Every finding on record at Westminster Village Muncie Inc

Based on observation, interview, and record review, the facility failed to ensure food was served in a method to prevent possible cross contamination and/or foodborne illness for 56 of 56 residents who ate meals served in the skilled unit facility kitchen. Findings include: During a lunch meal service, on 5/6/26 from 11:35 a.m. to 11:40 a.m., the following food service concerns were observed:Cook 5 was wearing disposable gloves. Using her gloved hands, she touched resident meal tickets, clean dishes, scoops, tongs, sweat potato fries, and a sandwich. She repeated this process touching meal tickets, the outside of the bread bag, fries, sandwich wraps, and plate rims. She left the steam table area, and using the same soiled gloves, she took a hot dog out of bag and placed it on an electric griddle. She returned to the food service line, and using her soiled gloved hands, touched meal tickets, plates, sweet potato fries, and wrap sandwiches. She then went over to the grill, and with the same soiled gloves, touched the wrapper on a bag of hot dog buns, removed the bun from the bag, and picked up the dog off of the grill using her gloved fingertips. She placed the hot dog in the palm of her soiled gloved hand and carried it from the grill area to the steam table service area. She used her soiled gloved hands and placed the hot dog on the plate. She continued to touch meal tickets, sweet potato fries, and wrap sandwiches. She continued this method for the service of nine meal trays. She removed her soiled gloves. During an interview, on 5/6/26 at 11:40 a.m., [NAME] 5 indicated printed meal tickets were taken in packets to the units, where staff carried the forms to residents and helped them complete their food orders. The paper forms were handled by both staff and residents before arriving back in the kitchen. She had not considered that touching unclean items, such as meal tickets and bread bag wrappers, contaminated her gloves and she would need to change her gloves before touching food. During an interview on 5/7/26 at 2:27 p.m., the DON indicated all of the 56 residents who lived in the skilled healthcare area of the facility ate food prepared in the facility kitchen.A current, undated, facility policy titled Bare Hand Contact with food and Use of Plastic Gloves, provided via email by the Chief Financial Officer on 5/6/26 at 1:15 p.m., indicated: Plastic gloves will be worn when food handling food directly with hands to ensure that bacteria are not transferred from the food handler's hands to the food product being served.3. Gloved hands are considered a food contact surface that can get contaminated or solid. If used, single use gloves shall be used for only one task.6. Remember gloves are just like hands. They get soiled.must be changes.During food preparation as often as necessary to remove soil and contaminated to prevent cross contamination when changing tasks.410 IAC (Indiana Administrative Code) 16.2-3.1 -21(i)(1)

A. Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) and utilize proper hand hygiene during suprapubic catheter (urinary catheter inserted into the bladder via the abdomen) care for 1 of 2 residents reviewed for urinary catheters. (Resident 17)B. Based on observation and interview, the facility failed to properly handle medications utilizing infection prevention and control measures during medication administration for 2 of 4 residents reviewed for medication administration. (Resident 37 and Resident 40)Findings include:A1. During an observation, on 5/6/26 at 11:38 a.m., Resident 17 was in his bed. The urinary catheter drainage bag and tubing were directly against the floor. An EBP sign was hung on the right side of the doorway above the canister of personal protective equipment. The sign indicated everyone must clean their hands before entering and when leaving the room. Providers and staff must wear gloves and a gown for high-contact care activities such as urinary catheter device care or use. Resident 17's clinical record was reviewed on 5/7/26 at 3:33 p.m. Diagnoses included obstructive uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and Alzheimer's disease.Current orders included enhanced barrier precautions related to suprapubic catheter every shift (9/20/25), Suprapubic catheter size 14 French 10 cc (12/22/25), and cleanse suprapubic catheter site with soap and water then apply a thin layer of bacitracin (antibiotic ointment) around the tube site for redness once a day (3/19/26).A 3/29/26, annual, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. Resident 17 required substantial assistance from staff for toileting hygiene, toileting transfers, and walking. The resident had an indwelling urinary catheter. Skin interventions included application of ointments/medications. Resident 17's current care plans included the following:A current care plan, last reviewed on 3/31/26, indicated the resident required a suprapubic catheter related to obstructive uropathy, urethral stricture, and urinary retention. Interventions included nursing staff to provide catheter care as ordered each shift, and as needed (5/29/25), and utilize principles of infection control and universal/standard precautions (5/29/25).A 6/11/25 problem of enhanced barrier precautions related to his suprapubic catheter. Interventions included proper hand hygiene (6/11/25) and catheter care every shift (6/11/25). A progress note, dated 3/23/26 at 9:52 p.m., indicated the resident continued an antibiotic related to the resident's catheter site. The resident's catheter site continued to have brown drainage. During a catheter care observation, on 5/11/26 from 10:52 a.m. to 11:03 a.m., Resident 17's room had an EBP sign to the right of the resident's door. LPN 7 entered the resident's room with catheter care supplies, moved the resident's overbed table, and placed the supplies directly on top of the resident's personal papers on his overbed table. Previously opened cleansing wipes were retrieved from the resident's bathroom counter and placed on the overbed table. LPN 7 opened the lid of the wipes, donned gloves, and used both gloved hands to pull the resident's blankets and brief down below the suprapubic catheter cite. She removed the old dressing, which was soiled with purulent and blood-tinged drainage. The catheter insertion site contained purulent drainage and redness surrounding the catheter tubing. With the same gloves, she opened clean gauze and wiped away the drainage at the insertion site with her right hand. While holding the package of wipes with her left hand, she removed wipes with her right hand and performed supra pubic catheter care with the wipes in her right hand. Another wipe was pulled out with her right hand and used to cleanse the catheter tubing. A split gauze package was opened with the same gloves and placed around the catheter insertion site. LPN 7 doffed her gloves, opened the door, pulled keys out of her pocket, unlocked the medication door, and moved items around in the medication cabinet. Without hand hygiene, she re-entered the resident's room, donned clean gloves, and placed tape on the resident's split gauze around the catheter insertion site. LPN 7 placed the wipes back into the resident's bathroom, doffed her gloves, exited the room, pulled keys out of her pocket, and unlocked the [NAME] Court Unit medication cart. She used the keyboard and mouse to log into her computer and moved items around on her medication cart without hand hygiene. A gown was not worn at any time during the catheter care observation. Hand hygiene was not performed throughout the observation. During an interview on 5/11/25 at 11:03 a.m., LPN 7 indicated Resident 17 required enhanced barrier precautions. She should have worn a gown during the suprapubic catheter care to prevent cross contamination and infections. The resident's suprapubic catheter insertion site was reddened and contained purulent blood-tinged drainage. On 5/12/26 at 11:53 a.m., the DON indicated staff were required to follow enhanced barrier precautions for suprapubic catheter care. A lack of proper hand hygiene and following infection control practices placed the residents at risk for infection. A current facility policy, dated 1/25/26, titled Subrapubic [sic] Catheter Care, provided by the Administrator on 5/12/26 at 12:21 p.m., indicated the following: 1. Wash your hands thoroughly before handling the catheter and/or site. 2. Clean the catheter insertion site daily with mild soap and water.A current facility policy, dated 1/25/26, titled Hand Hygiene, provided by the Administrator on 5/12/26 at 12:21 p.m., indicated the following: Policy All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. A current facility policy, dated 1/25/26, titled Enhanced Barrier Precautions, provided by the Chief Financial Officer on 5/12/26 at 12:37 p.m., indicated the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.B1. During a random medication administration observation on 5/11/26 at 9:28 a.m., LPN 7 prepared Resident 37's medications for administration. The medications included: amiodarone hydrochloride (heart rhythm)100 mg tablet, biotin (supplement) 1000 mcg tablet, buspirone hydrochloride (anxiety) 5 mg 0.5 tablet, cholecalciferol (vitamin D3) 25 mcg tablet, dorzolamide-timolol (glaucoma) 22.3 - 6.8 mg/ml ophthalmic one drop to each eye, apixaban (blood thinner) 5 mg tablet, levothyroxine sodium (thyroid) 88 mcg tablet, prednisone (steroid) 5 mg tablet, and Viactiv (calcium supplement) 650 mg-12.5 mcg chewable tablet.On 5/11/26 at 9:42 a.m., LPN 7 took Resident 37's medications into her room and placed the medication cup on the overbed table. The medication cup spilled over, and two white pills spilled out onto the floor. LPN 7 used her right gloved hand, picked up the pills, placed the contaminated pills back into the resident's pill cup, and handed the cup to the resident. LPN 7 did not offer or attempt to replace the contaminated medications. Resident 37 took all the pills in the cup. B2. During a random medication administration observation on 5/11/26 at 9:56 a.m., LPN 7 prepared Resident 40's medications for administration. The medications included: aspirin 81 mg tablet, carvedilol (blood pressure/heart rate) 3.125 mg tablet, CoQ-10 (supplement) 100 mg two capsules, cyanocobalamin (vitamin B)1000 mcg capsule, fish oil (supplement) 1000 mg capsule, escitalopram (depression) 10 mg tablet, losartan potassium (blood pressure) 50 mg tablet, and pantoprazole (acid reflux) 40 mg delayed release tablet. On 5/11/26 at 10:06 a.m., LPN 7 handed Resident 40 his medications in a cup, in the hallway outside of the dining room. The resident poured the pills into his hand, dropping one pill on his wheelchair seat and one pill on the floor. LPN 7 picked up a pill from the resident's wheelchair and a pill from the floor with her right bare hand and placed them back into Resident 40's hand with the other medications. LPN 7 did not offer or attempt to replace the contaminated medications. Resident 40 took all the pills. During an interview, on 5/11/26 at 10:11 a.m., LPN 7 indicated she should not have administered the contaminated medications. The contaminated medications should have been identified and replaced. On 5/12/26 at 11:49 a.m., the DON indicated medications touched with bare hands, dropped on the floor, or contaminated in any way, should have been destroyed. They should not have been administered to any residents.A current facility policy, dated 1/25/26, titled Medication Administration, provided by the Administrator on 5/12/26 at 10:24 a.m., indicated the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .14. Remove medication from source, taking care not to touch medication with bare hand. If a medication is dropped refer to medication destruction policy.410 IAC (Indiana Administrative Code) 16.2-3.1-18(l)410 IAC (Indiana Administrative Code) 16.2-3.1-18(a)

Based on record review and interview, the facility failed to have a system in place to respond to and promptly resolve resident council concerns. Finding includes: Review of the facility's Resident Council Minutes, on 6/16/25 at 9:36 a.m., included the following Resident Council concerns: On 4/17/25 at 10:30 am., six residents attended the resident council meeting. A concern in the minutes under dietary indicated the hot foods not. The Resident Council Action Form was left blank. The form had areas for the reported concern, date the form was due back to resident council, staff response and action plan, and staff signature and title. On 5/15/25 at 11:00 a.m., seven residents attended the resident council meeting. The Old Business section was left blank. A concern under dietary indicated some residents reported the food was cold sometimes. The minutes lacked a Resident Council Action Form. During an interview on 6/16/25 at 10:03 a.m., Life Enrichment Director 12 indicated she did not have additional follow-up/action information to provide regarding the concerns brought to her attention during Resident Council meetings. She typically took minutes during the meetings and handled any concerns brought up verbally with the different departments. The facility did not have a record of those interactions. She did not know how one would know when/if a concern was addressed or resolved for response to the resident group. During a resident group interview on 6/16/25 at 11:06 a.m., two of two residents in attendance indicated they were uncertain if anyone responded to the resident council concerns discussed during the monthly meetings. On 6/16/25 at 11:30 a.m., Life Enrichment Director 12 indicated she had taken the minutes in the resident council meetings for April and May 2025. In both April and May 2025, the Resident Council group had reported concerns with foods being cool, rather than hot, when it was served. She was unable to provide information or follow up on the concerns to show what had been done to correct the resident group concerns for April and May 2025. Life Enrichment Director 12 indicated she should have completed the Resident Council Action Form for each concern and followed up with the Resident Council group. On 6/16/25 at 2:36 p.m., Dietary Aide 14 indicated dietary management staff typically informed them if there were concerns regarding the food temperatures. She was unaware of any food temperature complaints for several months. She was unaware of any new processes put into place to ensure the resident's food was delivered warm. On 6/16/25 at 2:51 p.m., the Food Services Director denied knowledge of food temperature concerns brought to his attention from the Resident Council meeting concerns. He received information regarding a concern about the food being cold from management staff during a care plan meeting on 6/11/25. On 6/16/25 at 3:14 p.m., Administrator 1 indicated the Resident Council Action Form was not completed in April 2025 and May 2025 when food temperature concerns were reported in the Resident Council minutes. She was unable to provide additional information. On 6/16/25 at 3:17 p.m., Life Enrichment Director 15 indicated responses to the Resident Council group concerns should have been documented on the Resident Council Action Form. Without the Resident Council Action Forms for follow-up, one would not know if the concerns had been addressed. Further information was not provided. A current facility policy, revised on 5/14/25, titled Resident Council Meetings, provided by the facility on 6/16/25 at 1:31 p.m., indicated the following: Policy: This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council . Policy Explanation and Compliance Guidelines: . 6. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council 3.1-3(l)

Based on record review and interview, the facility failed to provide bed hold policy and transfer/discharge notifications to the resident/representative for 2 of 2 residents reviewed for hospitalizations. (Residents 1 & 17) Findings include: 1. Resident 1's clinical record was reviewed on 6/17/25 at 11:41 a.m. Diagnoses included acute on chronic diastolic (congestive) heart failure, hypertensive heart disease with heart failure, and hypertension. A 4/6/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 5/31/25, discharge, MDS assessment indicated the resident discharged with a return anticipated. A 5/31/25, progress note indicated the resident complained of pain in the right upper and lower quadrant of her chest, right side of her back, and under her right shoulder. The pain was getting worse and the resident requested to be sent to the emergency room. The ambulance arrived and all parties were notified. The clinical record lacked indication of whether a transfer/discharge form and the bed hold policy were provided to the resident or their representative. 2. Resident 17's clinical record was reviewed on 6/16/25 at 11:16 a.m. Diagnoses included primary hemiplegia and hemiparesis following a cerebral infarction, hypertension, and oropharyngeal dysphagia. A 5/18/25, quarterly, MDS assessment indicated the resident was severely cognitively impaired. A 4/16/25, progress note indicated the resident had fallen and suffered a forehead laceration. The nurse practitioner recommended the resident be sent to the emergency room. 911 was called and a verbal report of the situation was given. The resident Power of Attorney (POA) was notified. The clinical record lacked indication of whether a transfer/discharge form and the bed hold policy were provided to the resident or their representative. During an interview, on 6/17/25 at 3:05 p.m., LPN 16 indicated she utilized a transfer/discharge checklist to ensure she did not miss any steps when discharging a resident. Once an order for the discharge was obtained, she called for transportation or 911 and gave a verbal report to the hospital. The resident's family would be notified. She printed out the resident's code status, diagnoses, orders, medications, and other documents related to the discharge or transfer. These papers would be given to the emergency medical technicians (EMT) as the left with the resident. She would fill in the transfer event in the electronic medical record (EMAR) and document in a progress note. On 6/17/25 at 3:32 p.m., RN 9 indicated when a resident required a transfer or discharge to the hospital her first step was to contact the doctor and obtain an order to send the resident to the emergency room. She called 911 or transportation and would call to give verbal report to the hospital. She notified the resident's family and printed out resident information for the EMTs. She printed the resident's face sheet, code status, diagnoses, medications, progress notes, and any other documents related to the resident's discharge. She gave the papers to the ambulance drivers or EMTs. She would document this information in a progress note in the resident's medical record. On 6/18/25 at 10:16 a.m., the DON indicated the staff were required to call report to the receiving facility, complete the transfer/discharge form, fill out a bed hold form, print the resident's face sheet and orders, and the staff should have included in the clinical record information regarding who the information and copies of the above documents were given to. This information had not been done for Resident 1's discharge on [DATE] and Resident 17's discharge on [DATE]. She was unable to find transfer/discharge notifications or bed hold notifications for either of the above mentioned residents. A current facility policy, dated 5/15/25 and titled, Bed Hold Notice, provided by the DON on 6/18/25 at 10:16 a.m., indicated the following: . 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or resident representative written information that specifies: a. The duration of the State bed-hold policy, of any, during which the resident is permitted to return and resume residence in the nursing facility . 2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed hold policies to the resident and/or resident representative within 24 hours . A current facility policy, dated 5/15/25, titled, Transfer and Discharge (including AMA), provided by the DON on 6/18/25 at 10:16 a.m., indicated the following: .3. The facility's transfer/discharge notice will be provided to the resident and resident's representatives in a language and manner in which they can understand . 10. Emergency Transfers to Acute Care . d. The original copies of the transfer or discharge form and advance directives will accompany the resident. Copies will be retained in the medical record . g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated . 3.1-12(a)(6)(A)(i)

Based on interview and record review, the facility failed to ensure staff competency regarding narcotic administration and reconciliation for 2 of 3 residents reviewed for narcotic use. The deficiency had potential to impact 11 residents who received narcotic pain medication from the unit medication cart. (Resident 5 and Resident 263) Findings include: During a medication storage observation with LPN 6 on 6/13/25 at 12:58 p.m., the 50s hallway narcotic log indicated Resident 5 received as needed (PRN) doses of tramadol (a narcotic pain medication) on the following dates: 6/4/25 at 10:00 p.m. 6/5/25 at 9:00 p.m. 6/12/25 at 8:30 p.m., and signed by RN 7 6/6/25 at 8:00 p.m. 6/7/25 at 7:00 p.m. 6/8/25 at 7:12 p.m. 6/9/25 at 8:00 p.m. 6/10/25 at 7:30 p.m. 6/11/25 at 6:30 p.m. 6/12/25 at 8:30 p.m. and signed by RN 8 Resident 263 received PRN doses of oxycodone (narcotic pain medication) at the following dates and times: 5/28/25 at 9:44 p.m., 6/7/25 at 8:53 p.m., 6/9/25 at 12:30 a.m., and signed out by RN 8 and on 6/5/25 at 10:34 p.m., signed out by RN 7. Resident 5's clinical record was reviewed on 6/16/25 at 8:32 a.m. Diagnoses included, infection of internal joint prosthesis and left above knee amputation. Current physician orders included tramadol 50 milligram (mg) tablet, give one tablet for pain as needed (12/27/24). The electronic medication administration record (EMAR) indicated she received PRN doses of tramadol on 6/1/25 at 11:30 p.m., 6/2/25 at 11:02 p.m., and 6/5/25 at 9:44 p.m. The EMAR lacked documentation of administration and follow-up for doses given on 6/4, 6/6, 6/7, 6/8,6/9, 6/10, 6/11, or 6/12/25. Resident 263's record was reviewed on 6/16/25 at 8:31 a.m. Diagnoses included, right humerus (upper arm bone) fracture, type two diabetes, and hypertension (high blood pressure). Current physician orders included oxycodone (pain medication) 5 mg capsule orally every 6 hours as needed for pain greater than seven on a zero to ten scale (5/23/25). The EMAR indicated the resident received PRN doses of oxycodone on the following dates and times: 5/28/25 at 11:07 a.m. 5/29/25 at 6:42 a.m. and 7:08 p.m. 5/30/25 at 11:06 p.m. 5/31/25 at 11:28 p.m. 6/2/25 at 1:52 a.m. 6/4/25 at 11:10 p.m. 6/5/25 at 10:58 a.m., 6/6/25 at 7:55 a.m. and 8:25 p.m. 6/8/25 at 4:03 a.m., 10:12 a.m., and 4:56 p.m. 6/9/25 at 5:59 a.m. 6/10/25 at 10:35 a.m. 6/11/25 at 10:03 a.m. 6/12/25 at 6:42 a.m. and 8:18 p.m. 6/13/25 at 1:53 a.m. and 4:40 p.m. 6/14/25 at 3:40 a.m. and 6:03 p.m. 6/15/25 at 4:08 a.m. 6/16/25 at 5:35 a.m. The EMAR lacked documentation of administration and follow-up for doses given 5/28/25 at 9:44 p.m., 6/5/25 at 10:34 p.m. , 6/7/25 at 8:53 p.m. and 8:53 p.m., and 6/9/25 at 12:30 a.m. During an interview with RN 9 on 6/16/25 at 1:56 p.m., she indicated when narcotic pain medication was requested by a resident, the medication was signed out in the narcotic log book, given to the resident, then charted in the MAR. She indicated that it would never be appropriate to document in only the MAR or the log book. During an interview with the DON on 6/16/25 at 2:03 p.m., she indicated staff should have documented the narcotic administration in both the MAR and the narcotic log book. During an interview with RN 7 on 6/16/25 at 6:44 p.m., he indicated when a resident requested pain medication he got a pain rating from the resident, performed the 5 rights of medication administration, counted the narcotics, signed them on the narcotic sheet, then checked the medication off on the MAR. He was unable to provide reasoning for the discrepancies. During an interview with RN 8 on 6/17/25 at 2:28 p.m., she indicated when a resident requested pain medication, she looked to see which narcotic was available, signed it out on the narcotic log book, administered the medication, and documented it in the MAR. She noted she was not the best at documenting in both the narcotic log book and the MAR due to time constraints and there was not a place in the MAR to document a late administration or to amend administration time. During an interview with the DON on 6/17/25 at 2:35 p.m., she indicated unit managers audited the narcotic count sheets on a monthly basis. A current facility policy titled, Medication Administration, provided by the DON on 6/17/25 at 9:36 a.m. included the following: .20. Sign MAR after administered. 21. If medication is a controlled substance, sign narcotic book . A current facility policy titled, Controlled Substance Administration & Accountability, provided by the DON on 6/17/25 at 1:02 PM included the following: .The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure .ii.All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form.iii. All specially compounded or non stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy. G. In all cases, the doses noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record(MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy. j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances

Based on observation, interview, and record review, the facility failed to ensure shift to shift narcotic reconciliations were completed to account for controlled medications for 2 of 5 medication carts reviewed for medication storage. ([NAME] Court Unit and Bristol Court Unit) This deficient practice had the potential to affect 21 out of 57 residents who resided in the facility and received controlled medications from [NAME] Court Unit and Bristol Court Unit medication carts. Findings include: 1. During a medication storage observation, accompanied by RN 10 on 6/13/25 at 11:40 a.m., the Narcotic Count Log for [NAME] Court Unit medication cart was reviewed and lacked a count or off-going staff signature when RN 10 took over the cart at the beginning of his shift at 6:00 a.m. on 6/13/25. During an interview on 6/13/25 at 11:51 a.m., RN 10 indicated a shift to shift count had not been completed at the beginning of his shift because the off-going nurse left before the count was completed. Counts and signatures of both staff members were required at each exchange of the cart. The Narcotic Count Log for May and June 2025 had multiple dates lacking counts and signatures for the [NAME] Court medication cart. During a controlled medication reconciliation of [NAME] Court medication cart, RN 10 indicated there were two controlled medications in the narcotic drawer that did not have a Controlled Substances Record sheet in the narcotic binder which included: Resident 42's unopened 15 milliliter (ml) bottle of morphine sulfate (opiate pain medication) 20 mg/5 ml and Resident 20's tramadol (opiate pain medication) 50 milligrams (mg) with one tablet left in the card. The morphine had been pulled from the emergency drug kit, on the previous shift, for a resident that recently admitted to hospice. A Controlled Substance Record sheet for the morphine had not been started nor placed in the binder to show the amount of remaining medication for the shift to shift medication reconciliation. Since he had not done a shift to shift reconciliation of the controlled medications at the exchange of the cart, he had not identified the missing Controlled Substance Record sheets nor notified anyone of the discrepancies. This was an opportunity for potential drug diversion. Review of the Narcotic Count Log records for [NAME] Court Unit medication cart, from 5/21/25 through 6/6/25, lacked shift to shift reconciliation of controlled substances for 37 out of 50 opportunities. Resident 42's clinical record was reviewed on 6/17/25 at 11:03 a.m. Diagnoses included Parkinson's disease and anxiety. Current orders included morphine solution 20 mg/5 ml- administer 0.25 ml by mouth every two hours as needed for pain, shortness of breath, or air hunger. A 4/13/25, quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. Resident 20's clinical record was reviewed on 6/17/25 at 11:16 a.m. Diagnoses included osteoarthritis and spinal stenosis. Current orders included tramadol 50 mg by mouth every six hours as needed for pain. 11/13/24 A 4/20/25, quarterly MDS assessment, indicated the resident was severely cognitively impaired. 2. During a medication storage observation of the Bristol 1 cart, accompanied by LPN 5, on 6/13/25 at 12:44 p.m., the Narcotic Count Log was reviewed and was missing the beginning card count and ending card count numbers for 6/8/25. LPN 5 indicated the narcotic sign in sheet was completed at the beginning and end of each shift. The nurse on the cart filled in the columns showing if any medication cards had been added or removed from the cart during their shift. Then the oncoming nurse and the offgoing nurse counted the narcotic cards in the narcotic box and signed the count log to show it was completed. Review of the Bristol 1 cart Narcotic Count Log records from 5/21/25 through 6/8/15, lacked shift to shift reconciliation of controlled substances for 4 out of 45 opportunities. During an interview, on 6/16/25 at 2:06 p.m. LPN 16 indicated the narcotic sign in sheet was to be completed at the beginning and ending of each shift. The outgoing nurse and the oncoming nurse count the narcotics on the cart and sign the log to show the count was correct and completed. During an interview on 6/16/25 at 4:33 p.m., the DON indicated both staff were required to complete shift to shift controlled medication reconciliation with each exchange of the medication cart. During the reconciliations, both staff members were required to count the Controlled Substances Record sheets and the medications for identification of discrepancies. A facility policy, dated 6/16/25, titled, Controlled Substance Administration & Accountability, provided by the DON on 6/18/25 at 10:16 a.m., indicated the following: . f. All controlled substances (Schedule II, III, IV, V) are accounted in one of the following ways . iii. All narcotic are to be counted by the nurse's/QMA's with a change of hands of narcotic cart keys. ALL narcotic counts are to be recorded on the narcotic count log. The nurse's/QMA's are to also count a total number of all narcotic medications (cards, bottles, bags of patches, narcan, and refrigerated items) with ever narcotic count. iv. All specially compounded or non stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplies with the medication or other designated form per facility policy . j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify: .ii. Medications removed from either the automated dispensing system or medication cart/cabinet have a documented physician order . 3.1-25(b)(3)

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) during catheter care for 1 of 3 residents reviewed for EBP. (Resident 255) Finding includes: During an observation on 6/11/25 at 3:49 PM, EBP signage was observed to the left of resident 255's door and indicated the following: Stop. Enhanced barrier precautions. Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. During a catheter care observation on 6/17/25 at 1:17 PM, LPN 5 performed hand hygiene and donned gloves, but not a gown prior to entry into Resident 255's room. She knocked on the door, announced herself, and explained the procedure to the resident. LPN 5 prepared wet and dry wash cloths, then pulled the resident's blankets down and wiped his penis and the catheter tubing with a wet washcloth. A new dry washcloth was used to dry the aforementioned areas. She then removed her gloves, performed HHG, and exited the room. During an interview, immediately following the observation, LPN 5 indicated she had not worn a gown while performing catheter care. She indicated gowns and gloves should be worn when performing high contact resident care procedures, but she forgot to don a gown. Resident 255's record was reviewed on 6/13/25 at 11:58 AM. Current diagnoses included hypertension (high blood pressure), type two diabetes mellitus, unspecified dementia, and stage three chronic kidney disease. Current physician orders included the following: EBP for indwelling catheter twice a day (6/4/25), catheter care every shift (5/30/25), and change catheter bag monthly (5/30/25). A current facility policy titled, Enhanced Barrier Precautions, and provided by the DON on 6/16/25 at 2:33 p.m. indicated the following: .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .4. High-contact resident care activities include: f. Changing briefs or assisting with toileting. G. Device care or use: central lines, urinary catheters, 3.1-18(l)

Based on observation and interview, the facility failed to ensure the name and contact information for the State Long Term Care Ombudsman was posted and readily available for the resident and visitors. This deficiency had the potential to affect 57 of 57 residents in the facility. Finding includes: During an observation on 6/16/25 at 12:18 p.m., a tour of the skilled areas of the facility was completed. The State Ombudsman information was not posted and readily available for residents and visitors. During an observation of the nursing home units of the facility, on 6/16/25 at 1:24 p.m., accompanied by the DON and Administrator 2, Administrator 2 indicated the State Ombudsman contact information was not located and should have been posted for the residents' access. During an interview on 6/17/25 at 10:28 a.m., Administrator 2 indicated the facility did not have a policy regarding posting of resident advocacy numbers. They followed the Indiana Department of Health guidelines regarding posting of advocacy numbers. 3.1-4(j)(3)

Based on observation, interview, and record review, the facility failed to provide safe and secure storage of medications for 17 of 17 residents on the Bristol Unit and to label a multi-use medication vial with an open date for 1 of 4 residents reviewed for medication storage. (Resident 14) During an observation on 5/22/24 at 2:31 p.m., a medication cart was unattended and unlocked in a common area of the unit. At 2:34 p.m., RN 5 approached the cart and confirmed the cart was unlocked. RN 5 indicated it should be locked and contained medications for the residents on the unit only. During a medication administration observation for Resident 14, on 5/23/24 at 9:58 a.m., QMA 6 indicated an open vial of prescription eye drops, Latanoprost 0.005% solution (for glaucoma), did not have an open date on it, but should be dated. She was unsure which types of prescription eyedrops were supposed to be dated upon opening. A current facility policy titled LTC Facility's Pharmacy Services and Procedures Manual, revised on 7/21/22, was provided by the Health Operations Administrator on 5/28/24 at 12:01 p.m. The manual, under General Storage Procedures - 3.3, indicated the following: .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The same policy, under the heading Ophthalmic Solutions Storage Parameters, indicated the following: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow manufacturer instructions, or facility policy. (e.g., Latanoprost - 42 days) 3.1-25(k)(6) 3.1-25(m)

Based on record review and interview, the facility failed to implement the facility's pneumococcal vaccines policy utilizing the Centers for Disease Control and Prevention (CDC) guidelines and failed to offer appropriate pneumococcal vaccinations for 1 of 5 residents reviewed for vaccinations. (Resident 49) Findings include: The clinical record for Resident 49 was reviewed on 5/22/24 at 2:39 p.m. Diagnosis included hypertensive heart disease with heart failure, unspecified chronic atrial fibrillation, and type 2 diabetes mellitus. Resident 49 was over [AGE] years of age. Resident 49's current vaccination record indicated she received the Pneumococcal Conjugate vaccine (PCV) 13 on 3/18/15 and the Pneumococcal Polysaccharide vaccine (PPSV) 23 on 5/22/18. The clinical record lacked indication of any other offered pneumococcal vaccinations. During an interview, on 5/28/24 at 10:10 a.m., RN 3 indicated she only utilized the Children and Hoosiers Immunization Registry Program (CHIRP) for all new residents. The CHIRP website contained the recorded vaccinations of residents and at the top of the document was a section to forecast upcoming and/or missed vaccinations. She indicated she was not aware Resident 49 was to have been offered the PCV 20 vaccine according to CDC guidance. Review of the current online CDC Pneumococcal vaccination guidelines, retrieved from www.cdc.gov/vaccines/vpd/pneumo/index.html on 5/29/24 at 11:56 a.m., indicated the following: . Adults [AGE] years or older have the option to get PCV 20 if they have already received PCV 13 (but not PCV 15 or PCV 20) at any age AND PPSV 23 at or after the age of [AGE] years old . A facility policy, provided by the Health Operations Administrator on 5/28/24 at 12:02 p.m., titled Pneumococcal Vaccine (Series) and implemented on 11/6/23, indicated the following: Policy: It is our policy to offer residents and staff immunizations against pneumococcal disease in accordance with the current CDC guidelines and recommendations 6. The type of pneumococcal vaccine (PCV 15, PCV 20, or PPSV 23) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations 3.1-13(a)

Based on observation, interview and record review, the facility failed to ensure employees were trained in and knowledgeable of the facility elopement policy and protocol, resulting in a cognitively impaired resident being unsupervised outdoors for 17 minutes (QMA 16). Findings include: Resident B's clinical record was reviewed on 3/5/24 at 10:23 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Her physician orders included check placement of the wanderguard to her left ankle twice daily and check motion sensor for placement by her door and to make sure it was on and worked properly. An admission Minimum Data Set (MDS) assessment, dated 1/10/24, indicated she was severely cognitively impaired. She had a current care plan for psychosocial well-being, as she had the potential to exhibit wandering and exit seeking behaviors (1/12/24). Her interventions included document in the progress notes the intensity, duration or frequency of behavior, complete a behavior event when she wandered/exit sought (1/12/24), provide redirection or distraction to minimize frequency of behavior, identify pattern of behavior and behavior triggers (1/12/24), wanderguard in place and staff to check for placement each shift (1/12/24), and when she began to wander, provide comfort measures for basic needs (pain, hunger, toileting, too hot/cold, etc.) (1/12/24). A nurses note, dated 2/17/24 at 6:45 p.m., indicated at 6:11 p.m., the door 6 alarm on the Bristol Unit sounded at the same time the wanderguard system alerted at the nurses station. Per QMA 16, she saw the door 6 alarm alerting and switched it off. The alert light was still on, but the sound was turned off. She saw Resident B's name on the monitor of the wanderguard system. She went to Resident B's room and did not see her in there, then she went to the Bristol Unit's entrance and looked down the halls for Resident B. She asked the nurse on the [NAME] Unit if she had seen Resident B and was told no. The Unit Manager met QMA 16 in the hallway by the health center dining room and asked her about Resident B and what had happened. QMA 16 told her that she said she had heard the alarm but was not able to locate Resident B. The Unit Manager told her that Resident B was outside, but was inside now, and she was walking back with staff to the Bristol unit. From 6:20 p.m. to 6:23 p.m., a facility nurse was driving in front of the building and saw a person that could had possibly been a resident walking on the east side of the building by the Coopervista side doors. As he drove up closer to the building, he saw the resident fall to her knees in the snow. He was able to help her to her feet and assist her inside the Coopervista doors. At 6:28 p.m. the [NAME] Unit wanderguard alarm sounded as staff walked Resident B back to the Bristol Unit. Fifteen minute checks and one on one observations for Resident B were started at 6:45 p.m. There was a 17-minute difference between the door 6 alarm sounding and her being assisted back to the Bristol Unit. During an interview with QMA 16, on 3/5/24 at 2:21 p.m., she indicated prior to the elopement, she assisted Resident B to the bathroom and gave her medications. Resident B sat on her bed playing with a babydoll. The QMA heard a noise and went to another resident's room. She then heard an alarm going off and went to the wanderguard system monitor and saw Resident B's name across the monitor screen. She went to the [NAME] Unit, and they had not seen Resident B. She headed towards the Coopervista Unit, but didn't go all the way to the unit because she didn't think she could had gotten that far. She went back to the Bristol Unit and the alarm was still going off and still indicated Resident B's name. She headed back towards Coopervista Unit, and she met the Unit Manager in the hallway. The Unit Manager told her to go back to the Bristol Unit. QMA 16 didn't know the exit doors opened. She thought that was why the keypad was located on the wall at the exit doors. She had not really been educated on what to do when there was an elopement or who to call. Resident B was an exit seeker, and they kept her with staff, in the lounge, or occupied with activities. She was the only staff on the unit due to shift change and waiting for a CNA to come from another unit. During an observation of door 6, accompanied by the Bristol Unit Manager on 3/5/24 at 3:28 p.m., she had a wanderguard unit in her hand. As she approached the door, the keypad on the wall to the left of the door began to make a chirping sound and the small red light flashed. She opened door 6 and an alarm began to sound. At the back corner of the nurses station, there was a monitor for the wanderguard system with a map of the Bristol Unit on the screen. The wanderguard system was making a chiming sound and the door alarm was sounding, and she silenced the door alarm. The wanderguard monitor screen had a red dot on it where the wanderguard alarm was triggered and at the top of the screen showed the name of whom the wanderguard belonged to. During an interview with CNA 21, on 3/6/24 at 9:14 a.m., she indicated if a resident's wanderguard was alarming, she would go find and see where the resident was or where the alarm was going off at. She wouldn't know who was eloping, but she could find if any residents were going off the unit. She pointed towards the wanderguard monitor, but looked at the other CNA that was present during the interview for guidance. The other CNA then explained how the wanderguard system worked. During an interview with Housekeeper 18, on 3/6/24 at 1:51 p.m., she indicated she didn't know what to do if a resident eloped and she would need to ask her supervisor. At 2:20 p.m., she indicated she would alert the nurse and the front desk. During a review of the video footage (without audio) from the camera located at the Bristol Unit nurses station, on 3/6/24 at 2:25 p.m., with the Maintenance Director, the DON and Administrator 2 present, the Maintenance Director indicated the times to the video footage were not the same as the video footage from the Coopervista camera due to being on different Digital Video Recorders (DVRs). At 6:24 p.m., Resident B walked into the camera view from the vicinity of her room, passed the nurses station, and walked to the hall with door 6. At 6:25 p.m., QMA 16 walked from a medication cart located beyond the nurses station (opposite the hall of Resident B's room), towards Resident B's room and then to the nurses station. She walked towards the back corner of the nurses station where the wanderguard monitor system and the door alarm panel were located. (The wanderguard monitor and the door alarm panel were out of the camera view.) She walked out of the nurses station and towards Resident B's room. At 6:28 p.m., QMA 16 walked back into the nurses station to the back corner and back out of the nurses station towards Resident B's room. At 6:32 p.m., QMA 16 came into the camera view and walked towards the exit door 3, located in the lounge area across from the nurses station, then walked towards the nurses station and then to her cart at 6:33 p.m. At 6:35 p.m., QMA 16 walked towards the nurses station then towards exit door 5, then exit door 4 (located beyond her medication cart, at the end of the hallway). At 6:36 p.m., QMA 16 walked into the nurses station towards the back corner, then walked towards the hall where resident eloped from. At 6:37 p.m., RN 7 walked into the camera view, and QMA 16 came back into the camera view and walked in the direction of Resident B's room. At 6:38 p.m. QMA 16 walked towards her cart, and RN 7 walked in the direction of the hall from where Resident B eloped from. During an interview, after reviewing the video footage with Administrator 2 and the DON, with the Maintenance Director present, on 3/6/24 at 2:50 p.m., the DON indicated QMA 16 acknowledged Resident B was missing and Administrator 2 indicated QMA 16 knew what she was doing, but there was opportunity for education. During an interview with RN 7, on 3/6/24 at 3:06 p.m., she indicated she was alerted by the door alarm on Coopervista Unit where she was working. A family member opened the door for both the Resident B and the nurse who had found her outside back into the building. RN 7 took the wanderguard off Resident B to test it to make sure it was working properly. She checked it at the doors of the [NAME] Unit, then she went to the Bristol Unit. As she went onto the Bristol Unit, she was unable to find staff. The wanderguard system alarm and the door alarm were sounding simultaneously. She was not sure what door she exited from, because the Velcro stop signs to the exit doors were in place. In her opinion, QMA 16 didn't know the difference between the sounds of the door alarm and the wanderguard system alarm. QMA 16 was the only one on the Bristol Unit at the time of the incident, the CNA had already left, and the CNA from the Coopervista Unit was to replace the Bristol Unit CNA. Normally, the CNA was to wait until their replacement arrived on the unit before they were to leave. A current facility policy, titled ELOPEMENT/MISSING RESIDENT POLICY AND PROCEDURE PROGRAM FOR SKILLED FACILTY, dated 10/1/13, and provided by the DON, on 3/5/24 at 2:19 p.m., indicated the following: .IN THE EVENT OF A MISSSING RESIDENT .1. With occurrence of a Missing Resident/Elopement a call will be placed to the Front Desk to initiate an all call FREE BIRD over the intercom. 2. All areas/rooms checked will have a Yellow Door Tag placed to verify that area is cleared .3. An organized facility and grounds search will be initiated by all available staff including Maintenance and Security. The Front Desk and Administrator will be notified This citation relates to complaint IN00428793. 3.1-14(i)

Based on observation, interview, and record review, the facility failed to ensure residents, who were at risk for falls, had interventions in place in accordance with their care plan for 4 of 8 residents reviewed for fall prevention. (Residents 16, 38, 41 & 42 ) Findings include: 1. Resident 16's clinical record was reviewed on 2/7/23 at 1:05 p.m. Current diagnoses included dementia, hypertension, depression and chronic obstructive pulmonary disease. The resident had a current,8/12/22, physician's orders for a bed pad alarm, a low bed,a single blue mat on the floor beside the bed, and wheel chair anti- tippers. A current, 12/31/22, care plan problem indicated the resident was at risk for falls. Interventions included, chair alarm & bed pad alarm in place, check proper placement and functioning (attempt to place alarm boxes out of resident reach so she does not take them apart 3/17), and anti-tippers on wheelchair. A 1/22/23,quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, used a wheelchair for mobility, could only stabilize her balance with the support of another person, and used a bed alarm daily. A 1/20/23 fall risk assessment indicated the resident was at risk for falls. Factors contributing to the identified risk included, intermittent confusion, poor recall, and poor safety awareness. During the following observations, the resident did not have fall prevention devices in place: On 2/6/23 at 9:48 a.m., the resident was in the lounge, seated in her wheel chair. The wheel chair did not have anti-tippers in place. On 2/7/23 at 9:16 a.m., the resident was seated in a wheelchair in the lounge, The wheelchair lacked anti-tippers. On 2/8/23 at 2:22 p.m., the resident was in her room seated in a personal recliner. No alarm was in place on the recliner. On 2/8/23 at 11:43 a.m., the resident was in the lounge, seated at a table in her wheelchair. The chair did not have anti-tippers. On 2/9/23 at 9:59 a.m., the resident was seated in her room in a personal recliner. There was no alarm in place. A clip alarm was observed attached to the empty wheelchair. During an observation and interview, with the Assistant Director of Nursing (ADON) and the Health Operations Administrator on 2/8/23 at 2:29 p.m., the ADON indicated the resident did not have a personal alarm on while she was sitting in her personal recliner. During an interview, on 2/08/23 at 2:36 p.m., the ADON indicated the resident did have current 8/12/22 orders for both bed and chair alarms. Additionally, care plans and orders should match. The facility would need to review care plans and orders and seek clarification. During an interview, on 2/8/22 at 2:38 p.m., the Health Operations Administrator indicated the resident's wheelchair had just been observed and was lacking anti-tipper devices, in conflict with her orders and care plan. 2. Resident 38's clinical record was reviewed on 2/7/23 at 1:09 p.m. Current diagnoses included Alzheimer's disease, hypertension, and atrial fibrillation. The resident had a current, 5/24/22, order for a low bed, bed pad alarm, and pull tab alarm while in the bed or chair. A current, 3/1/22, care plan problem indicated the resident was at risk for falls. Interventions included pressure pad alarm in bed, clip alarm on bed and chair, and bed in the lowest position. A 1/08/23, quarterly, MDS assessment indicated the resident was moderately cognitively impaired, used a wheelchair for mobility, could only stabilize her balance with the support of another person, and used a bed and chair alarm daily. An 11/14/22 fall risk assessment indicated the resident was at risk for falls. Factors contributing to the identified risk included, intermittent confusion, poor recall, and poor safety awareness During the following observations, the resident did not have fall prevention devices in place: On 2/8/23 at 2:19 p.m., the resident was in a recliner chair in the lounge. There was no alarm clipped to the resident in the recliner. An alarm was attached to the resident's wheelchair, which was a few feet away from the resident. During an observation and interview, on 2/8/23 at 2:25 p.m., the ADON indicated the resident did not have an alarm attached while in the recliner in the lounge. An alarm should have been moved from his wheelchair and placed on the recliner. During an interview, on 2/8/23 at 2:39 p.m., the ADON indicated the resident had an order for an alarm to be applied while he was in a chair. 3. Resident 41's clinical record was reviewed on 2/07/23 at 1:11 p.m. Current diagnoses included a history of traumatic hemorrhage of cerebrum, a history of fracture of neck, and dementia. A current, 3/27/22, care plan problem indicated the resident was at risk for falls. Interventions included a low bed, double blue mats to the floor beside the bed, and clip alarm to the bed and chair. A 12/11/22, annual, MDS assessment indicated the resident was severely cognitively impaired, used a wheelchair for mobility, could only stabilize her balance with the support of another person, and used a bed and chair alarm daily. A, 12/22/22, fall risk assessment indicated the resident was at risk for falls. Factors contributing to the identified risk included, intermittent confusion, poor recall, and poor safety awareness. During the following observations, the resident did not have fall prevention devices in place: On 2/7/23 at 1:37 p.m., the resident was in bed in his room. There was no mat of any kind on the floor by the bed. On 2/7/23 at 2:22 p.m., the resident was in bed in his room. There was no mat on the floor. On 2/8/23 at 2:21 p.m., the resident was in bed. There was no mat on the floor and no alarm present on the bed. During an observation and interview, on 2/08/23 at 2:27 p.m., the ADON indicated there was no mat or alarm in place while the resident was in bed. The ADON indicated the care plan should reflect the resident's current needs. During an interview, on 2/08/23 at 2:40 p.m., the ADON indicated the alarm and mat had been discontinued on 1/25/23. The care plan should indicate the current safety devices needed by the resident. 4. Resident 42's clinical record was reviewed on 2/7/23 at 1:06 p.m. Current diagnoses included dementia, chronic kidney disease, hemiplegia, and hypertension. The resident had a current, 9/2/22, order for a high-backed wheelchair with a left half-lap tray and a pummel cushion to assist with positioning and comfort related to hemiplegia. A current, 5/1/22, care plan problem indicated the resident was at risk for falls. Interventions included use appropriate assistance device and level of assistance as recommended: high back wheelchair, pummel cushion in chair, and two assist for transfers. A 10/30/22, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, used a wheelchair for mobility, and could only stabilize her balance with the support of another person. An 11/14/22 fall risk assessment indicated the resident was at risk for falls. Factors contributing to the identified risk included, intermittent confusion, poor recall, and poor safety awareness. During the following observations, the resident did not have fall prevention devices in place: On 2/6/23 at 9:47 a.m., the resident was in the lounge in a wheelchair. The wheelchair did not have a lap tray or pummel cushion. On 2/7/23 at 9:15 a.m., the resident was in the lounge in a wheelchair. It did not have a lap tray or pummel cushion. On 2/8/23 at 9:20 a.m., the resident was in the lounge in a wheelchair. It did not have a lap tray or pummel cushion. On 2/8/23 at 10:05 a.m., the resident was in the activity room in a wheelchair. It did not have a lap tray or pummel cushion. During an observation and interview, on 2/8/23 at 2:42 p.m., the ADON indicated the resident was using a chair without a half lap tray or a pummel cushion. During an interview, on 2/9/23 at 9:45 a.m., the ADON indicated the resident had therapy and hospice services, and should have had orders and a care plan for a modified low Broda chair. The current care plan and orders were incorrect. A current, 11/19/22, facility policy titled Fall Prevention Program, provided by the Health Operations Administrator on 2/10/23 at 11:35 a.m., indicated the following: .b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors . d. Provide additional interventions as directed by the resident's assessment, including but not limited to: .i. Assistive devices .v. Low bed . 8.b. The plan of care will be revised as needed 3.1-45(a)

Based on record review and interview, the facility failed to complete a baseline care plan for 1 of 1 residents reviewed for accidents. (Resident 13) Findings include: The clinical record for Resident 13 was reviewed on 2/8/23 at 10:14 a.m. Diagnoses included, but were not limited to, history of falling, osteoarthritis, and major depressive disorder. The resident admitted to the facility on [DATE] from an acute care hospital. An admission Minimum Data Set (MDS) assessment, dated 1/12/23, indicated the resident had moderate cognitive impairment, was not steady, and only able to stabilize herself with assistance from staff when moving from seated to standing and during transfer, and required extensive assist of two staff for transfer and toileting. The resident had fallen in the last month, prior to her admission to the facility. The clinical record lacked a baseline health care plan. A comprehensive care plan was completed on 1/12/23 at 1:09 p.m. On 1/11/23, the resident had a fall from her recliner. During an interview, on 2/10/23 at 8:58 a.m., the Unit Manager indicated the baseline care plan was not created in a timely manner, and staff were to develop the baseline care plan on admission. A current facility policy, dated 11/19/21, titled, Baseline Care Plan, provided for the Assistant Director of Nursing on 2/10/23 at 3:32 p.m., indicated the following: .Policy: The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. be developed within 48 hours of resident's admission 3.1-30(a)

Based on record review and interview, the facility failed to obtain daily weights per physician's order for 2 of 3 resident reviewed for edema (Residents 15 and 52), and failed to notify the physician of weight gain per physician's ordered parameters for 3 of 3 resident's reviewed for edema. (Residents 15, 52 and 157) Findings include: 1. Resident 15's clinical record was reviewed on 2/9/23 at 11:06 a.m. Diagnoses included, but were not limited to, congestive heart failure (CHF) and diabetes mellitus. An admission minimum data set (MDS) assessment, dated 1/10/23, indicated the resident was cognitively intact, had no verbal or physical behaviors and no rejection of care. A baseline health care plan, dated 1/3/23, included a condition of CHF with a goal including no edema and an intervention of daily weights. A current physician's order, dated 1/4/23, indicated the resident was to be weighed daily for 30 days and to notify the physician of a gain of two pounds in 24 hours or four pounds in a week due to a diagnoses of CHF. A review of the resident's clinical records for weights, for January and February of 2023, indicated the following: a. The record lacked weights for 1/2/23, 1/4/23, 1/6/23, and 1/9/23. b. The record indicated a 5.2 pound weight gain for the week of 1/3/23 to 1/10/23 and lacked physician notification. c. The record indicated a 5.8 pound weight gain for the week of 1/5/23 to 1/12/23 and lacked physician notification. d. The record indicated a 2.8 pound weight gain on 2/4/23 in one day and lacked physician notification. During an interview, on 2/10/23 at 10:53 a.m., the Unit Manager indicated the physician had not been notified of resident's weight gain, per physician's order. 2. Resident 52's clinical record was reviewed on 2/9/23 at 9:01 a.m. Diagnoses included, but were not limited to, pulmonary edema, CHF, and presence of a implanted cardiac defibrillator. An admission MDS assessment, dated 1/8/23, indicated the resident had moderate cognitive impairment, had no verbal or physical behaviors, and no rejection of care. A health care plan, dated 1/29/23, indicated the resident was at risk for cardiac dysfunction, and included an intervention to obtain weights as ordered, and to notify the physician of significant changes. A current physician's order, dated 1/29/23, indicated the resident was to be weighed daily for 30 days and to notify the physician of a gain of two pounds in 24 hours or four pounds in a week. A review of the resident's clinical records for weights for February 2023, indicated the following: a. The record lacked weights on 1/4/23 and 1/6/23. b. The record indicated a 5.2 pound weight gain for the week of 1/3/23 to 1/20/23 and lacked physician notification. During an interview, on 2/10/23 at 10:28 a.m., the Assistant Director of Nursing (ADON) indicated the physician should have been notified of the weight gain on 1/10/23 per physician's order. 3. Resident 157's clinical record was reviewed on 2/07/23 at 2:08 p.m. Diagnosis included, but were not limited to, diabetes mellitus, atrial fibrillation, and stage three chronic kidney disease. An admission MDS assessment, dated 2/5/23, indicated the resident was cognitively intact, had no verbal or physical behaviors, and no rejection of care. A health care plan, dated 1/29/23, included resident was a risk for cardiac dysfunction, and included an intervention to obtain weights as ordered and to notify the physician of significant changes. A current physician's order, dated 1/29/23, indicated the resident was to be weighed daily for 30 days and to notify the physician of a gain of two pounds in 24 hours or four pounds in a week. A review of the resident's clinical records for weights, for February of 2023, indicated a 2.8 pound gain on 2/4/23 in one day. During an interview, on 2/10/23 at 10:57 a.m., the Unit Manager indicated the physician had not been notified regarding the resident's weight gain per physician order. A current facility policy, dated 11/19/22, titled, Following Medication-Physician Orders/Vital Sign Parameters, and provided by the ADON on 2/10/23 at 1:21 p.m., indicated the following: .Procedures: .R. Notification of Physician/Prescriber .2 abnormal test results, vital signs 3.1-37(a)

Based on interview and record review, the facility failed to develop a care plan for hospice care for 1 of 3 residents reviewed for hospice care. (Resident 51) Findings include: The clinical record for Resident 51 was reviewed on 1/28/22 at 9:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change Minimum Data Set (MDS) assessment, dated 12/29/21, indicated he had a life expectancy of less than six months. The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's clinical record lacked a care plan for hospice services. During an interview on 1/28/22 at 3:45 p.m., the Director of Nursing (DON) indicated the resident's clinical record lacked a care plan for hospice services. No further information was provided prior to exit. 3.1-35(b)(1)

Based on record review and interview, the facility failed to maintain hospice documentation of provider visits for 2 of 3 residents reviewed for hospice care. (Residents 13 and 51) Findings include: 1. The clinical record for Resident 13 was reviewed on 1/28/22 at 10:18 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident's clinical record lacked documentation related to hospice care for June 2020 through present. 2. The clinical record for Resident 51 was reviewed on 1/28/22 at 9:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's clinical record lacked documentation related to hospice care for December 29, 2021 through present. During an interview on 1/28/22 at 3:45 p.m., the Director of Nursing (DON) indicated the hospice binders lacked required documentation of hospice provider notes of visits with the residents. No further information was provided prior to exit. 3.1-37(b)

Based on observation, interview and record review, the facility failed to prevent developement of a pressure ulcer for a cognitively impaired resident for 1 of 4 residents reviewed for pressure ulcers (Resident 11). Findings include: During an observation on 1/24/21 at 12:00 p.m., Resident 11 was seated in his recliner with his foot rest up. During an interview at the time of observation on 1/25/22 at 2:23 p.m., Resident 11 was seated in his recliner with his foot rest up and indicated he had a blister on his heel and his dressing was changed every day on his left heel. Resident 11's clinical record was reviewed on 1/28/22 at 8:23 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 11/5/21, indicated Resident 11 had a risk for pressure ulcers with no pressure ulcers on admission. Skin interventions lacked any pressure relieving devices. Resident had mild cognitive impairment and had not exhibited behaviors of rejection of care. The resident required extensive assistance of two staff members for bed mobility, dressing, transfers, and personal hygiene. Review of the pressure ulcer risk assessment, provided by RN 3 on 1/28/22 at 11:40 a.m., indicated the resident was at mild risk for pressure ulcers. Orders included, but were not limited to the following: a. Heels/inflatable bunny boots while in bed for wound healing, dated 11/16/21. b. ROHO (pressure relieving) cushion, dated 12/3/21. c. Cleanse wound to left heel daily with Vashe (wound solution), pat dry, apply skin prep to peri wound, apply Santyl (wound debridement ointment) to wound base, apply saline moist gauze, dry gauze, and wrap with Kerlix, dated 1/10/22. d. Alternating air mattress to bed for pressure relief, dated 12/3/21. The clinical record lacked indication there was a pressure relieving measures prior to the development of Resident 11's left heel pressure ulcer. Weekly skin assessments included, but were not limited to the following: a. A skin assessment, dated 11/1/21, indicated bilateral heels were intact. b. A skin assessment, dated 11/10/21, indicated an open blister had developed on the left heel. c. A skin assessment, dated 11/15/21, indicated resident had a Stage II pressure ulcer on his left heel. d. A skin assessment, dated 11/22/21, indicated an unstageable pressure ulcer was on the left heel with necrotic (black) tissue. It measured 2.3 centimeters in length by 2.5 centimeters in width, and no depth. e. A skin assessment, dated 11/29/21, indicated an unstageable deep tissue injury pressure ulcer was on the left heel with necrotic tissue. The measurements were unchanged. f. A skin assessment, dated 12/27/21, indicated an unstageable deep tissue injury pressure ulcer was on the left heel with necrotic tissue. It measured 2 centimeters in length by 2.3 centimeters in width, and no depth. g. A skin assessment, dated 1/17/22, indicated an unstageable deep tissue injury was on the left heel and black tissue started to fall off. It measured 2 centimeters in length by 2.5 centimeters in width, and 0.1 centimeters in depth. A Skin Integrity care plan, dated 11/9/21, indicated Resident 11 was at risk for further skin breakdown related to functional decline, weakness related to a left hip fracture with repair, required assistance with activities of daily living, and pain. Interventions included, but were not limited to, monitor skin regularly for alteration. A Skin Integrity care plan: Presence of Skin Breakdown, dated 11/9/21, indicated Resident 11 had a wound to his foot. Interventions included, but were not limited to, assist with turning and positioning regularly. An Activities of Daily Living care plan, dated 11/9/21, indicated the resident required assistance with activities of daily living related to weakness and functional decline secondary to a left hip fracture repair and pain. Interventions included, but were not limited to, assist with all activities of daily living to the extent required. A Cognitive Deficit care plan, dated 11/9/21, indicated the resident had moderate cognitive deficits evidenced by short term memory problems with intermittent confusion and forgetfulness, and required assistance with activities of daily living. Interventions included, but were not limited to, assist with activities of daily living as required. A Nurse's Note, dated 10/30/21 at 3:12 a.m., indicated the resident was admitted for a left hip fracture and required excessive assistance of two staff members for activities of daily living. A Nurse's Note, dated 11/3/21 at 11:56 p.m., indicated the resident required extensive assistance of two staff members for transfers, toileting, dressing, and bed mobility. During an interview on 1/28/22 at 10:54 a.m., Registered Nurse (RN) 4 indicated she was familiar with Resident 11's left heel pressure ulcer which had plateaued. She indicated the dressing was changed to Santyl and the edges of the eschar began to loosen. During an interview at the time of a wound observation with RN 4, on 1/28/22 at 11:02 a.m., RN 4 indicated the left heel pressure ulcer was unstageable as evidenced by the necrotic tissue on the left heel. The size of the left heel pressure ulcer was consistent with the weekly skin assessment. During an interview on 1/28/22 at 11:22 a.m., RN 4 indicated Resident 11 was at risk for skin breakdown. She indicated the pressure ulcer to the left heel developed as a result of weakness following the left hip fracture. Additionally, she indicated the resident always wanted to wear his old shoes prior to the development and did not want to remove them. During an interview on 1/28/22 at 11:32 a.m., RN 3 indicated Resident 11's left heel pressure ulcer was facility acquired and all of the skin pressure relief interventions were initiated after the left heel pressure ulcer developed on 11/15/21. She indicated since the resident was a mild risk for pressure ulcers, they would not typically have pressure ulcer prevention interventions in place. RN 3 indicated Resident 11 required assistance from staff for activities of daily living. During an interview on 1/28/22 at 2:04 p.m., RN 4 indicated Resident 11 required assistance from staff to put on his socks and shoes. During an interview on 1/28/22 at 3:31 p.m., the Director of Nursing (DON) was requested to provide skin pressure relief documentation prior to the development of Resident 11's left heel pressure ulcer and documentation regarding family education about the condition of the resident's shoes. No further documentation was provided. A current policy, titled SKIN INTEGRITY POLICY AND PROCEDURE PROGRAM FOR SKILLED FACILITY, provided by the DON on 1/28/22 at 2:53 p.m., indicated the following: POLICY: It is the policy of Westminster Village to uphold the standard of providing quality care to the residents we serve A preventative approach will be taken in order to promote the safety and wellbeing of each resident. The interdisciplinary team will promote communication and monitor outcomes of the program. PURPOSE: 1. Identify residents at risk for skin related concerns 3. Initiate preventative approaches 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by not implementing transmission-based precautions (TBP) for residents requiring aerosol generating procedures (AGP) per CDC and IDOH guidance for 3 of 5 residents reviewed for TBP (Residents 12, 36, 28). Findings include: During a tour of the facility, on 9/10/21 at 10:02 a.m., one room in the facility had signage to indicate TBP were in place. During an interview, on 9/10/21 at 10:15 a.m., RN 5 indicated there were residents in the facility who required AGP. There were no TBP in place while the resident's received these procedures, and all of the rooms except one was considered green (no TBP required). a. Review of Resident 12's clinical record was completed on 9/10/21 at 1:15 p.m. She had current orders for, but not limited to, use of a [CONDITION(S)] (apnea machine) at night. b. Review of Resident 36's clinical record was completed on 9/10/21 at 1:30 p.m. She had current orders for, but not limited to, [MEDICATION(S)]/[MEDICATION(S)] (bronchodilators) three times daily per nebulizer. c. Review of Resident 28's clinical record was completed on 9/10/21 at 1:40 p.m. He had current orders for, but not limited to, use of a [CONDITION(S)] at night. Review of the IDOH document titled Long-term Care Facilities Guidelines in Response to COVID-19 Vaccination, dated 8/6/21 and published in the 8/13/21 Long Term Care Newsletter, indicated the following: .For unvaccinated residents or AGP on anyone during moderate or high community positivity; > 5% or if facility is in outbreak testing: CDC guidance for aerosol-generating procedures should be followed for infection control measures for the duration of the AGP and one (1) hour after the procedure in positive pressure rooms. Resident is placed on transmission-based precautions: both contact and droplet precautions for the duration of the procedure and 1 hour post procedure. This includes N-95 mask, eye protection, gown and gloves and keeping the door closed throughout the procedure and one hour after, and disinfecting all surfaces following the procedure Review of the CDC COVID Data Tracker, obtained at covid.cdc.gov, indicated the county positivity rate for Delaware County, Indiana was 15% on 9/10/21. 3.1-18(b)(2)

Based on observation, record review and interview the facility failed to cohort residents who were COVID-19 positive together away from negative residents, failed to place signage to indicate when a COVID-19 positive zone was entered, failed to have dedicated staff for the COVID-19 positive residents and failed to follow CDC guidelines for Transition Based Precautions (TBP) isolation for 5 of 5 residents reviewed for admission or readmission to the facility after an inpatient hospital stay. (Residents B, C, D, E and F) Findings include: 1. The clinical record for Resident B was reviewed on 10/20/2020 at 12:23 p.m. [DIAGNOSES REDACTED]. Last admitted was 10/9/2020. The resident was not placed in 14 day isolation upon admission. Review of the clinical record indicated the resident tested positive for COVID-19 on 10/15/2020 after exposure with a COVID-19 positive individual. A nursing progress note dated, 10/15/2020 at 2:30 p.m., indicated the resident had been given a second test for COVID-19 with positive results. The resident's room was then set up for isolation in place -room [ROOM NUMBER]. 2. The clinical record for Resident C was reviewed on 10/20/2020 at 12:38 p.m. [DIAGNOSES REDACTED]. Last admitted was 10/8/2020. The resident was not place in 14 day isolation upon admission. A progress note dated, 10/8/2020 at 1:53 p.m., indicated the resident was admitted from the hospital to room [ROOM NUMBER]. A progress noted, dated 10/15/2020 at 5:00 p.m., indicated the resident was tested for COVID-19, as a precaution, due to a positive case being discovered on unit. A progress note, dated 10/16/2020 at 11:43 a.m., indicated the resident was re-tested for COVID-19. Isolation continued. A progress note, dated 10/16/2020 at 1:49 p.m., indicated the resident was transitioned to room [ROOM NUMBER]. 3. The clinical record for Resident D was reviewed on 10/20/2020 at 12:44 p.m. [DIAGNOSES REDACTED]. Last admitted was 9/10/2020. A progress note, dated 9/10/2020 at 5:40 p.m., indicated the resident was admitted to room [ROOM NUMBER]. A progress note dated, 10/14/2020 at 6:00 p.m., indicated the resident had audible wheezing, shortness of breath and rhonchi in the bilateral lower lobes. A late entry progress note, dated 10/16/2020 at 11:15 a.m. for 10/15/2020, indicated the resident was given a rapid test for COVID-19 with negative results. A progress note, dated 10/19/2020 at 12:48 p.m., indicated a rapid test for COVID-19 was administered with negative results. A progress note, dated 10/20/2020 at 4:31 a.m., indicated the resident had a temperature of 99.1 and a congested productive cough. The physician was notified and a chest x-ray was ordered. A progress note, dated 10/20/2020 at 11:15 a.m., indicated a rapid COVID-19 test had been administered with positive results. The resident was placed in isolation. 4. The clinical record for Resident E was reviewed on 10/20/2020 at 1:00 p.m. [DIAGNOSES REDACTED]. Review of the clinical record indicated the was admitted to room [ROOM NUMBER] on 10/2/2020. The resident was not placed in 14 day isolation for monitoring. The resident tested positive for COVID-19 on 10/19/2020. The resident was relocated to the red zone on 10/20/2020. 5. The clinical record for Resident F was reviewed on 10/20/2020 at 1:05 p.m. [DIAGNOSES REDACTED]. Review of the clinical record indicated the resident was admitted from the hospital to room [ROOM NUMBER] on 8/21/2020. The resident tested positive for COVID-19 on 10/19/2020 and isolated in place. During an observation on 10/20/2020 at 1:37 p.m., the double doors leading to the Cooper Vista unit indicated visitation had been restricted until further notice. The sign was dated 10/15/2020. Upon entering the unit, no signage was posted indicating the area had confirmed COVID-19 positive residents or suspected COVID-19 residents present. During an interview on 10/20/2020 at 1:38 p.m., RN1 indicated the facility had isolated the COVID-19 resident in place due to having private rooms. She indicated no specific dedicated staff had been assigned to the COVID-19 positive residents. She indicated no new admissions were being admitted to the facility, only re-admissions and they were not placed in isolation for 14 days or put in a specific zone for monitoring. She indicated the unit was currently in the process of moving residents to establish a red zone. During an interview on 10/20/2020 at 11:50 a.m., the Director of Nursing and the Executive Director indicated contact tracing lead to a staff member who tested positive on 10/15/2020. This staff member had a family member who was a resident that also tested positive. The DON indicated the residents who tested positive were not moved and a red zone had not been established because the residents were in private rooms and isolated in place. The DON indicated no dedicated staff were assigned to the care of the COVID-19 positive residents. Five COVID-19 negative residents were moved off the red zone during the survey. COVID-19 LTC Facility Infection Control Guidance Standard Operating Procedure( last updated 10/20/2020) was retrieved on 10/21/2020 from the Centers of Disease Control and Prevention (CDC) website indicated the following: .· Cohort confirmed or presumed COVID-19 positive residents. · Cohort, if possible, direct care providers caring for confirmed or presumed COVID-19 residents into one area of the building. Staff should be dedicated for the COVID unit. . Unknown COVID-19 status (Yellow): All residents in this category warrant transmission based precautions (droplet and contact.) HCP will wear single gown per resident, glove, N95 mask and eye protection (face shield/or goggles). Gowns and gloves should be changed after every resident encounter with hand hygiene performed. . Waiting for test results - These are residents whose COVID-19 status is unknown. This can include residents who have been tested and are waiting on results, or residents who are admitted , or readmitted , to a facility where they are likely to have been exposed to COVID-19 (e.g., transferred from a facility with an outbreak). Residents in this category should, if possible, be isolated from residents with a known COVID-19 status (both positive and negative). Residents in this category are to remain in TBP for full 14 days. Preparing for COIVD-19 in Nursing Homes (June 25, 2020) was retrieved on 10/21/2020 from the Centers of Disease Control and Prevention (CDC) webside indicated the following: . Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. 3.1-18(b)(2)

Based on interview and record review, the facility failed to provide restorative services for 2 of 2 residents reviewed for restorative nursing care (Residents 20 and 23). Findings include: 1. The clinical record for Resident 20 was reviewed on 4/24/19 at 10:41 a.m. His [DIAGNOSES REDACTED]. During an interview on 4/22/19 at 2:47 p.m., the resident's daughter indicated he was supposed to be on restorative care, but that the two restorative staff had often been pulled away to work elsewhere in the facility. The resident had been bicycling in the therapy room at least four times a week, but that had also dropped off. The resident's care plan for Activity of Daily Living (ADL) Functional/Rehabilitation Potential, effective 3/9/18 through 6/30/19, indicated the resident was at risk for functional decline related to a history of a [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke), and a left above-the-knee (AKA) amputation. Interventions included, but were not limited to, restorative exercise as recommended per therapy and nursing. During an interview with Physical Therapist (PT) on 4/29/19 at 9:37 a.m., she indicated Resident 23 had been receiving restorative care since (YEAR). The PT indicated the therapists developed residents' restorative plans and the restorative nurse then worked to schedule the residents therapy. The facility had not been doing restorative nursing because there was not enough staff and while some residents didn't need full therapy, they needed at least minimal activity in order to maintain their abilities. The PT's restorative plan for Resident 23 was reviewed on 4/29/19 at 9:41 a.m. The plan's goal was to maintain the resident's current functioning. Recommendations included, but were not limited to, bilateral active range of motion exercises, bicycling, and ambulating with his prosthesis. During an interview on 4/25/19 at 9:44 a.m., LPN/MDS 1 indicated Resident 23 was scheduled 5 times a week for his restorative program, but did not receive it 5 times per week because the facility did not have a restorative aide. The aide often got pulled to the unit floor to work. The facility did have two restorative aides, but currently had only one. 2. The clinical record for Resident 23 was reviewed on 4/25/19 at 11:23 a.m. Her [DIAGNOSES REDACTED]. During an interview on 4/26/19 at 10:04 a.m., the resident indicated she loved to ride the bike in therapy but didn't get to do it every day. If the therapy nurse had time, she would come to get the resident but, they've been really busy around here. A review of the resident's ADL Functional/Rehabilitation Potential care plan, dated 8/27/18 through 5/19/19, included, but was not limited to,the intervention restorative exercise as recommended per nursing and therapy. During an interview on 4/29/19 at 9:38 a.m., the PT indicated Resident 23 was planned for a restorative program two to three days per week. The goal for her restorative program was to maintain current functioning and bilateral upper extremity strength. Recommendations included bilateral active range of motion, ambulation, and completion of 10 feet on arm bicycle. During an interview on 4/25/19 at 11:52 a.m., LPN/MDS 1 indicated residents on hospice care were still on restorative care and we just see how they do. If we saw she was unable, we wouldn't continue. She does refuse restorative care at times. LPN/MDS 1 indicated Resident 23 was planned for four days a week of restorative care, but over the past two weeks, she had restorative one time and refused one time. LPN/MDS 1 further indicated the restorative program was not staffed well, and there was only one restorative aide currently. The DON indicated during an interview on 4/29/19 at 10:33 a.m., the facility had to pull restorative aides to the floor in order to provide essential care. One restorative aide transferred out of restorative, and that had been a problem. The facility's Restorative Nursing Program policy was provided by the DON on 4/30/19 at 9:38 a.m., which indicated, .9. Restorative aides will implement the plan for a designated period of time, performing the activities . 3.1-38(a)(1)

Based on, interview, and record review, the facility failed to provide Peripherally Inserted Central Catheter (PICC) care for 1 of 3 residents reviewed for PICC line care. (Resident B) This deficient practice resulted in the resident being hospitalized with septic shock and Coagulase-negative staphylococcus (bacteria that causes infection) cultures growing in both the resident's blood and the PICC line catheter tip. Findings include: The clinical record for Resident B was reviewed on 4/24/18 at 10:23 a.m. The resident [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment, dated 3/23/18, indicated the resident was cognitively intact, required extensive assistance for transfers, bed mobility, dressing and hygiene. Review of the hospital PICC line insertion procedure report indicated the line was placed on 2/23/18. The resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. She had a current care plan titled, Invasive lines which indicated the resident had a PICC line for antibiotics administration with the potential for infection. Interventions included, but were not limited to, assess site every shift, flush PICC as ordered and administer medications as ordered. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].by intravenous route 2 times per day Review of the nurses notes indicated the following: 3/16/18 at 4:37 p.m., .PICC Line to Left upper arm 3/17/18 at 5:47 p.m., .PICC in her LEFT arm 3/19/18 at 3:22 p.m., .PICC line in upper LEFT 3/21/18 at 11:26 a.m., .Resident has PICC line in place at left upper arm. Completed antibiotics last night 3/2318 at 11:15 a.m., .Resident has PICC 3/31/18 at 11:05 a.m., .PICC PATENT 4/10/18 at 10:28 a.m., .Resident requested .Nausea pill, provided at 9:30 am, approx. 9:50 am residents husband came to get this nurse & stated that resident had vomited black liquid, upon inspection noted approx. 120cc'c (sic) of black liquid noted. Also noted that [MEDICAL CONDITION] bag contained black liquid .send resident to ER Review of the (MONTH) and (MONTH) Treatment Administration Record (TAR), the documentation lacked any treatment orders for dressing changes, measuring external catheter length or arm circumference measurements. The clinical record lacked assessments and indication of dressing change for the resident. The hospital records for Resident B were reviewed on 4/24/18 at 3:45 p.m. An emergency department note, dated 4/10/18 at 12:39 p.m., indicated Upon arrival to ER this RN noticed that the pt's (patients) PICC, in the upper left arm, the bio disc (a foam disc with antiseptic, antimicrobial and antifungal properties) under the pt's dressing is extremely soiled. It is apparent that the disc has been soiled for a while. Dried blood present under dressing. Bio disc is soiled all the way through and was stiff on removal Family is unable to report when the last time it was changed An admission note, dated 4/10/18, indicated .Impression and Plan .[MEDICAL CONDITION]: with leukocytosis, lactic acidosis and [MEDICAL CONDITION], potential sources included catheter related bacteremia (had PICC in place for few week), left [MEDICAL CONDITION] with hydro [DIAGNOSES REDACTED] and abdominal wall abscess A final microbiology report, dated 4/14/18, indicated the blood sample for culture from the catheter tip grew Coagulase-negative staphylococcus (bacteria that causes infection). A final microbiology report, dated 4/16/18, indicated the resident's blood sample contained Coagulase-negative staphylococcus. A critical care staff note, dated 4/24/18, indicated medications included, but were not limited to, [MEDICATION NAME] (antibiotic) 1 gram every 24 hours, start 4/13/18. Resident B had a central venous catheter place in her left jugular on 4/11/18. The Impression and Plan, indicated 1. Septic shock: Resolved. Potential sources include catheter related bacteremia (CONS (Coagulase-negative staphylococci) from cath tip), During an interview with the Director of Nursing (DON), Administrator, Assistant Director of Nursing (ADON) and Unit Manager 2 on 4/24/18 at 2:24 p.m., Unit Manager 2 indicated there was no order to change the dressing on the PICC line from admission to discharge. She indicated the pharmacy sent two dressing change kits and they returned one, which would indicate the dressing was changed one time, but it was not documented. On 4/24/18 at 5:03 p.m., the DON indicated she had received several staff statements related to the PICC line, but no staff person indicated they had changed the dressing during her admission. She had not heard back from all the staff involved in her care. Review of a current policy, titled Midline Catheter Dressing Change, dated 1/15/04 and revised 7/1/12 was provided by the ADON on 4/24/18 at 1:01 p.m., indicated the following: .Guidance: 1. Sterile dressing change using transparent dressing is performed: 1.1 24 hours post-insertion or upon admission 1.2 At least weekly 1.3 If the integrity of the dressing has been compromised (wet, loose or soiled) .7. Length of external catheter is obtained 7.1 24 hours post insertion or upon admission 7.2 During dressing changes 8. Arm circumference . 8.1 During insertion procedure 8.2 Upon admission if no insertion measurement available, then weekly Procedure: .22. Label dressing with: 22.1 Date and time 22.2 Nurse's initials This Federal tag relates to complaint IN 549 3.1-47(a)(2)

Based on interview and record review the facility failed to provide adequate supervision for a severely cognitively impaired dependent resident which resulted in a fall. This fall resulted in Resident B receiving a C-2 vertebral body fracture. This deficient practice affected 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/3/2018 at 10:30 a.m. [DIAGNOSES REDACTED]. The most recent Admission Minimum Data Set (MDS) assessment, dated 12/15/2017, was reviewed on 1/3/2017 at 10:30 a.m. The MDS indicated Resident B was severely cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 5. The resident received the following Activities of Daily Living (ADL) assistance; transfer-extensive assistance with one person physical assistance, dressing bathing and hygiene- extensive assistance with one person physical assistance, and extensive assistance with one person physical assistance for toilet use. The resident was incontinent of bladder. The resident had no impairments to range of motion in all extremities. Review of a current care plan, dated 12/9/2017 indicated the following: Focus Falls Resident is at risk for falls, injury r/t (related to) new surroundings, Hx (history of ) falls. Interventions included, but were not limited to, observe for any pattern with falls if resident has fallen more than once; assist resident with ADLs as required and use appropriate assistive devices and level of assistance as recommended. Review of a current care plan, dated 1/2/2018, indicated the following: Focus Cognitive Deficits Res (Resident) has cognitive deficits AEB (as evidenced by) STM (short term memory) problems, intermitted confusion and forgetfulness, BIMS score, dx (diagnosis) of dementia. Res requires assist with ADLs (activities of daily living). The care plan had no documented interventions and was not documented until after the resident's discharge. Review on 1/3/2018 at 1:00 p.m. of a fall risk assessment, dated 12/6/2017, prior to the fall, indicated the resident was a high risk for falls. Review of a Nursing Progress note, dated 12/21/2017 at 6:45 a.m., indicated the following: Res (resident) has used her call light to go to the restroom. Staff walked her in and put her on the toilet and reminded her to use call light when done, res indicated understanding. Staff heard noise from hall and immediately went in to check on res. Res was found on floor with walker knocked over. Staff came down to nurses station to get assistance. One staff member remained with res at all times while vitals, paperwork, and care was being done. VS taken Q (every) 5 min, going down with each assessment. Grips equable. Res able to follow directions. The family and doctor were notified and the resident was sent to the emergency room by ambulance. Review of the Nursing - Fall Investigation Report indicated the resident fell on [DATE] at 6:45 p.m The resident was documented as alert and confused. High risk factors identified at the time of the fall included, but were not limited to, new admission, hearing deficit, dementia and previous falls. During an interview on 1/3/2018 at 1:45 p.m., QMA 5 indicated she was working at a CNA at the time the resident fell . She indicated the resident put on her call light and indicated she had to go to the bathroom. QMA 5 indicated she got the resident out of bed and walked her to the bathroom and gave her a call light. She indicated she always left her on the toilet and told the resident to put on the call light when finished. The QMA indicated she went back to the cubbie where the CNAs sit and after about four minutes she heard the walker fall and heard a smack. She indicated she immediately jumped up and ran to the residents room. The resident was laying by the wall and there was blood on the floor. The other CNA went to get the nurse and she instructed the resident not to move until the nurse got there. QMA 5 indicated when the nurse arrived and together they rolled the resident and saw a wound on the residents head. She indicated the resident was not confused and required one person assistance to the bathroom. She did not know the resident had a [DIAGNOSES REDACTED]. The QMA indicated she did know the resident was visually impaired and that resident specific information could be found on the kiosk. During an interview on 1/3/2018 at 3:26 p.m. QMA (Qualified Medication Aide) 1 indicated she would never leave anyone in the bathroom alone unless they asked her too. During an interview on 1/3/15 at 3:07 p.m., RN 3 indicated the following: . one of the aides came and told me 'that little lady is on the floor'. I went behind the desk and got my equipment. I hear (name of QMA 5) yell 'She's bleeding', so I walked faster. I got in there and she was on the floor and (name of QMA 5) was holding her hand and supporting her head. She was bleeding. She could answer simple questions. Her vitals were stable. I told them not to move her until the ambulance got there. (Name of QMA 5) remained with her I while went to get things to get her cleaned up. (Name of RN 2) stayed with her as well. I monitored vitals every five minutes until the ambulance got there. Her blood pressures and other vitals were slightly dropping until the ambulance got here. She was able to answer simple yes/no questions, which was normal for her. She could alert you if she needed to use the bathroom. She couldn't hold a long conversation. But she could let us know when she was done by using the light. RN 3 indicated the CNAs only have care directions in the kiosk and do not have access to the resident's care plans. During an interview on 1/4/2018 at 9:23 a.m., the Director of Nursing (DON) indicated the staff follow the RAI Manual guidelines in regards to how we deem assistance with mobility and safety. The facility re-educated the staff member involved with the incident on safe practices with regard to leaving the cognitively impaired resident unattended in the bathroom. She indicated they did this in an effort to prevent any potential detrimental effect to the safety and security of all residents. The DON provided the facility fall policy which lacked any instruction on prevention by not leaving impaired (cognitive or physical) residents unattended in the bathroom. This Federal tag relates to Complaint IN 017. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident received sufficient supervision to prevent an accident for 1 of 3 residents reviewed for accidents. This deficient practice resulted in the resident receiving broken ribs as a result of a fall. (Resident B) Findings included: The closed clinical record for Resident B was reviewed on 6/21/2017 at 10:07 p.m. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 4/22/2017, indicated Resident B was severely cognitively impaired and required extensive physical assistance of two persons for transfers and personal hygiene. A nurses note, dated 4/19/2017 at 5:22 p.m., indicated she was in her room and included a shift update on Resident B. This was the last documented staff observation prior to the fall. Review of a progress note, dated 4/20/2017 at 12:23 a.m., indicated the following: Resident was witnessed by (name of CNA) (Certified Nursing Aide) while entering the room where resident was losing her balance and falling into the foot board of her bed after climbing out of the side of her recliner. CNA could not get to resident in time to prevent the fall from happening. Resident did not hit her head and is not complaining of anything other than her back hurting where there is an abrasion and a bruise from the witnessed fall. Resident was yelling and threatening CNA with punching her in the face while making a fist and screaming in her face while CNA was trying to clean her up after another episode of diarrhea. Resident exhibits much confusion and aggression towards staff. Review of the self reportable, for this incident, indicated the resident fell at 11:50 p.m. on 4/19/2017. The in house x-ray results were reviewed on 6/21/2017 at 11:30 p.m. The results indicated View of the right ribs were obtained. The visualized osseous structures demonstrate acute displaced fractures involving the right fifth through ninth ribs. The results indicated the physician was notified on 4/21/2017 but no time of notification was documented. Review of a progress note, dated 4/23/2017 at 12:45 p.m., indicated the resident was transferred to the hospital for evaluation and treatment for [REDACTED]. During an interview on 6/21/2017 at 2:31 p.m., a family member of the resident indicated she had called the facility on 4/19/2017 at approximately 9:00 p.m., and had spoken to the nurse on duty requesting her mother not be left to sleep in the recliner. The daughter indicated she feared her mother would attempt to get up without calling for assistance due to her confusion and the nurse told her she would make sure her mother was assisted to bed and not left in the recliner. The daughter also indicated she had been in the facility earlier that evening and when she left her mother was in the recliner ready and dressed for bed. During an interview on 6/21/2017 at 10:47 p.m., CNA 1 indicated while she was assisting people to bed she heard the resident screaming. CNA 1 indicated she entered the room and witnessed the resident leaning back over the arm of the recliner and fall into the foot board of her bed. CNA 1 indicated the recliner was in a supine position at the time. CNA 1 indicated she believed the reason the resident was still in the recliner was because they were waiting for the last medication pass before assisting her to bed. CNA 1 indicated a resident's refusal of care should be documented, but did not remember if the resident had refused to go to bed. CNA 1 indicated the resident was complaining of back pain and had an abrasion along with bruising to the right side of her back. During an interview on 6/22/2017 at 12:33 p.m., LPN 3 indicated she reported for duty on 4/19/2017 at 6:00 p.m. and she had gotten in report the family did not want the resident left in the recliner and wanted her assisted to bed. LPN 3 indicated the resident often refused to get out of the recliner and preferred to sleep in the recliner instead of the bed. Her family was aware of her desire to sleep in the recliner, but wanted her in the bed. They asked if we would make sure she got in the bed. LPN 3 indicated the resident was repeatedly asked if she wanted to get in bed but had refused. LPN 3 indicated she did not document the refusals and clinical record lacked any care refusal documentation. LPN 3 could not give any other reason why the resident was still in her recliner at 11:50 p.m. on 4/19/2017. Review of the CNA documentation lacked any indication the staff had attempted to assist the resident to bed or that the resident had refused on the night of 4/19/2017. During an interview on 6/22/2017 the Director of Nursing (DON) indicated all refusals of care should be documented in the progress notes and/or the CNA documentation. The DON indicated she did not have a reason for the resident to still be in her recliner at 11:50 p.m. During an interview on 6/22/2017 at 2:38 p.m., CNA 7 indicated all resident care refusals should be documented in the CNA charting. This federal tag relates to Complaint IN 84. 3.1-45(a)(2)