During a confidential telephone interview, on 1/5/2025 at 11:30 A.M., the interviewee indicated indicated the resident and his family members were informed on 12/23/24 that the resident's insurance had cut him and would not pay the bill for the resident to stay at the facility. The complainant indicated the resident was not given any prior notice and/or documentation regarding an impending discharge. During an interview with the SSD, on 1/5/25 at 4:10 P.M., she indicated during the Admission Care Plan Meeting, the resident's sisters had informed her the discharge goal was for the resident to go to a group home setting. She indicated she had informed the sisters that the resident did not have any qualifying diagnoses for a group home admission and the process to admit someone to a group home took up to six months to complete. She indicated the plan was for the resident to discharge to his sister's home but when she notified them on 12/23/24 of the resident's need to be discharged on [DATE], both sisters indicated he could not stay with them. She indicated the resident asked to be discharged to the hospital because his car was there. The SSD indicated she told the resident and his sisters he had to leave because he had been discharged from therapy services and the facility had no skilled service for him. When asked about his payor source or if there was a letter from the resident's insurance of his notice of eligibility change, the SSD indicated she did not pay attention to resident's payor sources and she was not aware of any cut letters (from Resident E's insurance) or any NOMNC (Notice of Medicare/Medicaid Non-Coverage form) being provided for Resident E. When asked if the resident was given a written 30-day discharge notice, the SSD indicated she was not familiar with the form. When asked if the local hospital had been informed of Resident E's desire to be taken to the hospital and if any paperwork had been faxed to the local hospital, the SSD indicated nursing would have taken care of those types of things and she was unsure if any communication had been given to the local hospital regarding Resident E. When asked if there were any more discharge planning notes or documentation for Resident E, the SSD indicated the only notes were the ones provided in the electronic record progress notes. During an interview, on 1/6/25 at 11:00 A.M., the DON indicated she had completed the discharge forms and instructions for Resident E on 12/24/24. She thought the resident was being discharged due to an insurance thing, as rehabilitation-wise, the facility had nothing to skill him on. The DON had attempted to teach him how to use his PEG tube, but he refused all teaching and refused to take any tube feeding with him because he was going straight to the hospital to have the tube removed. When asked if the hospital was notified of his desire to go to the hospital, and a interfacility transfer set up with the hospital, the DON stated No, he was being discharged to the hospital parking lot because that was where his car was located. The DON indicated usually the SSD and the Assistant Director of Nursing (ADON) completed discharge planning for residents and she was unsure what planning had been completed for Resident E prior to his discharge from the facility. The week of his discharge, the ADON was on vacation and the DON was not sure what planning the SSD had documented. The DON indicated generally, short-term residents were not given a 30-day notice. During an interview, on 1/6/25 at 2:39 P.M., the Administrator indicated the resident was admitted for short-term rehabilitation to home. The resident needed to discharge because he had been discharged from therapy services and the facility was not able to skill him for just his gastronomy tube. She then indicated that the resident desired to discharge from the facility before the holidays to spend them with his family. However, there was no social service and/or nursing progress note to support the resident's desire to discharge from the facility on 12/24/24 or any notes leading up to the holidays documenting the resident and/or his family's desire for him to be discharged prior to the holidays. The Administrator indicated the resident's sister in Texas had left a phone message insisting the resident be discharged to the local hospital. However, on 1/6/24 at 4:01 P.M., the Administrator had played part of the audible recorded phone message and the resident's sister clearly stated neither she nor her sister were able to take care of the resident, he was homeless, and she was very upset the facility was kicking him out before Christmas. During an interview with the facility transportation staff member, Employee 41, on 1/6/25 at 4:00 P.M., she indicated she had dropped Resident E off by himself at the main entrance to the local hospital and he had walked into the hospital carrying his suitcase. She was not aware of any paperwork sent to the hospital. The facility policy and procedure, titled Transfer and Discharge Policy and Procedure provided by the Administrator as current on 1/6/25 at 9:05 A.M., included the following: 2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/responsible party. 3. The written notice will include the following: a. A statement that the resident has the right to appeal the section to State Department of Health including a current phone number of the Department, b. The name, address and telephone number of the State Long Term Care Ombudsman, .d. A state that, if the resident may appeal the transfer or discharge to the Department of Health within 10 days of being notified of the transfer/discharge 4. The resident may remain in the facility pending an appeal determination or 34 days if the department agrees that the transfer is appropriate .6. The facility will provide provisions for continuity of care and in non-emergency situations a care plan meeting will be held with the appropriate parties to determine a relocation plan . Discharge to Home or lower level of care where resident or family will be administering the resident's medications . 2. The attending physician is required to write a discharge order. Telephone orders are acceptable .Discharge Against Medical Advice 1. When the resident wishes to go home or the resident's family/Responsible Party wishes to take the resident home and the attending physician refuses to give a discharge order a 'Discharge Against Medical Advice' form must be signed by the resident or the resident's representative and placed in the health record. 2. No transfer form completed . 4. The facility should determine the need to contact the appropriate State agencies if the resident's safety is a concern .Emergency Transfer: 1. Obtain physician order for transfer. If the attending physician is not available in an emergency, contact the alternate physician. 2. If the alternate physician is not available, contact the Medical Director. 3. If the Medical Director is not available, contact the Director of Nursing .5. Call ambulance for transfer. 6. Explain transfer and reason to the resident and/or representative, if applicable send the original State Transfer/Discharge/Bed hold notice with the resident and/or representative or person(s) responsible for care. Place the facility copy in the health record. 7. Complete the Resident Transfer for make 2 copies of any portion of the heath record necessary for care of resident (E.g. Physician's Orders, History & Physical, chest x-ray, Immunization information, any pertinent lab work, etc) 8. Send original of transfer form and portions of health record that was copies with the resident, attach the second copy of the portions of the health record to the facility copy of the transfer form. Give the third copy of the transfer form to the DON There was no documentation in the record to indicate a 30-day notice was issued to Resident E prior to his facility-initiated discharge. The resident was also erroneously informed his insurance would not pay for his stay, when he had insurance coverage through 12/26/24. There was no signed copy of the Bed Hold policy located in the resident's medical record upon his discharge from the facility on 12/23/24. This citation relates to Complaint IN00448438. 3.1-12(a)(5)(A) 3.1-12(a)(7) 3.1-12(a)(9)

Based on record review and interview, the facility failed to ensure preparation and orientation for a resident's discharge was completed to minimize anxiety and ensure a safe and orderly discharge from the facility for 1 of 3 residents reviewed for discharge planning. (Resident E) Finding includes: The clinical record for Resident E was reviewed on 1/5/25 at 2:00 P.M. Resident E was admitted to the facility on [DATE] from an acute care facility following surgical repair of necrotizing pancreatitis. The resident's diagnoses included, but were not limited to, status post (s/p) perforation of the esophagus, acute pancreatitis with uninfected necrosis, gastroesophageal reflux disease with esophagitis, fistula of the stomach and duodenum, and gastrostomy placement. The resident was admitted with physician orders for enteral tube feedings and nothing by mouth (NPO) except diet soda and medications. The acute care transfer documentation indicated the plan was for the resident to receive nutrition via an enteral tube feeding in the extended care facility until a gastrointestinal surgical consult was completed in four weeks. The resident was to have a Computerized Tomography (CT) scan performed in two weeks. The surgical note indicated in January, the resident's condition was to be reevaluated, a cholecystectomy performed, surgical repair of the resident's intestinal system performed and the G/J tube removed. The Admission Minimum Data Set (MDS) assessment, completed on 11/30/24, indicated the resident was admitted for short stay rehabilitation from an acute care facility. The assessment indicated the resident was cognitively intact, had not displayed any mood issues or behaviors during the assessment period, was dependent on staff for feeding due to requiring enteral feedings, utilized a walker and/or wheelchair for mobility needs, required moderate staff assistance for lower body dressing, applying footwear, and bathing needs, received physical and occupational therapy and did not require an active discharge plan. An Admission Care plan meeting note, completed on 11/29/24 at 11:01 A.M., indicated the resident attended the meeting and both sisters had participated via telephone. The resident was working with therapy to evaluate his ability to perform his own Activities of Daily Living (ADL) needs and the discharge goal was for the resident to discharge to an assisted living group home setting. There were no recommendations documented as a result of the care plan meeting. There was no further follow-up with discharge planning. A Discharge care plan for Resident E, dated 12/16/24 with a target date of 2/28/25, indicated the resident's goal was to discharge from the facility after a short-term stay. The focus indicated the resident planned to return home with a family member. The goals were for the resident to actively participate in therapy, as shown by his attendance and cooperation, and to have a safe discharge home. The only intervention listed for the plan was to assist the resident and family with discharge planning. There were no nursing and/or social service progress notes regarding discharge needs until a Social Service Note, dated 12/23/24 at 2:35 P.M., indicated the Social Service Director (SSD) spoke with the resident and, via a phone call with one of the resident's sisters, informed the resident and his sister that the facility had nothing to skill the resident on, so he needed to leave because his insurance would not pay his bill. The resident informed the SSD he would be living on the streets. His sister was asked to come to the facility the following day for some training and the discharge. The resident's sister indicated she was going to call the State and bring them with her. A Social Service Note, dated 12/24/24 at 2:25 P.M., indicated one of the resident's sisters had left a phone message that the resident was to be transported to the local hospital because she refused to take him in. A follow-up entry from the SSD, dated 12/24/24 at 2:19 P.M., indicated the resident wanted to go to the local hospital to speak with his doctors and then he planned to get a bus ticket out of the state to go to his sister's. There was no documentation in the record that indicated the resident had any prior communication about wanting to discharge until he was informed he would have to leave. The physician's orders for Resident E lacked an order to discharge the resident from the facility. During an interview, on 1/6/25 at 3:36 P.M., the Medical Director indicated he had not been notified nor had any record of ordering a discharge for Resident E. A Nursing Progress Note, dated 12/24/24 at 4:12 P.M., indicated the resident was transported by the facility transporter to the local hospital as requested by the resident. However, a Nursing Progress Note, dated 12/24/24 at 4:14 P.M., indicated the resident was discharged to home. A Resident Discharge Summary, completed on 12/24/24 by the Director of Nursing (DON), indicated Resident E was discharged to Home/Community accompanied by his family - sister/family to drive him home. The resident was given discharge instructions and discharged with all of his personal belongings but declined education on his gastronomy tube. The resident was quoted as stating I am going to be dropped off at [name of local hospital] and they will take it [gastronomy tube] out for me. No community resources were listed and 'None Needed was marked. Additional comments on the form were as follows, Resident is discharging because we can no longer skill his services. He has no forwarding address so home health cannot be scheduled. A (Name of Hospital) Physician's Note indicated the resident arrived at the hospital on 12/25/24 at 4:27 P.M., after making suicidal statements. The documentation indicated the resident had been in the acute care facility for a prolonged stay, was discharged to the long-term care facility with tube feedings to be continued, and a GI (gastrointestinal) physician follow-up to have occurred in January 2025. The resident was discharged from the long-term care facility but was homeless with nothing set up for his tube feedings. The note indicated he was unable to go to any of the homeless shelters in the area due to the tube feeding, and so he had presented to the emergency department feeling hopeless. The emergency room note indicated the resident was not able to take in nutrition orally and had complex social issues. During a confidential telephone interview, on 1/5/2025 at 11:30 A.M., the interviewee indicated the resident and his family members were informed on 12/23/24 that the resident's insurance had cut him and would not pay the bill for the resident to stay at the facility. The resident was not given any prior notice and/or documentation regarding an impending discharge. During an interview with the SSD, on 1/5/25 at 4:10 P.M., she indicated during the Admission Care Plan Meeting, the resident's sisters had informed her the discharge goal was for the resident to go to a group home setting. She indicated she had informed the sisters that the resident did not have any qualifying diagnoses for a group home admission and the process to admit someone to a group home took up to six months to complete. She indicated the plan was for the resident to discharge to his sister's home but when she notified them on 12/23/24 of the resident's need to be discharged on [DATE], both sisters indicated he could not stay with them. She indicated the resident asked to be discharged to the hospital because his car was there. The SSD indicated she told the resident and his sisters he had to leave because he had been discharged from therapy services and the facility had no skilled service for him. When asked about his payor source or if there was a letter from the resident's insurance of his notice of eligibility change, the SSD indicated she did not pay attention to resident's payor sources and she was not aware of any cut letters (from Resident E's insurance) or any NOMNC (Notice of Medicare/Medicaid Non-Coverage form) being provided for Resident E. When asked if the resident was given a written 30-day discharge notice, the SSD indicated she was not familiar with the form. When asked if the local hospital had been informed of Resident E's desire to be taken to the hospital and if any paperwork had been faxed to the local hospital, the SSD indicated nursing would have taken care of those types of things and she was unsure if any communication had been given to the local hospital regarding Resident E. When asked if there were any more discharge planning notes or documentation for Resident E, the SSD indicated the only notes were the ones provided in the electronic record progress notes. During an interview, on 1/6/25 at 11:00 A.M., the DON indicated she had completed the discharge forms and instructions for Resident E on 12/24/24. She thought the resident was being discharged due to an insurance thing, as rehabilitation-wise, the facility had nothing to skill him on. The DON had attempted to teach him how to use his PEG tube, but he refused all teaching and refused to take any tube feeding with him because he was going straight to the hospital to have the tube removed. When asked if the hospital was notified of his desire to go to the hospital, and a interfacility transfer set up with the hospital, the DON stated No, he was being discharged to the hospital parking lot because that was where his car was located. The DON indicated she had sent his prescriptions for medication to a local pharmacy, but the resident told her he was probably not going to go get his medications because he did not have any money for them. She indicated she had sent a three-day supply of medications with him and gave him instructions for the medications. The DON indicated usually the SSD and the Assistant Director of Nursing (ADON) completed discharge planning for residents and she was unsure what planning had been completed for Resident E prior to his discharge from the facility. The week of his discharge, the ADON was on vacation and the DON was not sure what planning the SSD had documented. The DON indicated generally, short term residents were not given a 30 day notice, but Resident E should have been given a NOMNC when he was discharged from rehab (rehabilitation) services. She was not sure if the SSD had issued the form. During an interview, on 1/6/25 at 2:39 P.M., the Administrator indicated the resident was admitted for short-term rehabilitation to home. She understood home was to his sister's home in Michigan, as the resident was homeless otherwise. The Administrator thought the plan to discharge the resident to his sister's home in Michigan was documented on 12/4/24, but there was no documentation of this plan in the social service or nursing progress notes. The Administrator indicated the resident needed to discharge because he had been discharged from therapy services and the facility was not able to skill him for just his gastronomy tube. She then indicated that the resident desired to discharge from the facility before the holidays to spend them with his family. However, there was no social service and/or nursing progress note to support the resident's desire to discharge from the facility on 12/24/24 or any notes leading up to the holidays documenting the resident and/or his family's desire for him to be discharged prior to the holidays. The Administrator indicated the resident's sister in Texas had left a phone message insisting the resident be discharged to the local hospital. However, on 1/6/24 at 4:01 P.M., the Administrator had played part of the audible recorded phone message and the resident's sister clearly stated neither she nor her sister were able to take care of the resident, he was homeless, and she was very upset the facility was kicking him out before Christmas. During an interview with the facility transportation staff member, Employee 41, on 1/6/25 at 4:00 P.M., she indicated she had dropped Resident E off by himself at the main entrance to the local hospital and he had walked into the hospital carrying his suitcase. She was not aware of any paperwork sent to the hospital. The facility policy and procedure, titled Transfer and Discharge Policy and Procedure provided by the Administrator as current on 1/6/25 at 9:05 A.M., included the following: 2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/responsible party. 3. The written notice will include the following: a. A statement that the resident has the right to appeal the section to State Department of Health including a current phone number of the Department, b. The name, address and telephone number of the State Long Term Care Ombudsman, .d. A state that, if the resident may appeal the transfer or discharge to the Department of Health within 10 days of being notified of the transfer/discharge 4. The resident may remain in the facility pending an appeal determination or 34 days if the department agrees that the transfer is appropriate .6. The facility will provide provisions for continuity of care and in non-emergency situations a care plan meeting will be held with the appropriate parties to determine a relocation plan . Discharge to Home or lower level of care where resident or family will be administering the resident's medications . 2. The attending physician is required to write a discharge order. Telephone orders are acceptable .Discharge Against Medical Advice 1. When the resident wishes to go home or the resident's family/Responsible Party wishes to take the resident home and the attending physician refuses to give a discharge order a 'Discharge Against Medical Advice' form must be signed by the resident or the resident's representative and placed in the health record. 2. No transfer form completed . 4. The facility should determine the need to contact the appropriate State agencies if the resident's safety is a concern .Emergency Transfer: 1. Obtain physician order for transfer. If the attending physician is not available in an emergency, contact the alternate physician. 2. If the alternate physician is not available, contact the Medical Director. 3. If the Medical Director is not available, contact the Director of Nursing .5. Call ambulance for transfer. 6. Explain transfer and reason to the resident and/or representative, if applicable send the original State Transfer/Discharge/Bed hold notice with the resident and/or representative or person(s) responsible for care. Place the facility copy in the health record. 7. Complete the Resident Transfer for make 2 copies of any portion of the heath record necessary for care of resident (E.g. Physician's Orders, History & Physical, chest x-ray, Immunization information, any pertinent lab work, etc) 8. Send original of transfer form and portions of health record that was copies with the resident, attach the second copy of the portions of the health record to the facility copy of the transfer form. Give the third copy of the transfer form to the DON There was no documentation in the record to indicate the facility provided appropriate preparation or orientation to Resident E to ensure a safe discharge. This citation relates to Complaint IN00448438. 3.1-12(a)(3) 3.1-12(a)(18) 3.1-12(a)(19) 3.1-12(a)(20) 3.1-12(a)(21) 3.1-12(a)(22) 3.1-12(a)(23)

Based on observation, interview and record review, the facility failed to ensure dependent residents had received bathing opportunities according to their twice a week preferences for 2 of 3 residents reviewed for bathing. (Resident R and Resident X) Findings include: 1. During an interview, on 1/6/25 at 10:00 A.M., Resident R indicated there was only one aide on the floor and she had not received a shower in 2-3 weeks. The last time her hair had been shampooed had also been 2-3 weeks ago. The resident indicated her showers had been scheduled for Wednesdays and Saturdays. This past Saturday, the aide had indicated to the resident she was ready to assist with her shower, but it had been during lunch time, so the resident requested to have her shower after lunch. The aide never returned to provide her a shower. On 1/6/25 at 11:35 A.M., a review of the clinical record for Resident R was conducted. The resident's diagnoses included, but were not limited to, cerebrovascular accident (CVA), heart failure, colostomy status and anxiety. An Activity Admission Evaluation, dated 7/5/24, indicated the resident preferred a shower. The Quarterly Minimum Data Set (MDS) assessment, dated 10/6/24, indicated the resident's cognition was intact, had no rejection of care behaviors and required partial/moderate assist with showering/bathing. A Care Plan, dated 10/16/24, indicated the resident required assistance with ADLs (Activities of Daily Living). The interventions included, but were not limited to, encourage the resident to complete as much as they can, extensive assist of one person needed for transfer,s and bathe resident per the resident's preference twice a week. There was no care plan indicating the resident had a pattern of refusal of care. A form, titled Shower Report, indicated on the following dates the resident was offered a shower in December 2024 and January 2025: - 12/4/24 a Wednesday- indicated resident refused a shower. - 12/7/24 a Saturday-indicated the resident received a shower, with shampoo, lotion and nail care. - 12/11/24 a Wednesday-indicated the resident refused a shower. - 12/14/24 a Saturday- indicated the resident refused a shower. - 12/18/24 a Wednesday-indicated the resident refused as she had a shower on 12/17/24, however there was no shower sheet for that day. - 12/21/24 a Saturday-indicated the resident refused a shower. - 12/29/24 a Sunday-indicated the resident received a shower and shampoo - 1/1/25 a Wednesday-indicated the resident refused a shower. There was no shower sheet for 1/4/25 provided. A form titled, Documentation Survey Report for December 2024 and January 2025, was provided by the Director of Nursing. The form indicated the resident had a shower on the following days: 12/4, 12/7, 12/18 and none recorded for January 2025. The 12/7 shower report indicated no shampoo had been completed for the resident. 2. On 1/5/25 at 10:43 A.M., Resident X's son indicated he had concerns about the lack of showers provided by the facility staff. During an observation, on 1/5/25 at 10:53 A.M., Resident X was observed in bed, she was alert to her name but unable to recall what day it was. The room had an odor of stool. CNA 29 knocked on the resident's door and entered with supplies to change the resident. The CNA was observed to assist the resident and change her brief without concerns noted. On 1/7/25 at 2:53 P.M., a review of the clinical record for Resident X was conducted. The record indicated the resident was admitted on [DATE]. The resident's diagnoses included, but were not limited to; dementia, osteoporosis, difficulty walking and weakness. The Admission Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident's cognition was moderately impaired and required partial/moderate assistance of 1 person's with a shower. An Activity Admission Evaluation, dated 11/18/24, indicated the resident preferred a shower. The Care Plan for preferences, dated 11/20/24, indicated the resident a shower twice a week but care plan did not indicate what days the showers would occur. The ADL care plan was not received. A form titled Shower Report indicated on the following dates the resident was offered a shower in December 1014 and January 2025: - 11/24/24 a Sunday indicated the resident had a shower but did not want her hair washed. - 11/27/24 a Wednesday indicated the resident had refused a shower 3 times so staff provided a complete bed bath. - 12/12/24 a Thursday indicated the resident had a shower and shampoo - 12/23/24 a Monday indicated the resident had a shower and shampoo There were no shower reports provided for January 2025. A form titled, Documentation Survey Report for November 2024, December 2024 and January 2025, was provided by the Director of Nursing. The form indicated the resident had a shower on 11/23/24 and 1/6/25. The form indicated she received a bed bath on 11/27/24, 12/10/24 and 12/22/24. A form titled Sunshine Pod Showers, indicated Resident X should have received her showers on Mondays and Thursdays. On 1/6/25 at 4:04 P.M., the Regional Nurse Consultant provided a policy titled, Guidelines for Bathing, dated 9/21/23, and indicated the policy was the one currently used by the facility. The policy indicated .To cleanse the skin and to promote circulation On 1/7/25 at 11:02 A.M., the Regional Nurse Consultant indicated the facility had no ADL policy related to showers or bathing opportunities. This citation relates to Complaint IN00450476. 3.1-38(a)(3) 3.1-38(b)(2) 3.1-38(b)(3)

Based on observation, interview and record review, the facility failed to ensure tube feedings were documented as ordered by the physician for 2 of 3 residents reviewed for tube feeding. (Resident E and Resident S) Findings include: 1. The clinical record for Resident E was reviewed on 1/5/25 at 2:00 P.M. Resident E was admitted to the facility on [DATE] from an acute care facility following surgical repair of necrotizing pancreatitis. The resident's diagnoses included, but were not limited to, status post (s/p) perforation of the esophagus, acute pancreatitis with uninfected necrosis, gastroesophageal reflux disease with esophagitis, fistula of the stomach and duodenum, and gastrostomy placement. The resident had a gastrostomy/jejunostomy tube (a GJ tube - combination of a tube placed in the stomach and a tube placed in the jejunum that is secured with a balloon or plastic bumper in the stomach and a plastic disc around the outside of the body.) The resident was admitted with physician orders for enteral tube feedings and nothing by mouth (NPO) except diet soda and medications. The Admission Minimum Data Set (MDS) assessment, dated 11/30/24, indicated the resident was cognitively intact, was dependent on staff for feedings, required enteral feedings and received 51% or more of his total calories via a J-tube. A Care Plan, dated 11/25/24, indicated the resident had the inability to tolerate oral intake and had a jejunostomy in place for nutrition. The interventions included, but were not limited to, Give J-tube feeding as ordered, monitor J-tube site daily for signs of infection and report any problems to the physician. A Registered Dietician Note, dated 11/25/24 at 4:41 P.M., indicated Resident E was admitted from the hospital and a J-tube had been placed for feedings. The note indicated .Diet: NPO except ice chips and diet soda. Enteral Feed: current order is 4a-12p feed with no rate indicated, 60 ml flush q [every] shift. Review: Resident requiring enteral feeds via PEGJ tube for pancreatic rest post pancreatitis. J port (yellow) must be used for feeds. Noted per hospital notes resident can have ice chips and diet coke by mouth. Resident is mobile and would like some daytime off feed to move around facility etc. Resident will transition to [name of enteral feed] 1.5 per facility availability .[name of enteral feed] 1.5 total volume of 1575 per day provides: 2362 kcals/106 g protein/1202 ml free water. Tube flushed for patency before and after feeds. Meets 100% of assessed calories and protein needs. Resident to take water orally to meet fluids needs An Order Summary Report, indicated the following: .Enteral Feed Order every shift for supplemental feed Start 4am and end midnight 105ml/hr [milliliters per hour]. Flush before and after feed w [with] 60 ml of water Start date was 11/27/24. There was no end date documented .Enteral Feed Order every shift for supplemental feed [name of enternal feed] 105 ml/hr 12pm-2pm total volume Start 6pm to 7am 105 ml/hr. total volume 1365ml Flush before and after feed w [with] 60ml of water Start date was 12/5/24. The Medication Administration Record (MAR) for November 2024 indicated .[Name of enteral feeding] 1.5 on at 0400 off at midnight. Flush with water before and after each feeding Start date 11/23/24 with end date 11/27/24. Nurses initialed the MAR day, evening and night shift; however, there was no documentation on the MAR or Treatment Administration Record (TAR) which indicated the enteral feeding was started at 4:00 A.M., stopped at midnight, nor the amount the resident received during the eternal feeding. There were initials on 11/27/2, by the day nurse; however, starting 11/28/24, there were no other notes or initials on the November MAR indicating the resident had received his enteral feedings. The December MAR & TAR had no documentation related to the enteral feedings. The November and December 2024 MAR indicated NPO [nothing by mouth] except meds, ice chips or diet soda only by mouth Nurses were documenting the resident was NPO on the November and December MAR with start date of 11/23/24 and end date 12/24/24. During an interview, on 1/8/25 at 11:09 A.M., the Director of Nursing (DON) indicated she had not found other documentation of the enteral feeding for Resident E and indicated it would have been documented on the MAR/TAR. 2. On 1/6/25 at 10:47 A.M., a review of the clinical record for Resident S was conducted. The resident's diagnoses, included but were not limited to, Alzheimer's Disease, diabetes and dysphagia (difficulty swallowing). A Quarterly Minimum Data Set (MDS) assessment, dated 10/25/24, indicated the resident's cognition was severely impaired, received partial to moderate assistance with eating and received 51% or more of total calories via g-tube. (Gastrostomy tube is an opening in the stomach to insert a tube for nutritional support) A Care Plan, dated 6/13/24, indicated the resident had a diagnosis of dysphasia and had a G-tube in place for nutrition. The interventions included, but were not limited to, Give G-tube feeding as ordered, monitor G-tube site daily for signs of infection and flush G-tube as ordered. Physician Orders included the following: - 4/5/2024 Enteral feed, five times a day, for G-Tube Isosource 1.5, administer 237ml (milliliters). - 6/14/2024 Piston and container for G-Tube to be changed each night shift. Please make sure you date and initial every night shift. The Enteral and Oral Supplement record, dated December 2024, indicated .Enteral Feed Order five times a day for G-Tube Isosource 1.5cal [calores] give 237 mL. then flush with 30cc [cubic centimeter] before and after feeding The record indicated the times for the feeding were midnight, 8:00 A.M., noon, 4:00 P.M. and 8:00 P.M. The record indicated the resident did not receive enteral feeding on the following dates and times: -12/4/24 at 12:00 A.M. -12/4/24 at 4:00 P.M. -12/6/24 at 12:00 A.M. -12/13/24 at 12:00 A.M. -12/13/24 at 8:00 P.M. -12/14/24 at 4:00 P.M. -12/14/24 at 8:00 P.M. -12/18/24 at 8:00 P.M. -12/20/24 at 12:00 A.M. -12/20/24 at 4:00 P.M. -12/20/24 at 8:00 P.M. -12/22/24 at 4:00 P.M. -12/23/24 at 8:00 P.M. -12/23/24 at 4:00 P.M. -12/24/24 at 8:00 P.M. -12/24/24 at 4:00 P.M. -12/25/24 at 8:00 P.M. -12/25/24 at 4:00 P.M. -12/27/24 at 12:00 A.M. During an observation with LPN 21, on 1/6/25 at 11:25 A.M., the resident's piston syringe (device for administrating the G-tube formula) and water bottle were not dated. LPN 21 indicated both the piston's package covering and water bottle should have been dated. The night shift was responsible for throwing out both the piston syringe and bottle, replacing them with new devices and dating the equipment. LPN 21 indicated Resident S did not refuse any tube feedings. During an interview, on 1/6/25 at 2:31 P.M., the DON indicated the nursing staff should have documented each time a bolus feeding was administered. The blanks on the Enteral Oral Supplement record indicated that it was not signed and/or not administered as ordered. On 1/6/25 at 2:57 P.M., the Regional Nurse Consultant provided a policy titled, Guidelines for Enteral Feeding: Adult, dated 7/3/23, and indicated the policy was the one currently used by the facility. The policy indicated .Purpose: To provide guidance to qualified licensed clinical staff in hanging and maintaining and managing and administering Tube/Feeding and Enteral Nutrition-to residents to include medication administration .The feeding bag/tubing must be changed every 24 hours The Regional Nurse indicated the policy was the only one pertaining to enteral feeding. The policy did not indicate where or when to document the enteral feeding. A documentation policy was requested. On 1/6825 at 10:28 A.M., the Administrator provided a policy titled, Guidelines for Nursing Documentation, dated 5/17/23 and indicated the policy was the one currently used by the facility. The policy indicated .9. Remember If you did not write it down, you did not do it This citation relates to Complaint IN00448438. 3.1-44(a)(2)

Based on observation, interview and record review, the facility failed to ensure nurse staffing information was posted for the residents and their families to review. This had the ability to affect all of the residents and their family members. Finding includes: On 1/2/25 at 3:39 P.M., a posting of a form titled, Nursing Staff Directly Responsible For Resident Care, dated 11/18/24, was observed near the entrance to the facility behind a glass case. The form indicated how many Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA) were working in a 24 hour period. The bottom of the form indicated, .Daily posting of this information is required for nursing participation in Medicare and Medicaid On 1/2/25 at 4:46 P.M., the Director of Nursing (DON) observed the nurse staff posting and indicated this was the only place the form was displayed in the facility. The DON confirmed the date on the form was 11/18/24 and indicated it was the scheduler's job to post the nurse staffing daily. During an interview, on 1/2/25 at 5:09 P.M., the Administrator indicated it was the DON and Assistant Director of Nursing's responsibility to post the daily nurse staffing since the facility currently did not have a scheduler. On 1/2/25 at 5:12 P.M., the DON provided a policy titled, Guidelines for BIPA Staffing Posting Requirement, dated 7/24/23 and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of the facility, in cooperation with Medicare/Medicaid Services, (CMS), to comply with the requirement of daily posting of nursing staff in the facility

Based on record review, observation and interview, the facility failed to prevent a resident admitted with a red area receive appropriate interventions to prevent the development of stage 2 pressure areas for 1 of 5 residents reviewed for pressure areas. (Resident 92) Findings include: A clinical record review was completed on 9/27/18 at 8:20 A.M., indicating Resident 92's current [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 8/19/18, indicated Resident 92's BIMS (Brief Interview for Mental Status) score was 15, cognitively intact. He required extensive assist of 1 staff for bed mobility, transfers, limited assist of 1 staff for walking, dressing, and toilet use and supervision for eating. He was occasionally incontinent of bladder and bowels and the resident had one or more unhealed pressure ulcer at Stage 1 or higher. An admission assessment, dated 8/12/18, indicated Resident 92 was admitted with a red area on his coccyx which was covered with [MEDICATION NAME]. A wound assessment, dated 8/15/18, indicated new in house pressure area to coccyx stage II 1 x 0.4 x 0.2 cm (centimeter). Current treatments listed were: Medahoney with [MEDICATION NAME] to cover, ROHO cushion to recliner, pressure mattress, and proheal. A current 8/12/18, care plan problem indicated the resident was admitted with a wound that was potentially related to pressure, vascular insufficiency, diabetic [MEDICAL CONDITION], severe burns. Interventions included, but were not limited to: administer treatment as ordered, follow interventions listed on Potential for skin breakdown problem, monitor for complaints of pain or discomfort and notify responsible party and MD with any s/s of complications or need to alter treatment. A current 8/15/18, care plan problem indicated Resident 92 had developed actual pressure injury. Location: coccyx. related to: Exposure of skin to urinary and fecal incontinence, Impaired/decreased mobility and decreased functional ability, under nutrition, malnutrition and hydration deficits. Intervention included, but were not limited to: float heels off bed, follow interventions listed on Potential for skin breakdown problem, monitor for pain and administer pain medications as ordered, monitor meal intakes on the food acceptance records, Nurse to measure/assess weekly & notify family & physician as needed, administer treatment (product specific) as ordered: Medahoney/[MEDICATION NAME] and provide with pressure reducing device to chair: ROHO cushion. A current physician order, dated 8/15/18, indicated the treatment for [REDACTED]. Apply Medahoney, cover with [MEDICATION NAME] border to pressure injury on coccyx, change every 3 days and PRN if removed or soiled. The (MONTH) treatment record indicated the treatment was not completed on 9/20/18 and 9/23/18. During an observation on 9/27/18 at 11:55 A.M., Registered Nurse 5 with gloved hands removed a dressing from Resident 92's left outer leg. R.N. 5 then cleaned a pair of scissors with an alcohol pad and placed the scissors on a paper package on the table. R.N. 5 lifted Resident 92's left leg and on the posterior of the left calf was a brown area, measuring 0.9 x 0.6 x unknown depth with a hard brown substance covering the wound bed. R.N. 5 lifted Resident 92's right leg and on the posterior of the right calf was an area measuring 2 x 1.2 x unknown depth, due to a hard brown substance covering the wound bed. During an observation, on 9/27/18 at 12:05 P.M., Licensed Practical Nurse (LPN) 4 removed an adhesive dressing to Resident 92 coccyx. LPN 4 indicated the resident had a stage II open area measuring 0.1 x 01 x 0.1 to his right inner buttocks cheek. A new open area to the left inner buttocks was observed measuring .3 x .3x 0.1. LPN 4 indicated it was a stage II. A care plan dated 8/12/18, indicated Resident 92 had [MEDICAL CONDITION] to his lower extremities. Interventions included, but were not limited to: assist to elevate legs, observe [MEDICAL CONDITION] and notify MD as needed. During room observations, on 9/24/18 at 12:41 P.M, 9/25/18 at 2:34 P.M., 9/27/18 at 11:55 A.M., and 9/28/18 at 10:41 A.M. Resident 92 was sitting in his recliner with his legs resting on the foot rest. During an interview, on 9/28/18 at 10:41 A.M., Resident 92 indicated the staff had not been placing a pillow under his legs. A policy was requested on 9/28/18 for pressure prevention, but none was provided. 3.1-40(a)(2)