Every finding on record at Westridge Health Care Center

Based on interview, observation, and record review, the facility failed to ensure a resident's change in condition after a fall was assessed and treated which resulted in harm of a resident who had delayed treatment for a fractured right femur (thigh bone) that required surgery for 1 of 4 residents reviewed for accidents (Resident 8). Findings include:During an interview, on 3/15/26 at 1:33 p.m., Resident 8 indicated she had constant pain and recently had a fall and was hurt. Resident 8's record was reviewed on 3/17/26 at 11:56 a.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia, moderate, with mood disorder (fixed, false beliefs strongly held despite clear evidence to the contrary, often stemming from mental health, neurological, or substance-related conditions), major depressive disorder (serious mental health condition characterized by persistent sadness, hopelessness, and a loss of interest in activities lasting at least two weeks), right femur fracture (severe break in the right thighbone), and pain, unspecified (a patient experiences pain that cannot be traced to a specific injury, disease or anatomical cause). Facility census information indicated the resident admitted to the facility on [DATE]. A physician order, dated 1/24/24, indicated to assess resident's pain level and notify medical provider if new onset or worsening pain. A care plan, dated 5/20/25, indicated the resident had multiple risk factors for falls including impaired mobility, cognitive deficits, range of motion deficits, and dementia. Interventions included, but were not limited to, ensure pathways are clutter free, keep frequently used items within reach, and notify resident representative and physician if fall occurs. A progress note, dated 11/30/25 at 7:10 a.m., indicated Resident 8 was on the floor beside her bed when staff was called to her room. No injuries noted and no complaints of pain. A Hoyer lift (mechanical device used to safely transfer individuals with limited mobility between a bed, chair, or other surfaces) was used to get the resident back into bed. A progress note, dated 11/30/25 at 9:40 a.m., indicated the facility notified the Nurse Practitioner (NP) of the fall without injuries. Review of neurological check flowsheet indicated Resident 8 complained of pain to her knees on 12/1/25 at 11:00 p.m., 12/2/25 at 11:00 p.m., 12/3/25 at 3:00 a.m., and pain to knee/legs on 12/3/25 at 7:00 a.m. A progress note, dated 12/3/25 at 5:19 a.m., indicated Resident 8 was complaining of right knee pain and had her leg up prompt on pillows. The record lacked documentation that a physician was notified of increased pain after the fall. A progress note, dated 12/6/25 at 11:32 a.m., indicated Resident 8 had recent complaints of leg pain. The nurse assessed and noted bruising to bilateral knees and they were swollen. The nurse notified the NP and received an order for x-rays. The record lacked documentation that the x-rays were completed. A late entry progress note, dated 12/18/25 at 12:08 a.m., indicated that on 12/1/25 at 12:30 a.m. Resident 8 complained of increased pain in legs and all over with movement during care. An as needed pain medication was administered, and no bruising was noted to her legs or knees at that time. The record lacked documentation that a physician was notified of increased pain after the fall. A late entry progress note, dated 12/18/25 at 12:11 a.m., indicated that on 12/2/25 at 12:55 a.m. Resident 8 was given as needed pain medication for complaints of pain in knees and legs, no bruising noted at this time. The record lacked documentation that a physician was notified of increased pain after the fall. Review of November 2025 Medication Administration Record (MAR) indicated had complained of 3 out of 10 pain once in the month and all other complaints were 0 to 2 out of 10. Review of November 2025 MAR indicated the resident did not receive any as needed pain medication for the month. Review of December 2025 MAR indicated the resident complained of 10 out of 10 pain on 12/1/25 during the dayshift. On 12/2/25 during the night shift the resident complained of 6 out of 10 pain. On 12/5/25 during the night shift the resident complained of 7 out of 10 pain.Review of December 2025 MAR indicated the resident received as needed pain medication on 12/1/25 at 12:38 a.m. for 7 out of 10 all over pain. The resident received as needed pain medication on 12/2/25 at 12:58 a.m. for 6 out of 10 pain. A progress note, dated 12/7/25 at 5:00 p.m. indicated Resident 8 was sent to hospital for uncontrolled pain. A progress note, dated 12/7/25 at 5:32 p.m., EMS (Emergency Medical Services) arrived at the facility to transport the resident to the hospital. The facility census information indicated Resident 8 re-admitted to the facility on [DATE].Review of nurse practitioner progress note, dated 12/12/25, indicated Resident 8 had a right femur fracture and L(lumbar)1-L4 compression deformities and L5 TP (a break in the bony protrusion on the side of the lowest lumbar vertebra often caused by high-impact, blunt trauma or sever muscle contraction) fracture. The resident had experienced a fall at the facility the week prior. The resident underwent surgical fixation of right femur fracture on 12/8/25. A significant change in status Minimum Data Set (MDS) assessment, dated 1/19/26, indicated the resident had moderate cognitive impairment and was on a pain medication regimen. During an interview, on 3/19/25 at 10:42 a.m., the Clinical Consultant indicated she was aware of Resident 8's fall on 11/30/25 and at the time of the fall it was reported that there were no complaints of pain and no injuries. The consultant indicated the resident had chronic pain and when the resident started to complain of knee/leg pain after the fall they thought it was from her chronic pain. She did not know why the staff did not notify the physician when the resident started to complain of worsening pain. On 3/19/26 at 11:56 a.m., the Clinical Consultant provided a document dated 10/14, titled, Notification of Change, and indicated it was the current policy being used by the facility. The policy indicated, .To keep resident, legal representative (or interested family member), and physician (when applicable) aware of changes which directly affect the care and welfare of the resident.Facility personnel shall immediately inform resident, consult with resident's physician; and if known, notify the resident's legal representative or an interested family member when there is:.an accident involving the resident that results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status. 410 Indiana Administration Code (IAC) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure residents and their representatives participated in care plan meetings (a documented meeting where a resident, their family, and a team of health professionals meet to discuss the resident's goals, preferences, and necessary care services), for 4 of 16 residents reviewed for care plan meetings (Residents 41, 40, 1, and 8). Findings include:1. During an interview, on 3/15/26 at 12:53 p.m., Resident 41's brother indicated he was the resident Power of Attorney (POA-a legal document that allows someone else to act on another individual's behalf) and responsible party. He indicated he attended a care plan meeting right after the resident was admitted but had not known about or attended a meeting since that time. At the same time, the resident indicated she could not remember having a meeting since that time as well. Resident 41's record was reviewed on 3/18/26 at 8:43 a.m. The census indicated that the resident had been admitted to the facility on [DATE], for diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (one-sided weakness or paralysis on the right side of the body caused by a stroke in the left side of the brain). A quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident had no cognitive deficit. Review of the care conference meeting history indicated the following: A care conference meeting was held on 8/1/25. The conference note lacked documentation that the resident and/or her brother/POA had been invited or were in attendance, and why they had not attended the meeting. An Interdisciplinary Care Plan Conference Record form, dated 9/3/25, indicated that a meeting had been held on this date. The form indicated a care plan letter had been mailed on 8/25/25. The resident's brother/POA had attended. The form lacked documentation that the resident had been invited, had attended, and, if she did not attend, a reason why. An Interdisciplinary Care Plan Conference Record form, dated 10/1/25, indicated that a meeting had been held on this date. The conference note lacked documentation that the resident and/or her brother/POA had been invited, were in attendance, and why they had not attended the meeting. An Interdisciplinary Care Plan Conference Record form, dated 12/31/25, indicated that a meeting had been held on this date. The form indicated that the resident and her brother/POA had not attended the meeting. The conference note lacked documentation that the resident and/or her brother/POA had been invited and why they had not attended the meeting. During an interview, on 3/18/26 at 9:50 a.m., the Social Services Director (SSD) indicated she was not sure why the resident's brother/POA had not attended any of the care plan meetings. She had sent him letters to notify him of the meetings. She was unsure why there was not any documentation to indicate why the resident and/or her brother/POA had not attended any of the meetings. She kept a log of all the facility residents meetings, and those who were invited, but had no other documentation to explain if the resident or their representatives had attended or declined the invitation to attend. She acknowledged there was no consistency with any progress notes about the meetings. During an interview, on 3/18/26 at 11:10 a.m., the resident's brother/POA indicated he could not remember that he ever received a letter from the facility about care plan meetings. During an interview, on 3/18/26 at 9:20 a.m., the Corporate Social Services Consultant indicated the SSD would send letters out to invite resident representatives and residents to the care conference meetings. They did not have time to follow up to determine if the letter was received and/or if they were planning to attend or not. She believed that if the resident and their representatives had been invited, there was no need to document if and why they did not attend. At the same time, she acknowledged there was no consistency with documentation on who was invited and who attended the care plan meetings. 2. On 3/15/2026 at 10:39 a.m., during initial observation and interview Resident 40 indicated she had not been invited to any care plan meetings. She indicated she was bed bound and the staff were welcome to meet in her room to discuss her needs. On 3/18/26 the medical record of Resident 40 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), chronic pain (pain that lasts or recurs for more than 3 to 6 months), and atherosclerotic heart disease (a condition where arteries supplying the heart become narrowed or blocked due to a buildup of plaque). A quarterly Minimum data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact and required maximum assistance from the staff for daily care needs. Review of the medical record indicated the date of a care plan date had been entered. The record lacked documentation regarding the care plan meeting or if the resident was in attendance. On 3/18/26 at 9:47 a.m., during an interview the Social Service Director indicated the review team went to the room of Resident 40 for care plan meetings and she kept a written log of care plan invitations. The resident was always invited to attend. She indicated care plan meetings were completed quarterly and when the resident had a significant change in condition. She wrote invitation letters and sent them to family or responsible party. If the resident was their own person she hand delivered the letter to the resident. She indicated she did not have documentation for the actual care plan meetings of Resident 40. 3. During an interview on 3/15/26 at 12:49 p.m., Resident 1 indicated she did not remember having care plan meetings consistently. Resident 1's record was reviewed on 3/16/26 at 10:18 a.m. The profile indicated the resident's diagnoses included, but were not limited to, depression unspecified (clinically significant depressive symptoms that cause distress but do not meet the full criteria for specific disorders like Major Depressive Disorder), schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia (hallucinations [seeing things that aren't there], delusion, disorganized thinking) with a mood disorder such as depression or bipolar disorder), and fibromyalgia (a chronic multi system disorder characterized by widespread musculoskeletal pain, profound fatigue, and cognitive difficulties). Facility census information indicated the resident admitted to the facility on [DATE]. A care conference note, dated 5/7/25, indicated a quarterly review was conducted on this day for Resident 1, but the record lacked documentation if the resident or resident representative was invited or attended the meeting. A care conference note, dated 7/7/25, indicated a quarterly review was conducted on this day for Resident 1, but the record lacked documentation if the resident or resident representative was invited or attended the meeting. A care conference note, dated 9/18/25, indicated a quarterly review was conducted on this day for Resident 1, but the record lacked documentation if the resident or resident representative was invited or attended the meeting. A care conference note, dated 12/17/25, indicated a care plan meeting was conducted on this day for Resident 1. The documentation indicated the resident was in attendance. A quarterly Minimum Data Set (MDS) assessment, dated 12/19/26, indicated the resident had moderate cognitive impairment. 4. During an interview on 3/15/26 at 1:30 p.m., Resident 8 indicated she did not remember having care plan meetings regularly. She was unsure when the last one was. Resident 8's record was reviewed on 3/17/26 at 11:56 a.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia, moderate, with mood disorder (fixed, false beliefs strongly held despite clear evidence to the contrary, often stemming from mental health, neurological, or substance-related conditions), major depressive disorder (serious mental health condition characterized by persistent sadness, hopelessness, and a loss of interest in activities lasting at least two weeks), and right femur fracture (severe break in the right thighbone). Facility census information indicated the resident admitted to the facility on [DATE]. A care conference note, dated 6/11/25, indicated a quarterly review was conducted on this day for Resident 8, but the record lacked documentation if the resident or resident representative was invited or attended the meeting. A care conference note, dated 8/27/25, indicated a quarterly review was conducted on this day for Resident 8. The documentation indicated that the daughter and resident were in attendance. A care conference note, dated 11/5/25, indicated an annual review was conducted on this day for Resident 8, but the record lacked documentation if the resident or resident representative was invited or attended the meeting. A care conference note, dated 12/3/25, indicated an annual review was conducted on this day for Resident 8. The documentation indicated the resident was in attendance. A significant change in status Minimum Data Set (MDS) assessment, dated 1/19/26, indicated the resident had moderate cognitive impairment. A care conference note, dated 1/19/26, indicated a significant change review was conducted on this day for Resident 8, but the record lacked documentation if the resident or resident representative was invited or attended the meeting. During an interview on 3/18/26 at 2:00 p.m., the Social Service Director (SSD) indicated she was unable to provide documentation that the resident and/or resident representatives had attended quarterly care plan meetings. There were times she was unable to get the documentation completed on the computer or on paper. On 3/19/26 at 10:02 a.m., the SSD consultant provided a document, dated 10/07, titled, Care Plan Notification Log, and indicated it was the current policy being used by the facility. The policy indicated, .1. Social Service Director and/or appointed designee will be responsible to ensure the residents, family and responsible parties have been notified of all care plan meetings. 2. Social Service will utilize the Care Plan Notification Log to indicate date of notification, date of care plan meeting, who was notified and how they are notified. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(2)(C)

Based on record review and interview, the facility failed to ensure psychotropic medication consents were obtained for the initiation of or increase of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications (Residents 1 and 30). Findings include: 1. Resident 1's record was reviewed on 3/16/26 at 10:18 a.m. The profile indicated the resident's diagnoses included, but were not limited to, depression, schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia with a mood disorder such as depression or bipolar disorder), and fibromyalgia (a chronic multi system disorder characterized by widespread musculoskeletal pain, profound fatigue, and cognitive difficulties). Facility census information indicated the resident admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 12/19/26, indicated the resident had moderate cognitive impairment and received anti-psychotic and anti-depressant medications during the look back period. A physician order, dated 2/9/26, indicated to administer duloxetine (anti-depressant medication) 20 milligrams (mg), 1 capsule by mouth once a day. The electronic health record lacked documentation of a psychotropic informed consent was obtained for the use of the duloxetine medication. During an interview on 3/17/26 at 10:42 a.m., the Clinical Consultant indicated she had misinformed about psychotropic consents and when they needed to be obtained. She was unable to find documentation of the consent being obtained for when the duloxetine medication was initiated for Resident 1. She was now aware of the error and had started an audit tool regarding the psychotropic consents. 2. Resident 30's record was reviewed on 3/16/26 at 10:28 a.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder, recurrent (a mental health condition characterized by experiencing two or more major depressive episodes, separated by periods of improvement or remission) and generalized anxiety disorder (a mental health condition defined by chronic, excessive, and uncontrollable worry about everyday things for at least 6 months). A significant change Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had no cognitive deficits and received antidepressant medication (medication used to treat symptoms of depression). A care plan, dated 2/24/26, indicated the resident was at risk for side effects related to the use of psychotropic medications. A historical review of the resident's physician's orders for sertraline (antidepressant medication) indicated the following: a. A physician order, dated 10/1/24 and discontinued on 7/1/25, indicated to administer a 100 milligram (mg) tablet of sertraline, one time daily for anxiety and depression. b. A physician order, dated 5/6/25 and discontinued on 7/1/25, indicated to administer a 25 mg tablet of sertraline, one time daily for anxiety and depression. c. A physician order, dated 7/1/25 and discontinued on 11/19/25, indicated to administer one and a half-100 mg tablets of sertraline (150 mg), one time daily for anxiety and depression. The record lacked documentation of a consent form for the increase of the sertraline medication, ordered on 7/1/25. A Psychiatry progress note, dated 7/1/25, indicated the Psychiatrist had discussed the resident's increased depression and anxiety with the Interdisciplinary Team (IDT). The IDT agreed that the resident's depression had increased. The decision was made to increase the resident's sertraline from 125 mg daily to 150 mg daily. During an interview, on 3/17/26 at 9:57 a.m., the Regional Clinical Consultant indicated she was unable to locate a consent form for the sertraline medication increase, dated 7/1/25. On 3/17/26 at 12:55 p.m., the Regional Clinical Consultant provided a document, dated 4/2025, titled, Psychotropic Medication Consent, Use and Gradual Dose Reduction, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures.16. Residents receiving an order for a new psychotropic medication, or dosage increase to existing orders, shall have consent obtained from the resident or their representative. 410 Indiana Administrative Code (IAC) 16.2-3.1-3(l)(2)

Based on observation, record review, and interview, the facility failed to ensure Registered Dietitian (RD) recommendations were addressed by the physician and ordered interventions were implemented to prevent weight loss for 1 of 2 residents reviewed for weight loss (Resident 11). Findings include:On 3/15/26 at 10:30 a.m., during an initial observation, observed Resident 11 sitting up in bed drinking water from a two handle cup. The resident was alert with slow verbal response. Noted while drinking she was coughing frequently. Liquid was noted to be thin consistency. On 3/15/26 at 1:44 p.m., the medical record of Resident 11 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure) and anorexia (a serious, potentially fatal eating disorder characterized by an intense fear of gaining weight). A care plan, dated 10/7/25, indicated resident had incurred weight loss. Interventions included, but were not limited to, determine potential causal factor of decreased consumption/weight loss and involve appropriate disciplines to provide intervention, food preferences, depression/isolation, need for increased assistance, dining seating/atmosphere. Monitor consumption and encourage resident to consume 100% of meals, snacks, and supplements. Notify physician and dietician of continued weight loss. A physician order, dated 10/22/25, indicated diet: mechanical soft with diet condiment send sugar free cookies for bedtime (HS) snack per resident request every shift. A physician order, dated 10/22/25, indicated to send thrive ice cream at lunch and dinner twice a day. On 11/26/25 at 10:32 a.m., a Registered Dietitian (RD) note indicated the resident's November weight on 11/04/25 was 239.8 lb equaling 0.1% loss in 30 days, 2.6% loss in 90 days, and 7.9% loss in 180 days. There was no significant weight changes; however, weights had trended downward. Resident had been wanting to lose weight in the past; however, this trend likely was due to decreased intakes. Resident's diet changed on10/22/25 to mechanical soft with diet condiments. Send sugar free cookies for an HS snack per resident's request. Current intake at meals was 26 to 100% for breakfast and lunch and 26 to 75% for dinner. Resident also started to receive a thrive ice cream with lunch/dinner; however, uncertain of percentage consumed. Do recommend to supplement diet with Active liquid protein 60 ml twice daily, send a Boost Breeze (or Ensure Clear) with breakfast, and weekly weights continue. Continue with all other current interventions. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired and required maximum assistance for daily care needs. The MDS indicated, no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. Review of the Medication Administration Record (MAR) indicated from November 2025 to March 2026 the resident received thrive ice cream twice daily. The record lacked documentation of a physician order to administer, active liquid protein BID (twice daily), or administration of Boost Breeze (or Ensure Clear) with breakfast per Registered Dietitian (RD) recommendation. Review of the weight history indicated significant weight loss. Six month weight record on 10/7/25 weight was 240 pounds (lb). On 3/4/26 weighed 190.8 lb., equaling a 20.5 percent (%) loss in 6 months. Weight on 2/3/26 was 202.4, on 3/4/26 weight was 190.8, equaling a 5.73% loss in 30 days. The record lacked documentation of physician notification of continued weight loss.An evaluation completed by the RD was completed on 3/16/26. The evaluation indicated Current p.o. (by mouth) intakes are not adequate to meet estimated needs. Recommend 1) appetite stimulant per MD preference.The record lacked documentation of notification to the physician of the recommendation. On 3/19/26 at 1:15 p.m., during an interview the RD acknowledged she had made recommendations for the resident to receive additional protein liquid and an appetite stimulant. She was unsure of why the recommendations had not been implemented or followed. On 3/19/26 at 2:00 p.m., during an interview the Regional Nurse Consultant indicated the facility had posted the recommendation for the physician to review on the next scheduled visit. She acknowledged the recommendations had not been implemented and physician had not been notified. On 3/19/26 at 3:00 p.m., the Clinical Nurse Consultant provided a document, titled, Dietitian Recommendations, dated 10/2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures.6. Administrative staff shall be responsible to ensure said communications are communicated to the resident's physician as son as possible, but no later than three (3) days from receiving said recommendation. Physician response shall be documented and implemented accordingly. 410 Indiana Administrative Code (IAC) 16.2-3.1-46

Based on record review and interview, the facility failed to ensure a physician's order for an assessment of a resident's dialysis access site ( surgically prepared area on the body that allows easy, high-volume access to the bloodstream for filtering blood during hemodialysis [a medical treatment that acts as an artificial kidney for people with kidney failure] was accurate, for 1 of 1 resident reviewed for dialysis (resident 2). Findings include:Resident 2's record was reviewed on 3/16/26 at 11:17 a.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (the final stage of kidney failure, where kidneys lose roughly 90% of their function, or are no longer able to work well enough to sustain life) and dependence on renal dialysis. A quarterly Minimum Data Set (MDS) assessment, dated 1/22/26, indicated the resident had no cognitive deficit. A care plan, dated 2/11/25, indicated the resident had diagnoses of end stage renal disease and required hemodialysis. Interventions included, but were not limited to, monitor shunt for bruit and thrill every shift. Review of the nurse's notes indicated the resident had a dialysis port in her upper right chest. The notes lacked documentation that the resident had an AV Fistula site (an abnormal connection between an artery and a vein, allowing blood to flow directly between them). A physician's order, dated 7/17/25, indicated to monitor the resident's AV Fistula site for bleeding, redness, swelling and warmth. Notify the medical provider of complications every shift. A physician's order, dated 7/17/25, indicated to monitor the resident's AV Fistula site for bruit and thrill (A bruit is an audible whooshing or blowing sound heard with a stethoscope, indicating turbulent blood flow in an artery or vein. A thrill is a palpable, gentle buzzing sensation or vibration felt with the hand over the same area). If bruit of thrill is negative notify medical provider and document findings every shift. The record lacked documentation of an order to assess the resident dialysis port to her right upper chest. During an interview, on 3/17/26 at 1025 a.m., Registered Nurse (RN) 4 indicated that she knew that the resident did not have an AV Fistula. She was aware that the orders indicated assessments for an AV Fistula. During an interview, on 3/17/26 at 10:40 a.m., the Regional Clinical Consultant indicated the incorrect order had been overlooked by several staff who had responsibility to review the resident orders. She was unsure as to why the order had not been caught sooner. During an interview, on 3/18/26 at 8:30 a.m., the Regional Clinical Consultant indicated it had been brought to her attention that the resident did have an AV Fistula, but it was not accessible. She had a dialysis port in her right upper chest that was used for her dialysis treatments. A new order to assess the residents' port was added to the orders on 3/17/26. During an interview, on 3/18/25 at 9:40 a.m., the resident indicated she had the AV Fistula prior to coming to the facility. It had never worked, so they put the port in for her dialysis last fall. She had an appointment to get the A V Fistula removed, but she was not able to attend to get the procedure done. Nothing had ever been said about it since. On 3/17/26 at 12:55 p.m., the Regional Clinical Consultant provided a document, with a revised date of 9/2017, titled, Dialysis Coordination/Facility Services, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy.Review physician's orders for the resident receiving dialysis to confirm: Type of access site and location, Orders for care access site. 410 Indiana Administrative Code (IAC) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure insulins stored in the medication carts were labeled with the open date for 1 of 2 medication carts reviewed and 3 of 3 residents with insulins stored in the medication cart (Residents 37, 12, and 34). Findings include:On 3/17/26 at 1:25 p.m., observed the North hall medication cart with RN 6. The following insulin pens (a portable, easy-to-use medical device for injecting insulin to manage diabetes) were observed: Resident 37, Novolog - Insulin Pen. The medication label indicated the prescription had been filled on 2/13/26. No date opened was recorded on the label or the pen. Resident 37, Basaglar insulin pen. The medication label indicated the prescription had been filled on 7/2/25. No date opened was recorded on the label or the pen. Resident 37, Novolog insulin pen. The medication label indicated the prescription had been filled on 12/10/25. No date opened was recorded on the label or the pen. Resident 12, Glargine insulin pen. The medication label indicated the prescription had been filled on 2/13/26. No date opened was recorded on the label or the pen. Resident (34), Lantus insulin pen. The prescription label did not indicate a refill date. No date opened was recorded on the label or the pen. On 3/17/26 at 1:30 p.m., during an interview RN 6 acknowledged insulin pens must be dated once opened to ensure they were not administered after the expiration date. 1. The electronic medical record of Resident 37 indicated a diagnosis of diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A physician order indicated to administer Novolog FlexPen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL (milliliter) administer 13 units; subcutaneous (under the skin) with meals. The current physician orders, dated 3/1/26, lacked an order for Basaglar insulin for Resident 37. 2. The electronic medical record of Resident 12 indicated a diagnosis of diabetes. A current physician order indicated to administer glargine insulin 100 unit/mL (3 mL) administer 13 units; subcutaneous at bedtime. 3. The electronic medical record of Resident 34 indicated a diagnosis of diabetes. A current physician order indicated to administer Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL) administer 30 units; subcutaneous twice a day. On 3/19/26 at 9:12 a.m., the Director of Nursing provided a document titled, Medication expiration, dated 10/2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.1.d. Multiple dose injections such as insulin will expire 28 days after opening unless otherwise noted by manufacturer.2. Facility staff shall date the label of any multi-use vial when the vial is first accessed. 410 Indiana Administrative Code (IAC) 16.2-3.1-25(j)410 Indiana Administrative Code (IAC) 16.2-3.1-25(m)410 Indiana Administrative Code (IAC) 16.2-3.1-25(n)

Based on record review and interview, the facility failed to ensure lab services were completed as ordered, for 2 of 5 residents reviewed for unnecessary medications (Residents 30 and 3). Findings include: 1. Resident 30's record was reviewed on 3/16/26 at 10:28 a.m. The profile indicated the resident's diagnoses included, but were not limited to, other seizures (seizure types beyond common convulsions, characterized by temporary, abnormal brain activity causing sudden changes in movement, sensation, behavior, or awareness). A significant change Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had no cognitive deficit and received anticonvulsant medications (medications used to control seizures). A physician's order, dated 11/21/25, indicated to administer 1-500 milligram (mg) tablet of Keppra (anticonvulsant medication) two times a day. A Pharmacy recommendation, dated 2/3/26, indicated to consider checking the resident's Keppra level, if it had not been done lately. The physician agreed and signed and dated the document on 2/24/26. A physician's order, dated 2/24/26, indicated to obtain a Keppra level (a blood test that measures how much of the seizure medication is currently in a person's bloodstream). The record lacked documentation of the Keppra level had been obtained as ordered. A February 2026 lab order tracking form, indicated the resident had a physician's order, dated 2/24/26, to draw a Keppra level. The form indicated draws had been attempted on 3/4/26 (L hand) unsuccessful and a second attempt on 3/13/26 (L AC) and were unsuccessful. The form indicated the physician had not been notified of the failed attempts to draw the Keppra level until 3/17/26. The progress notes lacked documentation of the failed attempts to draw the Keppra level on 3/4/26 and 3/13/26 and lacked documentation that the physician had been notified of the failed attempts and notified on 3/17/26. During an interview, on 3/17/26 at 2:15 p.m., the Assistant Director of Nursing (ADON) indicated the facility had received an order to obtain the Keppra level on 2/24/26. The resident's veins were so bad, due to his cancer treatments, that it was difficult to get the labs drawn. The resident did not have a port (a small, soft-topped medical appliance surgically placed under the skin—usually in the upper chest) to draw from. They had tried a couple of times to get the blood, but they could not. During an interview, on 3/17/26 at 3:01 p.m., Registered Nurse (RN) 6 indicated the resident did have a port but it was not accessible for the nurses at the facility. She believed it was due to the policy of the facility. 2. Resident 3's record was reviewed on 3/16/26 at 3:14 p.m. The profile indicated the resident's diagnoses included, but were not limited to, osteomyelitis (a serious infection of the bone), dementia (a decline in mental ability severe enough to interfere with daily life), and personal history of pulmonary embolism (sudden life-threatening blockage in one or more pulmonary arteries in the lungs). A quarterly Minimum Data Set (MDS) assessment, dated 2/7/26, indicated the resident had severe cognitive impairment and was dependent on staff for showers and toileting. A physician order, dated 10/8/25, indicated to administer Rexulti (anti-psychotic medication) 0.25mg (milligrams) by mouth once a day. A pharmacy recommendation, dated 1/5/26, indicated to consider checking a fasting lipid panel (a blood test, requiring 8-12 hours of fasting that measures total cholesterol and good and bad triglycerides), A1C (a blood test that measures your average blood sugar levels over the past 2 to 3 months), and b12 (measures the level of cobalamin [water soluble vitamin] in the blood) level to monitor for safety and/or effectiveness of mediations. The physician signed and dated the recommendation for 1/6/26 and indicated the resident was in the hospital. Facility census information indicated Resident 3 re-admitted to the facility on [DATE] from the hospital. The record lacked documentation that the labs had been ordered or obtained as recommended by the pharmacy. A second pharmacy recommendation, dated 2/3/26, indicated to consider checking a fasting lipid panel, A1C, and b12 level to monitor for safety and/or effectiveness of medications. The physician agreed and signed the recommendation on 2/24/26. A physician order, dated 2/24/26, indicated to obtain a fasting lipid panel, A1C, and b12 level. The record lacked documentation of the labs being obtained as ordered. A February 2026 lab order tracking form, indicated the resident had a physician order, dated 2/24/26, to draw the lipid panel, A1C, and b12 level. The form indicated the resident refused the labs on 3/4/26 and were unable to attempt on 3/10/26 because Resident 3 had already ate. The form indicated a failed attempt in the left hand and left ac (shallow triangular depression located on the inside of the elbow) on 3/13/26. The form indicated the physician had not been notified of the failed attempts or refusal. During an interview on 3/17/26 at 8:56 a.m., the Clinical Consultant indicated she had attempted to draw labs on Resident 3 twice and was unable to obtain the labs. The physician had not been notified that the facility was unable to draw the labs as ordered. The consultant indicated the facility had lost the lab contract with a previous company at the beginning of November 2025. Since that time they have not had a consistent phlebotomist (a person who does lab draws), the facility also had to drive the labs to the hospital to be processed once obtained. The facility did not have a nurse available who was able to draw labs in a timely manner. During an interview, on 3/17/26 at 1:10 p.m., the Clinical Consultant indicated the facility had offered a phlebotomist a position and she was hopeful they would be starting soon. She was aware they had an issue with lab services and there was a system failure, and the facility would be working on getting it corrected. On 3/17/26 at 1:46 p.m., the Clinical Consultant provided a document, dated 10/14, titled, Laboratory Orders, Timely Draws, and indicated it was the current policy being used by the facility. The policy indicated, .Laboratory testing shall be conducted in a timely manner per physician orders.This facility shall ensure that physician's orders requesting laboratory services to be rendered are followed as specified in the order.3. If not specified to be drawn now .or in a given time frame.any laboratory blood ordered to be drawn shall be drawn on the next regularly scheduled facility lab day. 410 Indiana Administrative Code (IAC) 16.2-3.1-49(a)

Based on record review, observation, and interview, the facility failed to ensure sufficient dietary support personnel was implemented per their facility assessment. This deficiency had the potential to affect 44 of 44 residents who receive food from the kitchen.Findings include:Review of a confidential statement, on 1/29/26 at 9:47 a.m., indicated the food was disgusting from the kitchen and the kitchen didn't have enough workers. During an observation during lunch meal service, on 1/29/26 at 12:07 p.m., there were two dietary staff members in the kitchen. There were a Dietary Manager (cook) and a Dietary Aide. The Dietary Manager was the only staff member plating the food for both the dining room and hall trays. The Dietary Manager was unable to provide an additional food item per a resident's request because she stated, I don't have time right now, I have to get all the hall trays ready to go. During an interview, on 1/29/26 at 12:25 p.m., Resident C indicated the food had really gone down hill lately and she refused to eat most of it. She indicated the facility served the same food repeatedly and it wasn't worth eating. Resident C indicated they only had one cook in the facility, and she just couldn't do it all herself. During an interview, on 1/29/26 at 12:40 p.m., Resident F indicated the food was terrible and that they were not offered any alternatives because there was only one cook and she did not have time to cook other food. During an interview, on 1/29/26 at 2:00 p.m., the Administrator indicated the facility should have a full-time Dietary Manager, day cook, evening cook, and a dishwasher. She indicated they had other staff members that could help in the kitchen if needed, for example the Social Service Director, Activity Director, or a Certified Nurse Aide (CNA) in training. During an interview, on 1/29/26 at 3:22 p.m., the Dietary Manager indicated she had been the manager since the first of the year but had been performing the duties since the first part of August 2025. She had been working as the only cook in the building for a while. The facility had hired someone in November to cook but by the first of December he stopped showing up for his shifts and was no longer working at the facility. The Dietary Manager indicated she had been prepping, cooking, and cleaning up all the meals for the residents daily. She worked 14 hours a day, 7 days a week. She had worked over 30 days without a single day off. The Dietary Manager indicated she had not been trained on the computer system and what she needed to do with the computer, she didn't know how to order food in the system, so her Corporate Dietary staff was at the facility once a week to help her order food. The Dietary Manager indicated she was working so much, she did not have time to clean the kitchen properly or get her ServSafe (a leading food safety training and certification program) certification started. The Dietary Manager was unable to keep up with all the tasks that a manager should complete and cook all the food. During an interview, on 1/30/26 at 9:30 a.m., Resident E indicated the facility had staffing issues in the kitchen and her food was often late. She also indicated the quality of food had really declined but she knew there was only so much one person could do. Review of dietary staff schedule indicated the following information: On December 14- December 27, 2025, schedule:a. There was only 2 staff members in the kitchen on 12/15/25 with the Dietary Manager working 13.5 hours. b. There was only 2 staff members in the kitchen on 12/17/25 with the Dietary Manager working 13 hours.c. There was only 2 staff members in the kitchen on 12/20/25 with the Dietary Manager working 14 hours. d. There was only 2 staff members in the kitchen on 12/22/25 with the Dietary Manager working 14 hours. e. There was only 2 staff members in the kitchen on 12/24/25 with the Dietary Manager working 13 hours and 45 minutes. On December 28, 2025 - January 10, 2026, schedule:f. There was only 2 staff members in the kitchen on 12/29/25 with the Dietary Manager working 14 hours. g. There was only 2 staff members in the kitchen on 12/31/25 with the Dietary Manager working 14 hours. h. There was only 2 staff members in the kitchen on 1/5/26 with the Dietary Manager working 14 hours. On January 11 - January 24, 2026, schedule:i. There was only 2 staff members in the kitchen on 1/12/26 with the Dietary Manager working 14 hours. j. There was only 2 staff members in the kitchen on 1/14/26 with the Dietary Manager working 14 hours. k. There was only 2 staff members in the kitchen on 1/15/26 with the Dietary Manager working 14 hours. l. There was only 2 staff members in the kitchen on 1/16/26 with the Dietary Manager working 14 hours. m. There was only 2 staff members in the kitchen on 1/19/26 with the Dietary Manager working 14 hours. n. There was only 1 staff member in the kitchen on 1/20/26 with no cook scheduled. o. There was only 1 staff member in the kitchen on 1/21/26 with the Dietary Manager working 14 hours. p. There was only 2 staff members in the kitchen on 1/22/26 with the Dietary Manager working 14 hours. q. There was only 2 staff members in the kitchen on 1/23/26 with the Dietary Manager working 14 hours. r. There was only 2 staff members in the kitchen on 1/24/26 with the Dietary Manager working 14 hours. According to the dietary schedule the Dietary Manager worked December 16, 2025, until January 19, 2026, without a day off and worked 14 hour days during that time period. On 1/30/26 at 9:05 a.m., the Administrator provided a document dated 1/14/26 with a reviewed date of 1/29/26, titled, Facility Assessment Tool, and indicated it was the policy currently being used by the facility. The assessment indicated, .Staff type.The following types of staff and other professional practitioners reflect the staff necessary to care for the resident population.Food and Nutrition Services (e.g. Director, support staff, registered dietician) .Dietician or other clinically qualified nutrition profession to serve as the director or food and nutrition services (one) .Food and nutrition services staff (3). This citation relates to Intake 2727056. 3.1-20(h)

Based on observation, interview, and record review, the facility failed to assure staff provided safe and accurate administration of medication for 4 of 4 residents reviewed for pharmaceutical services (Residents D, E, F, and G). Findings include:1. During a random observation on 9/18/25 at 3:32 p.m., LPN 4 was observed seated at the 100 hall nurses' station. The desk had multiple cards of medications and plastic medication cups, with initials marked on the outer surface. LPN 4 was dispensing pills from the medication cards into her bare hands and placing the pills in the medication cups. She dropped a pill onto the desk surface, picked it up with her bare hands, and placed it into the medication cup. During the observation, LPN 4 indicated she was setting up her medications for administration later in her shift. There were nine filled medication cups, stacked one on top of the other, on the desk. She indicated these were for the east hall. The cups were labeled with initials in marker. The following was observed, with the Director of Nursing (DON), Nurse Consultant, and LPN 4 present: Resident E's cup contained two pills: one yellow, oblong; and one orange, round, and small. The Nurse Consultant later identified these as oxycarbazepin (to control seizures) 600 mg (milligram) and docusate sodium (to treat constipation) 100 mg, both medications were due to be administered between 6:00 p.m. and 10:30 p.m. A review of the resident's electronic Medication Administration Record (eMAR) indicated clonidine (to treat high blood pressure) 0.1 mg was due to be administered between 2:30 p.m. and 10:30 p.m. and had not yet been administered. The resident's medication cup, that had been prepared with the two other medications, lacked the clonidine tablet. Resident F's cup contained four pills: two white, oblong; one tan, oblong; and 1 small round. The Nurse Consultant later identified these as Vascepa (medication to lower triglycerides) 1 gram, due 6:00 p.m. to 10:00 p.m., metformin (to lower blood sugar levels) 500 mg, due 6:30 p.m. to 10:30 p.m., and rosuvastin 5 mg, due 6:00 p.m. to 10:00 p.m. A review of the resident's eMAR indicated magnesium oxide (a dietary supplement) 400 mg was due 6:00 p.m. to 10:30 p.m., primidon (to treat seizures or tremors) 50 mg was due 6:00 p.m. to 10:00 p.m., and sertraline (to treat depression) 100 mg was due 6:00 p.m. to 10:00 p.m. The resident's medication cup, that had been prepared with the three other medications, lacked the magnesium oxide, primidon, and sertraline tablets. Resident G's cup contained four pills: two yellow, oblong; one small, round; and one large, orange, oblong. The Nurse Consultant later identified these as oxycarbazepine 600 mg, furosemide (to treat edema) 20 mg, and calcium 600 with vitamin D3 (supplement). A review of the resident's eMAR indicated atorvastatin (to lower cholesterol) 40 mg was due 6:00 p.m. to 10:00 p.m, buspirone (to treat anxiety) 15 mg was due 6:00 p.m. to 10:00 p.m., gabapentin (to treat nerve pain) 100 mg (2 capsules for 200 mg dose) was due 6:00 p.m. to 10:30 p.m., pramipexol (to treat restless leg syndrome) 0.25 mg was due 6:00 p.m. to 10:00 p.m., sertraline 100 mg was due 6:00 p.m. to 10:00 p.m., and tizanidine (to treat muscle spasticity) 4 mg was due 6:00 p.m. to 10:30 p.m. The resident's medication cup, that had been prepared with the three other medications, lacked the atorvastatin, buspirone, two gabapentin, pramipexol, sertraline, and tizanidine medications. Resident G had an order for Xarelto 15 mg to be administered at 5:00 p.m. which was due to be administered prior to the 6:00 p.m. medications. During an interview on 9/19/25 at 3:48 p.m. the Nurse Consultant indicated at no time should medications be handled with bare hands. She indicated she believed staff were able to pre-set medications for one medication pass. The facility policy had referenced pre-pour, which she believed indicated prepare in advance. During an interview on 9/19/25 at 2:32 p.m., the DON indicated she believed pre-pour meant prepare in the facility policy. 2. During an interview on 9/18/25 at 2:55 p.m., Resident D indicated LPN 4 had tried to give him the wrong medications on two separate occasions while he was in the dining room for dinner. She would set a cup of medications down in front of him and walk away. He got her attention when she returned to give another resident their medication cup and told her the medications in his cup were not the ones he takes in the evenings. She indicated to him that they were not his medications, and she would return with his medications. On another occasion his sister was present at the dining table when LPN 4 set his medication cup down for him to take. He told his sister that these were not his medications, and his sister went to find LPN 4 to get his correct medications. The clinical record for Resident D was reviewed on 9/18/25 at 10:48 a.m. Diagnoses included hemiplegia/hemiparesis following a stroke affecting his right side, chronic respiratory failure, major depressive disorder, and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 8/5/25, indicated the resident was cognitively intact, had no delusions or hallucinations, no behaviors, and no rejection of care. During an interview on 9/19/25 at 1:21 p.m., Resident D's sister indicated she had visited Resident D for dinner and was seated in the dining room. LPN 4 brought his medication in a little, clear cup and set them down in front of him and indicated, here's your medications [Resident D], and left the dining room. Resident D looked at the medications and told her they were not his. She took the cup and went to locate LPN 4. She found her in the hallway and informed her the medications were not her brother's. LPN 4 replied that she had given him the wrong medications and took the cup. She later returned to the dining room and watched her Brother take his medications. She had reported this to the Director of Nursing the following day and the DON replied [Resident D] must be confused about what medications he's taking. The DON had not given her the opportunity to tell her that the nurse had admitted to providing the wrong medications. During an interview on 9/18/25 at 3:33 p.m., LPN 4 indicated she recalled the incidents with the medication cups. She had caught her error prior to the resident taking the cup. There was another occasion when she set another resident's cup of medications down for him to take and immediately realized her error and picked it back up. At no time had Resident D said anything to her about them not being his medications. Both times she had caught her error. He had not even known they were the wrong pills. A current facility policy, revised 4/2017, titled, Medication Administration, provided by the DON on 9/18/25 at 3:35 p.m., included the following: Purpose: To safely administer medications as per physicians' orders Preparation: .6. Never pre-pour medications .Infection Control: .3. Never touch medications with hands Guidelines for Medication Administration: .5. Medications are to be prepared just prior to administration. Never pre-pour medications for more than one medication pass 19. Always observe the resident taking their medication(s). This citation relates to Intake 1396147.

Based on observation and interview, the facility failed to assure nursing staff were using proper hygiene and infection control when preparing to administer medications for 1 of 2 observations for medication pass. Findings include:During a random observation on 9/18/25 at 3:32 p.m., LPN 4 was observed seated at the 100 hall nurses' station. The desk had multiple cards of medications and plastic medication cups, with initials marked on the outer surface. LPN 4 was dispensing pills from the medication cards into her bare hands and placing the pills in the medication cups. She dropped a pill onto the desk surface, picked it up with her bare hands, and placed it into the medication cup. She indicated she had not realized it was an issue after washing her hands. During an interview on 9/19/25 at 3:48 p.m. the Nurse Consultant indicated at no time should medications be handled with bare hands. A current facility policy, revised 4/2017, titled, Medication Administration, provided by the DON on 9/18/25 at 3:35 p.m., included the following: Purpose: To safely administer medications as per physicians' orders .Infection control: .3. Never touch medications with hands Guidelines for Medication Administration: 13. Never touch medications with your hands. This citation relates to Intake 1396147. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure residents were provided showers/bed baths as preferred for 2 of 3 reviewed for choices (Residents 41 and 40). Findings include: 1. During an interview, on 3/17/25 at 9:29 a.m., Resident 41 indicated he had requested to receive two complete bed baths twice a week, but it was a challenge to receive the bed baths because of the facility not having enough staff. He indicated the bed baths were scheduled to occur on Monday and Thursday evening, but they were not getting done twice a week as requested. Resident 41 would sometimes only receive a washcloth from staff to wash his face and armpits and that was all he would get washed because he was unable to complete the task himself. Resident 41's record was reviewed on 3/18/25 at 10:50 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 12/3/24, indicated the resident was cognitively intact and required 1 to 2 staff assistance with activities of daily living (basic tasks that individuals perform to maintain their health and well-being). Review of daily preference assessment, dated 8/29/24, indicated Resident 41 prefers bed baths two times a week in the evenings. Review of the scheduled showers/bed baths for the 200 hall, indicated Resident 41 was to receive a bed bath on Monday and Thursday from 2-4 p.m. Review of point of care (when healthcare services are provided) documentation, indicated the resident received a bed bath on 3/17/25, 3/10/25, 3/6/25, 2/24/25, 2/18/25. The record lacked documentation of a bed bath being completed on 3/13/25, 3/3/25, 2/27/25, and 2/20/25. In the last 30 days the resident didn't receive 4 of his scheduled bed baths. During an interview, 3/19/25 at 8:36 a.m., Certified Nurse's Aide (CNA) 6 indicated Resident 41 doesn't refuse his bed baths and was something he wanted to make sure he received as scheduled. The CNA indicated there were times she would have to stay past her scheduled shift to help the next shift get their showers/bed baths completed. There were times it was a challenge to get all tasks completed due to staffing. During an interview, on 3/19/25 at 2:07 p.m., the Administrator indicated Resident received his scheduled bed baths but was unable to provide documentation of the bed baths being completed by staff. 48226 2. On 3/16/25 at 2:21 p.m., during initial observation and interview Resident 40 indicated he did not receive regular showers. He indicated he was scheduled for two showers per week in the evenings but did not always receive them. On 3/17/24 at 11:00 a.m., Resident 40 record was reviewed. The most recent quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required 1 staff member for assistance with bathing and toileting. Review of the residents care plan dated 11/6/23, indicated the resident daily preferences were very important to him and he preferred to have two showers per week in the evening. A care plan dated 4/10/23, indicated the resident sometimes rejects care. Intervention included but not limited to attempt to determine the immediate cause for rejection. Seek solution if able. The medical record lacked documentation of resident refusals to take offered showers. On 3/18/25 at 1:44 p.m., during interview with Certified Nurse Aide (CNA)10., she indicated the residents are given showers at least two days a week and some are three days a week. She indicated the CNA's record of the shower on a document referred to as a shower sheet. Once it is filled out they turn the shower sheet into the Director of Nursing (DON) for review. She indicated blank shower sheet forms are kept in the nurses station, file cabinet. She indicated if the resident refused a shower they would complete a behavior sheet and a shower sheet, staple them together and report to the DON. She indicated Resident 40 was scheduled for two showers a week to be administered in the evenings. The CNA demonstrated the shower schedule was in the CNA record book and indicated the schedule is updated as needed. Review of the shower schedule indicated the resident was scheduled to be administered a shower on Mondays and Thursdays in the evening. On 3/18/25 at 2:26 p.m., during interview, CNA 9 indicated each resident is to receive two showers a week on the day or evening shift. And the shower schedule for each resident is in the CNA book. If a resident refused a shower, she would report it to the nurse and would complete a shower sheet. If the resident refused to take a shower she would record the refusal on a behavior sheet and a shower sheet. If the resident refused to sign the shower sheet she would record that as well. She would turn the behavior sheet and shower sheet into the DON. On 3/18/25 at 1:00 p.m., the DON provided several copies of CNA assignment sheet. The document indicated Resident 40 had refused some of the scheduled showers. The CNA assignment sheet was not part of the resident's medical record. The point of care record, part of the resident's medical record, lacked documentation indicating the resident had refused showers. On 3/18/25 at 1:30 p.m., the point of care documentation which was recorded by the CNA and was part of the medical record was reviewed. From December 1, 2024 to March 17, 2025 the resident was scheduled to receive a total of 30 showers. The record indicated the resident received 17 showers. From January 12 to 18, 2025 and March 16 to 18, 2025 the record lacked documentation of showers being administered. On 3/18/25 at 3:00 p.m., during interview the DON indicated if a resident refused a shower the staff would ask again and then they would ask the nurse to talk to the resident. She indicated if a resident refused to take a shower they do not have the resident sign a shower sheet. She indicated they have used shower sheets, but they use the CNA assignment sheet now and also document in the medical record. She indicated at times the staff would fill out a behavior sheet if the resident refused a shower, but many of the residents do not take regular showers. She indicated the residents should receive a minimum of 2 showers a week. The DON could not recall the last time the facility used shower sheets. I asked for a copy of any shower sheets they had used for Resident 40. The facility failed to provide requested documentation. On 3/19/25 at 9:34 a.m., during interview, CNA 3 indicated there were times when they did not have staff to administer showers. This had occurred mostly on the evening shift. She indicated she was not aware if Resident 40 had ever refused a shower. On 3/19/25 at 9:38 a.m., during interview Resident 40 indicated he had never refused a shower when it was offered. On 3/19/25 at 2:00 p.m., during an interview, the Administrator indicated Resident 40 had received several showers from the Occupational Therapist. The Administrator provided a document, dated 3/12/25, and indicated it was documentation of occupational therapy providing showers for the resident. The document lacked evidence of administration of a shower. She did not know if the staff could document a refusal in the resident's electronic record. The occupational therapy staff recorded showers they administered in their records. On 3/20/2025 at 11:54 a.m., the Regional Nurse Consultant provided a document, titled, Resident Rights, dated 9/17, and indicated it was the policy currently being used by the facility. The policy indicated, .This facility shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . This facility shall provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source 3.1-3(u)

Based on observations, interviews, and record reviews, the facility failed to ensure expired medications were disposed of for 1 of 2 medication carts and 1 of 2 medication storage rooms reviewed (Residents 36 and 26). Findings include: 1. On 3/19/25 at 09:35 a.m., the south hall medication cart contained two expired insulin (medication used to lower blood sugar) vials with an open date of 2/6/25. The insulin vials contained labels that indicated they were for Resident 36. During an interview, on 3/19/25 at 09:37 a.m., Qualified Medication Aide (QMA) 7 indicated insulin was good for 30 days once opened. The insulin vials in the cart should have been discarded. Resident 36's record was reviewed on 3/19/25 at 10:06 a.m. The profile indicated the resident diagnosis included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (occurs when the body either doesn't produce enough insulin or its cells don't respond properly to insulin, leading to a buildup of glucose [simple sugar] in the blood stream). A physician order, dated 2/5/25, indicated to administer Humalog (insulin medication) solution 100 unit/ml (milliliter). Inject 12 units subcutaneously (under the skin) three times daily. A physician order, dated 2/5/25, indicated to administer Lantus (insulin medication) solution 100 unit/ml. Inject 24 units subcutaneously at bedtime. 2. On 3/19/25 at 9:51 a.m., the north hall medication storage room contained an expired insulin pen (contains insulin in a cartridge that is administered into subcutaneous tissue through fine, replaceable needle) with an open date of 1/14/25, it was in the refrigerator, and it contained a label that indicated it was for Resident 26. During an interview, on 3/19/25 at 9:52 a.m., Qualified Medication Aide (QMA) 8 indicated insulin was good for 28 days once opened. She indicated she was unsure why the insulin pen was in the refrigerator and why it wasn't discarded. Resident 26's record was reviewed on 3/19/25 at 10:10 a.m. The profile indicated the resident diagnosis included, but were not limited to, type 2 diabetes mellitus without complications (a state where the body doesn't produce enough insulin or doesn't use it properly, leading to high blood sugar). A physician order, dated 12/11/24 with a discontinued date of 1/10/25, indicated to administer Humalog kwikPen 100 unit/ml. Inject 45 units subcutaneously twice a day. On 3/19/25 at 11:27 a.m., the Cooperate Nurse Consultant provided a document, dated 9/2017, titled, Medication Expiration, and indicated it was the policy currently being used by the facility. The policy indicated, .d. Multiple dose injections, such as insulin will expire 28 days after opening unless otherwise noted by manufacturer. 2. Facility staff shall date the label of any multi-use vial the first accessed and access the vial in a dedicated medication preparation area: If a multi-dose vial has been opened or accessed .the vial should be dated and discarded within 28 days unless the manufacturers specifies a different .date for the opened vial 3.1-25(o)

Based on observation and interview, the facility failed to label and date refrigerated and frozen food items, so it is used by its use-by date, frozen, or discarded, and the facility failed to prevent possible contamination of food in the refrigerator from water dripping onto food items for 2 of 2 kitchen observations. Findings include: On 3/16/25 at 10:05 a.m., during initial kitchen observation of refrigerated foods with Employee 11. The main refrigerator was observed with tomatoes in a clear plastic container date labeled with an opened date of 2/24. Two clear containers with lettuce inside with an opened date of 2/24. The tops of both containers were covered in water which was dripping down onto covered container of chicken noodle soup on the second shelf. The bottom of the refrigerator also had water on it and boxed food items were wet. On 3/16/25 at 10:10 a.m., an observation of freezer found an undated bag of frozen tater tots, two packages of undated frozen pie shells, two undated cakes, and four undated frozen pies. On 3/16/25 at 10:15 a.m., during interview employee 11 indicated the tots were from last night. She removed the item from the freezer and wrote a date on the bag. On 3/19/25 at 11:10 a.m., during second dietary kitchen observation with Employee 12. The refrigerator noted to have standing water on the top shelf of sealed food items. When moved, water spilled down inside of refrigerator and onto the floor. Boxes on the shelves were wet. Food items inside boxes were sealed. On 3/19/25 at 11:05 a.m., during interview the Dietary Manager indicated he did not know where the water in the refrigerator was from. On 3/18/2025 at 11:48 a.m., the Administrator provided a document titled, Magnolia Health Systems storage guidelines for Refrigerator/freezer/dry storeroom, dated 3/2017, and indicated it was the policy currently being used by the facility. The policy indicated, .Angel food cake 6-12 months, Pie Shells 12 months freezer, Shredded lettuce (opened) 3 days: reseal tightly, Tomatoes 3 days 3.1-21(i)(1) 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure documentation of the facility contact with the hospital prior to a resident transfer was completed timely for 1 of 4 residents reviewed for hospitalization (Resident 31). Findings include: Resident 31's record was reviewed on 3/17/25 at 2:31 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs), cerebral infarction (a condition where brain tissue dies due to a lack of blood flow caused by a blockage in a blood vessel), and late-onset Alzheimer's disease (a common form of dementia that starts after the age of 65. It can cause memory and cognition issues, impaired judgment, and other symptoms as it progresses). A 5-day Minimum Data Set (MDS) assessment, dated 2/4/25, indicated the resident had moderate cognitive deficit, was totally dependent with all activities of daily living (ADLs-fundamental tasks essential for independent living, including basic self-care and mobility, like bathing, dressing, eating, and toileting), and required continuous oxygen (O2). The census indicated that the resident had been hospitalized from 3/9/25 to 3/13/25. The initial review of the record lacked documentation of facility contact with the hospital emergency room (ER) to provide a report of the transfer. During a follow-up review of the resident's record, on 3/18/25 at 2:10 p.m., a late entry progress note, dated 3/18/25 at 1:48 p.m. for 3/9/25, indicated the family and ER had been notified. At the same time the Corporate Nurse Consultant indicated it was dated a late entry on 3/18/25, because the note had just been placed in the record. The note had been added as a plan of correction after it was discovered that there had not been a note written at the time of the transfer. On 3/18/25 at 3:40 p.m., the Administrator provided a document, dated 10/2014, titled, Charting and Documentation, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Nurse's notes shall be written on each resident .and shall address the resident's conditions .entries shall be dependent on individual residents' needs and any pertinent change in condition .Document significant information 3.1-50(a)(1) 3.1-50(a)(2) 3.1-50(h)(5)(F) 3.1-50(i) 3.1-50 (a)(1)(h)(3)

Based on observation, record review, and interview, the facility failed to ensure proper handling of the glucometer (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) meter during 2 of 2 blood glucose monitoring opportunities (Residents 42 and 35). Findings include: 1. During a blood glucose monitoring observation, on 3/19/25 at 11:11 a.m., the Qualified Medication Aide (QMA) 7 entered Resident 42's room and placed the glucometer onto her side table, no barrier placed under the meter. The QMA returned the glucometer to a resident specific black case and placed it back in the medication cart. Resident 42's record was reviewed on 3/19/25 at 1:10 p.m. The profile indicated the resident diagnosis included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (occurs when the body either doesn't produce enough insulin or its cells don't respond properly to insulin, leading to a buildup of glucose [simple sugar] in the blood stream). 2. During a blood glucose monitoring observation, on 3/19/25 at 11:17 a.m., QMA 7 entered Resident 35's room and placed the glucometer onto her side table, no barrier placed under the meter. The QMA returned the glucometer to a resident specific black case and placed it back in the medication cart. During an interview, on 3/19/25 at 11:17 a.m., QMA 7 indicated the night shift nurses clean the glucometers, but she also cleans the machines at the end of her shift daily. Resident 26's record was reviewed on 3/19/25 at 1:20 p.m. The profile indicated the resident diagnosis included, but were not limited to, type 2 diabetes mellitus without complications (a state where the body doesn't produce enough insulin or doesn't use it properly, leading to high blood sugar). During an interview, on 3/20/25 at 9:11 a.m., QMA 10 indicated a paper towel should be placed under the glucometer as a barrier when placing the glucometer on a surface. She indicated this was to prevent any cross contamination. On 3/19/25 at 1:30 p.m., the Cooperate Nurse Consultant provided a document, dated 10/2014, titled, Blood Glucose Measurement, Evencare G2, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Select the resident specific meter/case to be utilized. Place a clean paper towl on the bedside table or stand. Place the close case on the paper towel 3.1-18(a)

Based on observation, record review, and interview, the facility failed to update care plans with post fall interventions for 4 of 6 residents reviewed for falls (Residents B, C, H, and K). Findings include: 1. On 6/6/24 at 2:30 p.m., observed Resident A sitting up in wheel chair she was propelling herself in the hall. She had both shoes and socks on. She had difficulty communicating related to aphasia. Bed alarm was on the bed under an incontinent pad. Chair alarm was not visible on the wheelchair. On 6/7/24 at 11:57 a.m., observed Resident A, sitting in wheelchair in the main dining room. A call alarm was on the wheelchair with the alarm device on the back of the chair. On 6/6/24 at 10:49 a.m., the medical record for Resident A was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, hemiplegia, unspecified affecting right dominant side (a loss of strength in the arm, leg, and sometimes face on one side of the body), unsteadiness on feet, muscle weakness (generalized), vascular dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body), and hemiparesis (a relatively mild loss of strength) following cerebral infarction affecting right dominant side, aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) following cerebral infarction (stroke), and expressive language disorder. On 5/18/24 the resident fell , sustained a laceration to her head and was sent to the emergency room (ER) for sutures. Additional falls occurred on 4/8/24, 4/3/24, and 5/20/24 with no injuries reported from these falls. A quarterly Minimum Data Set (MDS) assessment indicated the cognition level of the resident was poor. The MDS lacked documentation of level of assistance required for transfers and mobility. A care plan, dated 12/5/23, indicated the resident was at risk for falls. A care plan, dated 1/25/24, indicated falls. The record lacked evidence of post fall immediate interventions. A care plan, dated 4/10/24, indicated falls with injury. The record lacked evidence of post fall immediate interventions. A care plan, updated 6/8/22, indicated she was an assist of one for Activities of Daily Living (ADL) and transfers and indicated the resident had a fall risk assessment dated [DATE]. An undated intervention indicated staff moved the resident's room closer to the nurses' station. On 5/18/24 an intervention indicated the resident sustained an injury requiring an ER visit. An intervention, dated 5/18/24, indicated monitor for attempts safe transfer remind to ask for assistance and use call light. The care plan did not indicate what the attempts were, and the record lacked documentation of monitoring. An intervention, dated 5/20/24, indicated to change alarm. An intervention was entered on 5/30/24 indicating a chair alarm. An intervention, dated 5/30/24, indicated position change alarm. The care plan lacked evidence of interventions for prevention of falls corresponding to a care plan root cause. 2. On 6/6/24 at 2:00 p.m. the medical record for Resident C was reviewed. Documentation indicated on 11/13/23 at 7:00 p.m., Resident C, fell out of wheelchair. The record lacked evidence of post fall immediate interventions. A care plan, dated 11/8/23, indicated falls. A care plan, dated 2/7/24, indicated falls with injury. The record lacked evidence of post fall care plan with immediate interventions. On 6/27/19 an intervention for anti-rollbacks to wheelchair was entered. An intervention dated 4/16/24 indicated frequent reminders to not sit back, hand on wheelchair and request assistance as needed. The record lacked documentation of interventions related to the root causes for the 11/8/23 fall, 2/7/24 fall with injury, and 4/16/24. 3. On 6/6/24 at 3:00 p.m., the medical record of Resident H was reviewed. Director of Nursing indicated the resident had fallen in the last 60 days. The record lacked documentation of a fall. A care plan, dated 2/14/19, indicated the resident was at risk for falls. An intervention, dated 2/21/20, indicated Dycem per Medical Doctor (MD) order. An intervention, dated 5/30/24, indicated a Broda Chair when up out of bed for comfort and safety. The record lacked documentation of post fall immediate interventions for the fall within the last 60 days. 4. On 6/7/24 at 11:30 a.m., during routine observation of Resident K, observed resident sitting on edge of bed. Call light was within reach and wheelchair sitting next to bed. The resident indicated he was not trying to get up he was just resting. He was alert and oriented indicated he had three falls while at the facility but no injuries from the falls. He knew to ask the staff for assistance. On 6/6/24 at 3:30 p.m., the medical record of Resident K reviewed. A care plan, dated 5/16/24, indicated the resident was at risk for falls. An intervention, dated 5/17/24, indicated to ensure door to room was open when leaving room for safety unless resident requested otherwise. The record lacked documentation post fall immediate interventions. On 6/6/24 at 1:57 p.m., during an interview Qualified Medication Aide (QMA) 4, indicated the care plans were on the paper chart. She was not sure who updated the care plans. On 6/6/24 at 2:02 p.m., during an interview with the Regional Nurse Consultant, she indicated the CNAs and nurses received report and discussed falls and interventions at that time. The interdisciplinary team (IDT) team updated the care plan after every fall with interventions initiated. On 6/7/24 at 9:30 a.m., the Regional Nurse Consultant provided a document, titled, Care Plan Development and Review, dated 9/17, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .7. The comprehensive care plan shall be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments .9. Care plans shall be re-written as needed to maintain an up-to-date legible document .Communication to personnel .2. Care plan interventions specific to direct care personnel will be included on the direct caregiver's assignment sheet, or similar tool in use This citation relates to Complaint IN00435269 3.1-35(c)(1)

Based on observation and interview, the facility failed to ensure clean linen was carried away from the body and failed to ensure soiled linen was in a container while transporting in the hallway during 5 of 5 random observations for linen handling. Findings include: During a random observation on 2/28/24 at 10:01 a.m., Certified Nursing Assistant (CNA) 21 retrieved a stack of linens from the clean linen closet located in the 100 hall, she then held the linens against her body while transporting them to a resident's room. During a random observation on 2/28/24 at 11:00 a.m., CNA 21 retrieved a stack of linens from the clean linen closet located in the 100 hall, she held the linens against her body while transporting. During a random observation on 2/29/24 at 9:50 a.m., Employee 3 was observed coming out of a resident's room on the 200 hallway wearing gloves and holding soiled linens that were unbagged against her body. She left the resident's room and indicated she needed to take the linens to the hopper. During a random observation on 2/29/24 at 2:48 p.m., CNA 20 retrieved a stack of linen from the clean linen closet located in the 100 hall, transported the linens against her body while entering a resident's room, walked out of the room still holding the linens against her body and transported them to a shower room. During a random observation on 3/01/24 at 8:45 a.m., CNA 21 retrieved a stack of linen from the clean linen closet located in the 100 hall and transported the linens against her body. During an interview on 2/28/24 at 3:01 p.m., Employee 8 indicated that staff were not to carry linens against their body and soiled linens were supposed to be transported in a plastic bag. During an interview on 3/1/24 at 9:55 a.m., CNA 22 indicated when they remove dirty linen it was to be put in a bag and then taken to the hopper room and placed in the linen barrel. When they remove linen from the clean linen closet, they were supposed to hold the items away from their body, never against their body. On 3/1/24 at 10:12 a.m., the Regional Nurse Consultant (RNS) provided and identified a document as a current facility policy titled, Linen, Handling, dated 12/2015. The policy indicated, . The facility shall handle linen in a manner to prevent the spread of infection . Procedure .2. Linen will not be carried against the body .7. Soiled linen will be placed in a container (i.e., linen barrel, plastic bag, etc.) prior to taking it into the hallway 3.1-18(b)(1)

Based on observation, record review, and interview, the facility failed to ensure a call light device was in reach for 1 of 16 residents reviewed for call light placement (Resident 34). Findings include: On 2/26/24 at 2:52 p.m., Resident 34's call light was observed to be draped on the outlet against the wall and out of reach. The resident indicated that staff stopped giving one to her recently, so she needed to ask for things when they came in. The resident indicated that she could not move her arms or legs very much and could not turn herself in bed without assistance. The resident was observed to be laying on her left side and the bed was positioned diagonally away from the call light device. On 2/27/24 at 11:57 a.m., Resident 34's call light was observed to be draped on the outlet against the wall and out of reach from the resident. On 2/28/24 at 11:04 a.m., Resident 34 requested help getting assistance from staff, her call light was observed to be draped on the outlet against the wall and out of reach from the resident. Resident 34's record was reviewed on 2/27/24 at 11:49 a.m. The profile indicated that the resident's diagnoses included, but were not limited to, right knee contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), left knee contracture, muscle weakness, stiffness of left hand, and gastrostomy status (the placement of a feeding tube through the skin and the stomach wall). An annual Minimum Data Set (MDS) assessment, dated 1/1/24, indicated Resident 34 was cognitively intact and had functional limitation in range of motion in the upper extremity (shoulder, elbow, wrist, hand) on both sides and in the lower extremity (hip, knee, ankle, foot) on both sides. She was dependent and required assistance for turning and repositioning in bed, and her vision was moderately impaired. During an interview with the Director of Nursing (DON) on 2/28/24 at 2:44 p.m., she indicated that Resident 34 did not use her call light very often and she was not ordered to have a soft touch call light. Resident 34's call light was observed with the DON. The call light was draped on the outlet against the wall and out of reach of the resident. The DON indicated that it should not be on the wall and then placed it within reach of the resident. On 3/1/24 at 10:12 a.m., the Regional Nurse Consultant (RNS) provided and identified a document as a current facility policy, titled, Call Light dated 10/2014. The policy indicated, .Purpose: Resident will have a call light to summon facility personnel to ensure the resident's needs will be met . Procedure . 8. Call lights must remain functional and within reach of each resident. Call lights must not be disabled. Call lights must not be removed from resident's reach 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure pressure ulcer treatments were completed by qualified staff and staff followed proper standards of practice for 1 of 1 residents reviewed for pressure ulcer care (Resident 29). Findings include: During an interview, on 2/26/24 at 10:54 a.m., Resident 29 indicated he had an open area to his bottom, and it had been there for a few months. He indicated it was a facility acquired pressure ulcer. During an interview, on 2/28/24 at 10:20 a.m., the Qualified Medication Aide (QMA) 6 indicated she had already completed Resident 29's dressing change to his open area in the morning and it was a dayshift dressing change daily. During an interview, on 2/29/24 at 9:11 a.m., Registered Nurse (RN) 14 indicated a QMA would need to let the nurse know that a dressing change needed to be completed because QMAs were not licensed to perform a pressure ulcer dressing change. During an interview, on 2/29/24 at 10:13 a.m., Resident 29 indicated there were two QMAs who normally completed the pressure ulcer dressing change to his bottom, and they were QMA 5 and QMA 6. During an interview, on 2/29/24 at 10:25, the Regional Nurse Consultant indicated it was against the company's policy for a QMA to complete a dressing change on a pressure ulcer that was greater than a stage I (pressure related alteration of intact skin with non-blanchable redness over a bony prominence) pressure ulcer. Resident 29's record was reviewed on 2/28/24 at 10:43 a.m. The profile indicated the resident diagnoses included, but were not limited to, Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems), and pressure ulcer of sacral region (pressure injuries occur when a bony prominence, such as sacrum, is subjected to prolonged pressure and can result in soft tissue injury). An annual Minimum Data Set (MDS) assessment, dated 2/7/24, indicated the resident was cognitively intact and had a stage III (full thickness tissue loss where subcutaneous fat may be visible) pressure ulcer. A care plan, dated 11/22/23, indicated the resident was at risk for the development of pressure ulcers related to the history of stage IV (severe full thickness tissue loss where muscles, bones, and/or tendons may be visible) pressure ulcer on sacrum. Interventions included, but were not limited to, low air loss mattress, pressure reducing cushion to chair, and staff to observe skin condition while providing care. Review of initial pressure ulcer assessment sheet, dated 12/12/23, indicated a stage III pressure ulcer to left coccyx. The wound measured 3 centimeters (cm) by (x) 1.5 cm with a depth of 1.8 cm. A physician order, dated 12/12/23 with an end date of 12/28/23, indicated wet to dry dressing to sacral wound, change daily and as needed for soilage. A physician order, dated 12/28/23 with an end date of 2/22/24, indicated cleans open area with normal saline, may use wound cleanser, pat dry. Apply skin prep to peri-wound (tissue surrounding wound). Apply wet to dry gauze, cover with Mepilex, once a day. Review of December 2023, MAR's (Medication Administration Record) indicated QMA 6 documented as completing the dressing change to Resident 29's stage III pressure ulcer 7 out of 19 days. QMA 11 documented completing the dressing change 5 out of 19 days. QMA 16 documented completing the dressing change 4 out of 19 days. A care plan, dated 1/11/24, indicated the resident had a pressure ulcer. Interventions included but not limited to, dressing change daily per medical doctor order, notify physician of any signs and symptoms of infection, and pressure relieving devices in place. Review of January 2024, MARs indicated QMA 5 documented completing the dressing change to Resident 29's stage 3 pressure ulcer 1 out of 28 days. QMA 6 documented completing the dressing change 11 out of 28 days. QMA 16 documented completing the dressing change 6 out of 28 days. Review of weekly skin assessment, dated 2/23/24, indicated the current wound measured 3 cm x 1.4 cm with a depth of 0.9 cm. A physician order, dated 2/22/24, indicated cleanse open area with normal saline, may use wound cleanser, pat dry, and apply skin prep to peri-wound. Cut Puracol wound dressing into rope and fit into wound bed. Cover with Mepilex, once a day. Review of February 2024, MARs indicated QMA 6 documented as completing the dressing change to Resident 29's stage III pressure ulcer 19 out of 28 days. QMA 16 documented completing the dressing change 1 out of 28 days. During an interview, on 3/1/24 at 9:26 a.m., QMA 16 indicated she had not performed any dressing changes on a wound greater than stage I because it was not allowed with her license. During an interview, on 3/1/24 at 9:28 a.m., QMA 11 indicated she would not perform any dressing changes that were not allowed under her license as a QMA. During an interview, on 3/1/24 at 9:38 a.m., the Director of Nursing (DON) indicated a QMA may only complete a dressing change on a wound that was a stage I or less. She was aware that the QMA's were signing off on the MAR that they were completing the dressing change to Resident 29's wound and that they would be educated on not signing off things that were beyond their scope of practice. On 2/29/24 at 11:01 a.m., the Regional Nurse Consultant provided an undated document titled, Qualified Medication Aide, Scope of Practice, and indicated it was the current policy being used by the facility. The policy indicated, .The following tasks shall NOT be included in the QMA scope of practice .(6) Administer a treatment that involves advanced skin conditions, including stage II, stage III, stage IV decubitus ulcers On 2/29/24 at 11:01 a.m., the Regional Nurse Consultant provided a document, with a year of 2023 titled, Job Description, Qualified Medication Aide, and indicated it was the current policy being used by the facility. The policy indicated, .6. Administer medications/treatments as taught per Indiana QMA curriculum 3.1-35(g)(1)

Based on record review, observation, and interview, the facility failed to provide treatment to prevent further decrease in range of motion for 1 of 2 sampled residents reviewed for range of motion (Resident 32). Findings include: On 2/26/24 at 11:10 a.m., during a routine observation, Resident 32 was sitting in a wheelchair. The left hand was contracted in a fist position, nails were long and touching the inside of the palm of the hand. No anti-contractual device was in Resident 32's hand. During an observation on 2/28/24 at 11:00 a.m., Resident 32 was sitting in a wheelchair in the activity lounge area. The left hand was contracted in a fist position, no anti-contracture device was in the left hand. During an interview, on 2/27/24 at 2:44 p.m., the Director of Nursing (DON) indicated if a resident had a contracture of the limbs, therapy evaluated the resident, and the therapist would decide if the resident needed an anti-contracture device. During an interview on 2/28/24 at 11:13 a.m., the Certified Occupational Therapy Assistant (COTA) indicated when a resident needed to be assessed the evaluation request was given to the therapist. Before the evaluation was completed and the therapist obtained an order from the physician to evaluate and treat the resident. The evaluation was completed by the therapist or the COTA. The information was placed in the hard copy chart. The COTA acknowledged the resident was to be evaluated on 2/28/24 for the contracture of the left hand. She received a referral to evaluate the resident last week, but she had not gotten to it yet. During an interview on 2/28/24 at 11:24 a.m., Certified Nurse Aide (CNA) 13 indicated the resident did not have an anti-contracture device in her left hand. She indicated the resident would probably not allow them to place anything in her hand. During an interview on 2/28/23 at 1:47 p.m., the Regional Nurse Consultant indicated she spoke to the COTA last week about the resident's contracture of her left hand. She thought an order was obtained for an evaluation. She acknowledged the contracture was not recent and an evaluation with treatment order by the physician had not been obtained. On 2/29/24 at 10:51 a.m., Resident 32's medical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses, dated 5/5/23, include, but are not limited to, Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body), and hemiparesis (a relatively mild loss of strength) following nontraumatic subarachnoid hemorrhage (subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover the brain) affecting left non-dominant side, muscle weakness (generalized), hypertension (high blood pressure), chronic obstructive pulmonary (a group of diseases that cause airflow blockage and breathing-related problems), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), not due to a substance or known physiological. Resident had a diagnosis, dated 6/1/23, of dysphagia (difficulty swallowing), oropharyngeal phase (the middle part of the throat, behind the mouth). The record lacked documentation of orders to complete range of motion (ROM), or prevention of contractures. A quarterly Minimum Data Set, (MDS), dated [DATE], indicated the resident was cognitively impaired and had mobility impairment to the left upper side. A care plan, dated 5/5/23, indicated the resident was at risk for complications related to hemiplegia/hemiparesis related to impaired physical mobility. Interventions included, but were not limited to, range of motion to be performed and repositioning of affected limb(s) by nursing staff due to impaired physical mobility. Documentation lacked evidence that range of motion had been provided by the nursing staff. On 3/1/2024 at 10:30 a.m., the Director of Nursing (DON) provided a document titled, Joint Mobility Screen, dated 10/2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose .To identify those residents who may be at risk for contractures/decreased range of motion .Procedure .2. Possible interventions included but were not limited to active or passive range of motion at least twice daily, O.T./P.T. (occupational therapy/physical therapy) screening and or treatments .assessment of contractures on a regular basis .3. Applicable recommendations will be made to the attending physician and orders obtained accordingly per their discretion .4. Interventions will be addressed on the individual care plan .5. The joint mobility screen shall be re-evaluated/completed .as necessary relative to .significant change in condition affecting range of motion, etc 3.1-42(a)(1) 3.1-42(a)(2) 3.1-42(a)(3)

Based on interview and record review, the facility failed to ensure a timely intervention and accurate documentation were completed after an incident resulting in actual harm when a resident experienced pain and delayed surgical intervention for a fracture for 1 of 2 residents reviewed for accidents (Resident 41). Findings include: During an interview, on 4/6/22 at 1:59 p.m., Resident 41 indicated she used to sleep and receive all care in her Broda chair (a specialized tilting positioning chair). A few months ago, staff provided incontinence care in the Broda chair, she rolled over, and heard an audible pop. Immediately afterwards, she felt pain. There was an x-ray completed in the facility, but no fracture was found. The fracture was not found for 12 days. She ended up having surgery. Resident 41's record was reviewed on 4/7/22 at 2:10 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) assessment, dated 3/11/22, indicated the resident was cognitively intact and was totally dependent on two staff members for bed mobility. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An accident and incident report, dated 7/15/21 at 8:00 a.m., indicated the resident rolled self over in bed by using the rail. Resident and staff heard a popping sound. Resident stated it hurt. The physician was notified, and an x-ray order was obtained. Two certified nursing assistants (CNA's) were in the room, stated the resident turned, and they heard a pop. A nurse's note, dated 7/15/21 at 8:00 a.m., indicated there were two CNAs in the resident's room when she rolled herself over. All three heard a pop. The resident complained of pain. The physician was notified and ordered an x-ray. A telephone order, dated 7/15/21, indicated to apply ice to the area, give Tylenol 1000 mg by mouth now, and stat (urgent) x-ray of right femur and hip related to severe pain. An x-ray report of the right hip, dated 7/16/21 at 3:18 p.m., indicated mild [CONDITION(S)] (a wearing down of flexible tissues at the ends of joints) of the right hip, no definite acute fracture. The report recommended to consider more sensitive imaging with computerized tomography (CT) (a medical imaging technique used in radiology to obtain detailed internal images of the body noninvasively for diagnostic purposes) as clinically directed. An x-ray report of the right femur, dated 7/16/21 at 3:18 p.m., indicated limited study with no orthogonal (images taken at 90 degrees of each other) view, therefore cannot rule out fracture or dislocation. A telephone order, dated 7/16/21, ordered a computerized tomography (CT) (a medical imaging technique used in radiology to obtain detailed internal images of the body noninvasively for diagnostic purposes) of right lower extremity. A telephone order, dated 7/19/21, indicated to apply Biofreeze (a topical ointment for pain relief) three times a day PRN for pain. A CT scan of the right lower extremity and femur without intravenous (IV) contrast, dated 7/26/21 at 2:03 p.m., indicated a nondisplaced basicervical (a fracture at the junction between the femoral neck and intertrochanteric [between the bony protrusions of the thigh bones] region) fracture of the right femoral neck with extension to the greater trochanter (the outside point of the hip). A nurse's note, dated 7/27/21, indicated the CT results were back. The physician at the hospital was consulted and ordered to send the resident to the hospital emergency room (ER). The primary care physician was notified. A telephone order, dated 7/27/21, indicated may go to ER for evaluation and treatment. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -On 7/15/21 at 8:00 a.m. for pain 8/10 which was effective, 7/15/21 at 12:00 p.m. for pain 8/10 which was effective, 7/15/22 at 4:00 p.m. for pain 7/10 which was ineffective, and 7/15/22 at 8:00 p.m. for pain 7/10 which was ineffective. -On 7/16/22 at 12:00 a.m. for hip pain 9/10 which was effective, 7/16/21 at 8:00 a.m. for pain 7/10 which was effective, 7/16/21 at 12:00 p.m. for pain 7/10 which was effective, 7/17/21 at 12:00 a.m. for pain in right hip 8/10 which was effective, 7/17/21 at 8:00 a.m. for pain 8/10 which was effective, 7/17/21 at 12:00 p.m. for pain 8/10 which was effective, and 7/17/21 at 4:00 p.m. for pain 7/10 which was effective. -On 7/18/21 at 12:30 a.m. for pain 7/10 which was effective, 7/18/21 at 4:00 p.m. for pain 7/10 which was effective, and 7/18/21 at 8:00 p.m. for pain 7/10 which was effective. -On 7/19/21 at 12:00 a.m. for pain 7/10 which was effective, 7/19/21 at 8:00 a.m. for pain at 7/10 which was effective, and 7/19/21 at 12:00 p.m. for pain 7/10 which was effective. -On 7/20/21 at 12:00 a.m. for pain 7/10 which was effective, 7/20/21 at 8:00 a.m. for generalized pain at 7/10 which was effective, 7/20/21 at 12:00 p.m. for generalized pain at 7/10 which was effective, 7/20/21 at 4:00 p.m. for pain at 7/10 which was effective, and 7/20/21 at 8:00 p.m. for pain at 7/10 which was effective. -On 7/21/21 at 12:00 a.m. for pain 7/10 which was effective, 7/21/21 at 8:00 a.m. for pain 7/10 which was effective, 7/21/21 at 12:00 p.m. for pain 7/10 which was effective, 7/21/21 at 4:00 p.m. for pain 7/10 which was effective, 7/21/21 at 8:00 p.m. for pain 7/10 which was effective, and 7/22/21 at 12:00 a.m. for pain 7/10 which was effective. -On 7/22/21 at 8:00 a.m. for pain 8/10 which was effective, 7/22/21 at 12:00 p.m. for pain 8/10 which was effective, 7/22/21 at 4:00 p.m. for pain 7/10 which was effective, and 7/22/21 at 8:00 p.m. for pain 7/10 which was effective. -On 7/23/21 at 12:00 a.m. for pain 7/10 which was effective, 7/23/21 at 8:00 a.m. for generalized pain 7/10 which was effective, 7/23/21 at 12:00 p.m. for generalized pain at 7/10 which was effective, 7/23/21 at 4:00 p.m. for generalized pain at 7/10 which was effective, and 7/23/21 at 8:00 p.m. for generalized pain which was effective. -On 7/24/21 at 8:00 a.m. for pain at 7/10 which was effective, 7/24/21 at 12:00 p.m. for pain 7/10 which was effective, 7/24/21 at 4:00 p.m. for pain 7/10 which was effective, and 7/24/21 at 8:00 p.m. for pain 7/10 which was effective. -On 7/25/21 at 12:00 a.m. for pain 8/10 which was effective, 7/25/21 at 8:00 a.m. for generalized pain 7/10 which was effective, 7/25/21 at 12:00 p.m. for pain 7/10 which was effective, 7/25/21 at 4:00 p.m. for pain 7/10 which was effective, 7/25/21 at 8:00 p.m. for pain 7/10 which was effective, and 7/26/21 at 12:00 a.m. for pain 7/10 which was effective. -On 7/26/21 at 8:00 a.m. for pain 7/10 which was effective, 7/26/21 at 12:00 p.m. for pain 7/10 which was effective, and 7/26/21 at 4:00 p.m. for pain 7/10 which was effective. -On 7/27/21 at 12:00 a.m. for pain 7/10 which was effective, 7/27/21 at 8:00 a.m. for pain 7/10 which was effective, and 7/27/21 at 12:00 p.m. for pain 7/10 which was effective. The July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An orthopedic staff initial consult notes, dated 7/27/21, indicated the patient presented to the ER with right hip pain. The patient reported about a week and a half ago she was being transferred at the nursing home, was rolled on her side, and felt and heard a loud pop in her right hip. She had immediate sharp pain. Since then, she had persistent pain in the hip and difficulty with any motions and transfers. An orthopedic staff progress note, dated 7/28/21, indicated the patient had a right hip intertrochanteric fracture. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Since the patient had persistent pain and inability to tolerate positioning in bed or transfers, surgical stabilization was reasonable. An operative note, dated 7/28/21, indicated the patient presented with right hip pain after feeling a pop while transferring. Pre-operative imaging demonstrated an intertrochanteric hip fracture. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surgical intervention was recommended to allow for stabilization, early weight bearing and mobilization, and avoidance of complications of bed rest. The patient agreed and moved forward with the procedure. A right hip closed reduction (a procedure to set a broken bone) and intramedullary nail (a rod placed to repair and stabilize a broken bone) placement was performed. A nurse's note, dated 7/30/21, indicated the resident had returned to the facility. During an interview, on 4/8/22 at 10:52 a.m., the Director of Nursing (DON) indicated she thought the resident was in bed when the incident occurred in July 2021. She was working the floor that day and followed up with the resident. During an interview, on 4/8/22 at 12:06 p.m., the DON indicated the physician did not want to send the resident to the ER after the incident in July 2021. At the time of the x-ray, they got her scheduled for a CT scan, but it took a while to get her in. She was not sure if the resident wanted to go to the hospital but did not think the resident had really thought there was a fracture. During an interview, on 4/8/21 at 1:51 p.m., Resident 41 indicated after the incident with her hip popping on 7/15/21, and until it was surgically repaired her hip was in very bad pain. She reported it to multiple staff members. Prior to the incident, she was able to roll and participate in care, but afterwards the pain was too bad for her to do anything. She was never asked if she wanted to go to the hospital. She wanted to go to the hospital because she could have had the fracture repaired more quickly. CNA 14 was in the room when the incident occurred, and Licensed Practical Nurse (LPN) 15 provided care to her afterwards. During an interview, on 4/8/22 at 2:23 p.m., LPN 15 indicated she had not worked at the time of the incident but had provided care to the resident later. The resident complained of pain but had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident continued to complain of pain after the x-ray. The CT scan was obtained, and the fracture found at a later date. During an interview, on 4/8/22 at 2:50 p.m., CNA 14 indicated she was in the room providing care to the resident when the incident on 7/15/21 at 8:00 a.m. occurred. The resident was in the Broda chair, not bed, when the incident occurred. At that time, the resident stayed in the Broda chair all the time and received care in the chair. The resident was provided incontinence care in the Broda chair, rolled over, and an audible pop was heard. It was reported to the nurse. After it occurred, the resident refused to be touched or allow care to be completed. The resident yelled out and said her hip hurt. During an interview, on 4/8/22 at 3:01 p.m., Qualified Medication Aide (QMA) 13 indicated she was familiar with the resident. She provided care to the resident after the incident occurred but was not in the room when it happened. The day after the incident occurred, she was able to get the resident out of the Broda chair and into bed. The resident screamed and cried with pain during care. Prior to the incident, the resident was able to receive incontinence care with one staff member. After the incident occurred QMA 13 brought another staff member with her to provide all care to the resident because she was in so much pain. It was unusual for the resident to require two staff members to roll in bed. She reported the pain the resident experienced to the nurse. During an interview, on 4/11/22 at 9:53 a.m., the DON indicated if an x-ray was requested in the morning, sometimes the x-ray service was able to get it done the same day. If it was not requested until later in the day, then they usually did not get it done until later the following day. She was not sure why it took so long to get Resident 41's stat x-ray completed. During an interview, on 4/11/22 at 10:17 a.m., the DON indicated stat x-rays should have been completed the same day, and she was not sure why Resident 41's was not done until the following day. As of the exit conference on 4/13/22, no clarification was provided for the contradicting information on if the resident was in the bed or the Broda chair at the time of the incident. On 4/11/22 at 11:34 a.m., Registered Nurse (RN) 5 consultant, provided a document titled, CHANGE IN RESIDENT CONDITION/EMERGENCY TRANSFER TO ACUTE CARE HOSPITAL, and indicated it was the policy currently being used by the facility. The policy indicated, .PURPOSE: Resident condition changes are reported to the physician, in a timely manner, in order to ensure provision of necessary care. POLICY: In the event a resident's condition changes warranting medical attention, the licensed nurse shall complete the SBAR Communication Form and contact the physician. If the physician cannot come to the facility and examine the resident, the nurse shall request an order to transport resident to the emergency room for evaluation, if indicated .PROCEDURE: .At the time of a critical condition change, the decision to transfer for emergency treatment may be made by the Director of Nursing or designee .Attempts would then be made to contact the resident's physician making him/her aware of resident status and necessary transfer 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure the physician was notified when a resident reported new onset right flank pain and requested to be sent to the hospital that resulted in harm when the resident was admitted to the hospital with [REDACTED]. The facility failed to ensure a resident with constipation was assessed and the physician bowel protocol was followed resulting in the potential for harm that is harm for 1 of 5 resident's reviewed for unnecessary medications (Resident 9). Findings include: 1. During a random observation, on 2/24/20 at 10:52 a.m., Resident 42 was observed in her room. At this time, the resident indicated in September of 2019 she had reported to the nurse she had pain and thought she had a kidney stone, she believed this to be a Wednesday night around 10:00 p.m. She requested to be sent to the hospital and the nurse on duty told her she would pass that on to the night shift nurse. On Thursday she had reported her pain to the dayshift nurse and again at around 2:00 p.m. requested to be sent out to the hospital. She was unsure if the physician had been notified. At around 7:00 p.m. the evening shift nurse assessed her when she reported not feeling well again and was sent out to the hospital. Resident 42's record was reviewed, on 2/28/20 at 9:07 a.m. [DIAGNOSES REDACTED]. A nurse's progress note, dated 9/18/19 at 9:40 p.m., indicated a Certified Nursing Assistant (CNA) had reported the resident was crying and reported she had a kidney stone. A nurse's progress note, dated 9/18/19 at 9:45 p.m. indicated the resident was checked on and was not crying. The writer (nurse) asked the resident what they had done for her kidney stones in the past and the resident indicated they had sent her to the hospital for x-rays, pain medication, and possible surgery. At that time, the writer indicated she would pass it along and see what the physician would recommend. The progress notes lacked documentation the physician had been notified of the resident's complaint of right flank pain and concern of kidney stone. A Medication Administration Record (MAR), dated September 2019, indicated Tylenol extra strength 500 mg tablet, give 1 tablet by mouth every 4 hours as needed (prn) for pain. The MAR lacked documentation the medication had been administered on 9/18/19 and 9/19/19. A MAR, dated September 2019, indicated [MEDICATION NAME] 400 mg tablet, give 1 tablet by mouth every 8 hours as needed for pain. The MAR lacked documentation the medication had been administered on 9/18/19 and 9/19/19. A MAR, dated September 2019, indicated [MEDICATION NAME] (opioid) 7.5-325 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for pain. The MAR lacked documentation the medication had been administered on 9/18/19 and 9/19/19. A prn medication flowsheet, dated 9/18/19 at 1:30 a.m., indicated the resident had pain and received [MEDICATION NAME]. The pain medication was effective. The flowsheet lacked documentation for the location of pain. A controlled drug record, dated 9/19/19 at 1:30 a.m., indicated the resident received [MEDICATION NAME] 7.5-325 mg 1 tablet by mouth. A nurse's progress note, dated 9/19/19 at 6:00 a.m., indicated the resident had not voiced any pain or that she had a kidney stone. A prn medication flowsheet, dated 9/19/19 at 8:00 a.m., indicated the resident had generalized pain and received [MEDICATION NAME]. The flowsheet lacked documentation if the medication was effective. A controlled drug record, dated 9/19/19 at 8:00 a.m., indicated the resident received a prn [MEDICATION NAME] 7.5-325 mg, 1 tablet by mouth. A prn medication flowsheet, dated 9/19/19 at 12:00 p.m., indicated the resident had generalized pain and received [MEDICATION NAME]. The flowsheet lacked documentation if the medication was effective. A controlled drug record, dated 9/19/19 at 12:00 p.m., indicated the resident received a prn [MEDICATION NAME] 7.5-325 mg, 1 tablet by mouth. A controlled drug record, dated 9/19/19 at 4:00 p.m., indicated the resident received a prn [MEDICATION NAME] 7.5-325 mg, 1 tablet by mouth. A nursing assessment, dated 9/19/19 and un-timed, indicated the resident had verbal pain, pain level was 6 to 8. The pain location was the back, and feet. Routine pain medication had been received and effective, and as needed pain medication had been administered 7 times in the past week. A review of progress notes, from 9/18/19 at 9:45 p.m. through 9/19/19 at 6:34 p.m., lacked documentation the physician had been notified of the resident's complaint of right flank pain and concern of kidney stone. A nurse's progress note, dated 9/19/19 at 6:35 p.m., indicated a CNA had come to the nurse's station and stated the resident's level of consciousness had changed. The writer (registered nurse) assessed the resident, and the resident reported body aches and was very weak. A pan of yellow bile was in the resident's lap and the resident was actively vomiting and shaking. The resident's blood pressure was 131/81, temperature 101.8, pulse 112, respirations 32 and labored. Resident voiced she wanted to go to the hospital. Physician was notified and transport was called. A inures' progress note, dated 9/19/19 at 7:05 p.m., indicated the resident was transported to the emergency room . A controlled drug record, dated 9/19/19 at 8:00 p.m., indicated the resident received a prn [MEDICATION NAME] 7.5-325 mg, 1 tablet by mouth. The resident was documented to be out of the facility at the emergency room at this time. A nurse's progress note, dated 9/19/19 at 11:30 p.m., the hospital phoned and the resident had been admitted to the hospital from the emergency room [MEDICAL CONDITION] and kidney stone. A cat scan (a scan of the abdomen and pelvis) report, dated 9/19/19, indicated a mild to moderate right hydronephroureter with a 2 millimeter (mm) obstructing stone in the distal right ureter and a slightly delayed enhancement pattern in the right kidney in related to the left. A physician final report note, electronically signed on 9/20/19, indicated [MEDICAL CONDITION], and would repeat [MEDICATION NAME] and continue to monitor for possible development [MEDICAL CONDITION]. A hospital discharge summary report, dated 9/23/19, indicated the resident was admitted to the hospital with [REDACTED]. The resident received intravenous (IV) antibiotics (atb) with a urology consult. A cystoscopy with right retrograde pyelogram and placement of right indwelling [MEDICAL CONDITION] stent was performed. The urine cultures did not grown anything during the hospital stay. The resident's hemoglobin dropped a couple of points and hematology was consulted, the drop was likely due to IV fluids. A nurse's progress note, dated 9/21/19 at 4:40 p.m., indicated the resident returned to the facility from the hospital. A care plan, initiated on 11/1/18, and revised on 1/22/20, indicated the resident had the potential for pain. Interventions included, but were not limited to, administer/offer pain medication as ordered and monitor for efficacy, document efficacy of approaches, and notify the physician if pain medications are ineffective and there resident's complaint persists. A care plan, initiated on 11/1/18, and revised on 2/22/20, indicated the resident had a [MEDICAL CONDITION] bladder and was at risk for [MEDICAL CONDITION]. Interventions included, but were not limited to, monitor for abdominal distention as needed, administer medications as ordered, and notify and follow up with physician as needed. A care plan, initiated on 9/21/19, indicated the resident had an uti. Interventions included, but were not limited to, antibiotic per physician's orders [REDACTED].>During an interview, on 2/28/20 at 10:43 a.m., the Director of Nursing (DON) indicated the resident went to the hospital on [DATE] due to a change of condition. The resident was admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She indicated she was unable to find documentation the physician had been notified on 9/18/19 when the resident had first reported the new onset pain. She was unsure why the physician had not been notified. On 2/27/20 at 10:38 a.m. the DON provided a document, revised 09/2017, and titled, PRN MEDICATIONS, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To ensure non-pharmacological interventions are attempted, as appropriate, prior to PRN medication administration .Procedure: 1. Each resident should have a PRN flow sheet with the applicable resident administration record. 2. Upon resident request or nurse observation potential for PRN pain/[MEDICATION NAME] medication, the resident will be observed/interviewed to determine pain severity .location etc .If multiple [MEDICATION NAME] are ordered, the nurse shall administer the appropriate [MEDICATION NAME] consistent with treatment of [REDACTED]. Should a PRN be necessary to treat another symptom (e.g., constipation, fever, etc.) the same shall be listed on the flow sheet and N/A .which do not apply .6. The nurse/QMA must re-visit the resident following PRN medication administration to evaluate medication efficacy, addressing efficacy (yes or no) and time of re-visit on the PRN medication flow sheet. Should the medication be ineffective, the nurse must further assess and determine the need to contact the physician relative to the resident's unresolved complaint/concern/symptom On 2/28/20 at 4:44 p.m., the DON provided a document, revised on 10/2014, and titled, Pain Assessment, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To identify those residents who utilize routine medications for pain or who utilize frequent PRN (as needed) pain medication in an effort to ensure adequate pain control is achieved. Policy: .If ineffective relief is noted, a Pain Assessment shall be completed in an effort to assess location, frequency, etc., and notify physician accordingly to ensure currently ordered pain medication is evaluated and revised, as necessary .Procedure: .4. Should, following admission, the resident exhibit pain which is not sufficiently controlled by current pain medication ordered, a Pain Assessment shall be completed and any necessary interventions implemented accordingly On 2/28/20 at 4:44 p.m., the DON provided a document, revised on 04/2017, and titled, Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To safely administer medications as per physicians' orders. Policy: Licensed or qualified personnel shall be responsible to follow accepted practices of medication administration as per physicians' orders .Guidelines for Medication Administration: .21. Always record the dose of mediation on the MAR after resident consumption 2. Resident 9's was reviewed on 2/27/20 at 9:00 a.m. [DIAGNOSES REDACTED]. A nursing assessment, dated 11/29/19, indicated the resident was incontinent of bowel. A Medication Administration Record (MAR), dated December 2019, indicated milk of magnesia (laxative), give 10 milliliters (ml) by mouth everyday as needed (prn) for constipation. The MAR indicated the medication had been administered on 12/22/19. A prn medication flow sheet, dated 12/22/19 at 11:30, indicated the resident was administered milk of magnesia for constipation. The flowsheet lacked documentation if the medication was effective. A bowel movement (BM) record, dated December 2019, indicated the resident had no BMs on the following dates: 12/8/19, 12/9/19, 12/10/19, 12/11/19, 12/13/19, 12/14/19, and 12/15/19. The MAR, progress notes, and prn medication flow sheet lacked documentation the bowel protocol had been implemented, auscultation of bowel sounds, or physician notification during this time. A physician's progress note, dated 12/16/20 at 11:55 a.m., indicated no new issues. The resident's abdomen was soft. A BM record, dated January 2020, indicated the resident had no bm's on the following dates: 1/14/20, 1/15/20, 1/16/20, 1/17/20, 1/18/20, 1/19/20. The MAR, progress notes, and prn medication flow sheet lacked documentation the bowel protocol had been implemented, auscultation of bowel sounds (except on 1/15/20), or physician notification during this time. A nursing assessment, dated 1/15/19, indicated the resident was incontinent of bowel and bowel sounds were present times 4 quads. A physician's progress note, dated 2/12/20 at 12:20 p.m., indicated the resident's abdomen was soft. A radiology report, dated 2/17/20, indicated an x-ray of the abdomen had been obtained. The conclusion indicated diffuse ileus (inability of the intestine (bowel) to contract normally and move waste out of the body) pattern. A progress note, dated 2/22/20 at 8:00 a.m., indicated the resident had complained of constipation and a fleet enema (laxative) was administered and was awaiting results. The abdomen was hard and distended. A BM record, dated February 2020, indicated the resident had no BM's on the following dates: 2/22/20, 2/23/20, 2/24/20, and 2/25/20. The MAR, progress notes, and prn medication flow sheet lacked documentation the bowel protocol had been implemented, auscultation of bowel sounds, or physician notification on 2/23/20 and 2/24/20. A progress note, dated 2/25/20 at 1:00 p.m., indicated the resident had a couple of small BM's and belly was firm. Resident had indicated she could not push. Bowel sounds present times 4, and prn milk of magnesia administered. The MAR and prn medication flow sheet lacked documentation the milk of magnesia had been administered and if it had been effective. A physician's progress note, dated 2/26/20 at 11:40 a.m., indicated the resident had complaints of lower left quadrant pain times 2 days. The resident was recently given fleets enema with no results. A late entry progress note, dated 2/27/20 at 9:35 a.m., indicated on 2/24/20 the resident had a large BM and were results from administration of a fleets enema. A MAR, dated February 2020, indicated fleet enema, give 1 rectally prn daily. The MAR lacked documentation this had been administered from 2/1/20 through 2/26/20. A MAR, dated February 2020, indicated to give a one time dose of [MEDICATION NAME] (laxative) suppository on 2/21/20. A MAR, dated February 2020, indicated [MEDICATION NAME], give 1 suppository rectally prn daily. The MAR lacked documentation this had been administered 2/1/20 through 2/26/20. A care plan, reviewed 12/17/19, indicated the resident was at risk for constipation due to decreased mobility and medication use. Interventions included, but were not limited to, monitor bowel movements, and administer medications as ordered, should resident exceed three days without a bowel movement, follow specific physician orders, or facility bowel protocol to promote bowel movement. During an interview, on 2/28/20 at 8:54 a.m., the Director of Nursing (DON) indicated she had found the nurses had not always assessed bowel sounds and implemented the bowel protocol when the resident was documented as not having a bowel movement. She indicated the staff should have followed through with documentation of effectiveness on the prn flow sheet for constipation. She was unable to find documentation the physician had been notified, but had talked with the physician herself so she knew he had been made aware. The nurse's should also document when the physician was notified per BM protocol. On 2/27/20 at 10:29 a.m. the DON provided a document, dated 10/2014, and titled, BOWEL ELIMINATION MONITORING, and indicated it was the policy currently being used by the facility. The policy indicated, PURPOSE: Assessment of bowel function will ensure provision of necessary intervention to prevent potential constipation and/or fecal impaction. Policy: It is the policy of this facility to monitor bowel function of each resident on a daily basis in an effort to intervene, as needed, should a resident fail to evacuate on a regular basis .Procedure: 2. Should a resident be observed to not have documentation of a BM within the past three days, the licensed nurse will conduct an assessment of the resident's bowel sounds .4. The evening shift licensed personnel will then administer the laxative and communicate to the oncoming shift the need to monitor resident for results. 5. If no results are evident in the anticipated time frame .orders shall be reviewed for appropriate next intervention, such as enema .7. The resident's bowel function shall continue to be monitored to ensure adequate evacuation. Should resident continue to experience difficulty, physician will be notified and further intervention taken as warranted On 2/27/20 at 10:29 a.m. the DON provided a document, dated 01/26/2008, and titled, Physician's standing orders, and indicated it was the policy currently being used by the facility. The policy indicated, BM PROTOCOL: After 3 days: (Prune juice) MOM 30 CC; if no results- [MEDICATION NAME] 10 mg rectally: If no results call physician On 2/27/20 at 10:38 a.m. the DON provided a document, revised 09/2017, and titled, PRN MEDICATIONS, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To ensure non-pharmacological interventions are attempted, as appropriate, prior to PRN medication administration .Procedure: 1. Each resident should have a PRN flow sheet with the applicable resident administration record. 2. Upon resident request or nurse observation potential for PRN pain/[MEDICATION NAME] medication, the resident will be observed/interviewed to determine pain severity .location etc .If multiple [MEDICATION NAME] are ordered, the nurse shall administer the appropriate [MEDICATION NAME] consistent with treatment of [REDACTED]. Should a PRN be necessary to treat another symptom (e.g., constipation, fever, etc.) the same shall be listed on the flow sheet and N/A .which do not apply .6. The nurse/QMA must re-visit the resident following PRN medication administration to evaluate medication efficacy, addressing efficacy (yes or no) and time of re-visit on the PRN medication flow sheet. Should the medication be ineffective, the nurse must further assess and determine the need to contact the physician relative to the resident's unresolved complaint/concern/symptom On 2/27/20 at 10:55 a.m. the DON provided a document, revised 04/2017, and titled, MEDICATION ADMINISTRATION, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To safely administer medications as per physicians' orders .21. Always record the dose of medication on the MAR after resident consumption 3.1-37(a)

(A) Based on observation, interview, and record review, the facility failed to maintain water temperatures less than 120 degrees F (Fahrenheit) to prevent burns to skin in contact with the hot water from sinks in 3 of 11 resident bathrooms on the 100 and 200 hall. This deficient practice had the potential to affect 2 of 2 cognitively impaired residents who independently accessed water from a shared bathroom with a water temperature of 137 degrees F (Residents #15 and #44). (B) In addition to the residents in the Immediate Jeopardy, the facility failed to ensure oxygen and harmful chemicals were safely stored resulting in harm or potential harm that is not Immediate Jeopardy for 3 of 5 residents (Residents #26, #54, and #55) reviewed for oxygen storage and 3 of 3 hallways observed for chemical storage. The Immediate Jeopardy was identified on 1/13/2016 and began on 1/13/16 when sinks in bathrooms shared by resident room #s 218, 216, 217, 212, 121 and 119 had water temperatures that exceeded maximum temperatures to prevent burns. The Administrator, Regional Director and Corporate Compliance nurse were informed of the Immediate Jeopardy on 1/13/2016 at 4:40 p.m. Findings include: A1. During an observation on 1/13/16 at 10:00 a.m. Resident #44 entered the bathroom between resident rooms #218 and #216. The water from the sink faucet was too hot to hold hands under the water for more than a few seconds without burning the skin. The Maintenance Supervisor checked the water temperature at 10:08 a.m. and indicated the temperature was 124 degrees F per the facility's thermometer. During an observation on 1/13/16 at 11:15 a.m., Residents #44 and #15's shared bathroom had a water temperature of 134 degrees F and was too hot to hold hands under the water for more than a few seconds without burning the skin. During an observation with Maintenance Supervisor on 1/13/16 at 11:30 a.m., the Maintenance Supervisor checked the water temperature of the shared bathroom for Residents #44 and #15 and indicated the temperature was 137 degrees F per the facility's thermometer. During an observation with Maintenance Supervisor on 1/13/16 at 3:25 p.m., the water temperature in Resident #44 and #15's shared bathroom was 131 degrees F per the facility's thermometer. The Medicare State Operation Manual, Rev. 133, (02-06-15) was referenced on 1/13/16 at 1:41 p.m. for safe water temperatures for bathing and indicated 100 degrees F was a safe temperature. Page 338 of the manual indicated the time required for 3rd degree burns from water temperatures of 124 degrees F was 3 minutes, 127 degrees F was 1 minute, 133 degrees F was 15 seconds, and 140 degrees F was 5 seconds. During an interview on 1/13/16 at 2:00 p.m., CNA #10 indicated Resident #15 accessed the bathroom independently to brush her own teeth and performed activities of daily living (ADLs) including washing her face independently. During an interview on 1/14/16 at 9:46 a.m., Resident #15 indicated sometimes the water from the sink faucet had been too hot to keep her hands under and indicated she turned cold water on to adjust the temperature Resident #44's record was reviewed on 1/13/16 at 2:33 p.m [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/19/15, indicated Resident #44 had severe cognitive impairment and required assistance of one person for transfers and required supervision for bathing/showering. Resident #15's record was reviewed on 1/13/16 at 2:28 p.m. [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], indicated Resident #15 had a Brief Interview for Mental Status (BIMS) score of 8, indicating cognitive impairment. The assessment indicated mobility impairment of the right upper and lower extremities and indicated the resident utilized a wheelchair for mobility. The resident required 2 person assistance for toileting and one person physical assistance for personal hygiene. A document, titled WEEKLY RANDOM RESIDENT ROOM TEMPS was provided by the Administrator on 1/13/16 at 4:00 p.m. The record did not indicate any rooms with temperatures outside parameters of 100-120 degrees F and indicated the last time the temperature was monitored in the shared bathroom between resident rooms #218 and #216 was 12/1/15 and the water temperature was 110 degrees F. A2. During an observation on 1/13/16 at 10:10 a.m., the shared bathroom between resident room #121 and #119 had a skink faucet with a water temperature of 123 degrees F. The residents who resided in the rooms did not independently access the bathroom. A3. During an observation on 1/13/16 at 11:55 a.m., the bathroom utilized by room #212 had a sink faucet with a water temperature of 122 degrees F. The resident residing in room #212 was assisted by staff to access the bathroom and did not turn on the faucet independently. A4. During an observation on 1/13/16 at 11:57 a.m., the bathroom for room #217 had a sink faucet with a water temperature of 127 degrees F. The resident residing in room #217 was totally dependent on staff for care and did not utilize the bathroom. During an interview on 1/13/16 at 11:30 a.m., the Maintenance Supervisor indicated the water temperature should have been less than 120 degrees F and indicated he adjusted the water heater after he became aware of the water temperature in the shared bathroom for resident rooms # 218 and #216. The Maintenance Supervisor indicated he checked 3 random rooms per week on each resident hall for water temperatures. During an interview with Administrator on 1/13/16 at 11:50 a.m., she indicated there had been no reported burns or scalding's as a result of water temperatures. During an interview with the Administrator on 1/13/16 at 1:25 p.m., she indicated maintenance staff had not reported hot water temperatures exceeding allowable parameters prior to today. A Preventative Maintenance Program, dated April 2012, and identified by the Administrator as current on 1/13/16 at 12:11 p.m., indicated, .Water Temps (temperatures) (Shower Rooms/Beauty Shop/Random Rooms: In that resident room water temps are assessed on at least a quarterly basis with resident room observations, the water temps of all shower rooms (both shower and sink temperature, beauty shop, and at least 3 random rooms from each hall shall be taken and logged on a weekly basis .Temperatures outside the parameters of 100-120 (degrees) F must be reported to the Administrator immediately and corrective action initiated . The Immediate Jeopardy that began on 1/13/16 was removed on 1/15/16, after the facility maintenance supervisor adjusted the water temperature, added a mixing valve and a contracted vendor (plumber) confirmed the modifications resulted in safe water temperatures. In addition to the environmental modifications, all facility staff received in-service training on the facility ' s policy for Excessive Water Temperature, and need monitor and immediately report concerns of excessive hot water temperatures to the Administrator. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued monitoring to ensure safe hot water temperatures. B1. On 1/13/16 at 10:43 a.m., Resident #26 was interviewed. The resident was observed to utilize liquid oxygen. A small e-cylinder of oxygen was observed next to the room's heating source. A large 41 liter liquid oxygen tank was next to that. The heating source was on and running. With the Maintenance Supervisor on 1/13/16 at 12:15 p.m., the external surface temperature of the heating unit was tested and was 77 degrees Fahrenheit. At the same time the Respiratory Therapist was interviewed. She indicated the large cylinder was half full and the small one, one-quarter full. She indicated she filled the large tank herself. The therapist indicated the e-cylinder was only utilized by the resident when out of the facility. She indicated it could be stored in the facility oxygen storage area. The therapist indicated the resident wanted the large cylinder on the right side of the bed which was why it was close to the heating unit. On 1/14/16 at 3:15 p.m. with the Maintenance Supervisor the distance from the heat source and the 41 liter liquid oxygen tank was measured at 14 inches. B2. On 1/14/16 at 3:18 p.m. with the Maintenance Supervisor Resident #55's room was observed with a large 41 liter liquid oxygen tank. The oxygen tank was in use. The distance between the rooms's heating source, which was on, and the cylinder was measured at 25 inches. B3. On 1/14/16 at 3:20 p.m., with the Maintenance Supervisor, Resident #54's room was observed. A large 41 cylinder liquid oxygen tank was observed in the room 30 inches from the room's heat source. The resident was observed on 1/13/16 at 10:14a.m., utilizing the oxygen tank. On 1/14/16 at 3:10 p.m. the Respiratory Therapist provided a policy, dated 10/2015, and identified as current, titled Oxygen Safety Standards. The policy included, but was not limited to, .General Oxygen Safety: 1. Keep oxygen equipment and oxygen tubing at least five (5) feet away from any heat source 4. Do not place any oxygen device near electrical heaters B4. During initial tour on 1/12/16 at 10:15 a.m., a housekeeping closet on the main hallway leading to the 3 resident units and across from the main dining room, was observed to be unlocked. The closet contained 2 gallon jugs of a chemical called Vertex, and 2 containers of Glance NA. On 1/13/16 at 9:35 a.m., the housekeeping closet on the main hallway, leading to the 3 resident units and across from the main dining room, was unlocked. The closet contained 2 gallon jugs of a chemical called Vertex, 2 containers of Glance NA, 2 boxes of Vectra, and 2 bottles of Virex TB. On 1/13/16 at 12:05 p.m., the housekeeping closet, on the main hallway leading to the 3 resident units and across from the main dining room, was observed to be unlocked. The closet contained 2 gallon jugs of a chemical called Vertex, 2 containers of Glance NA, 2 boxes of Vectra, and 2 bottles of Virex TB. On 1/14/16 at 9:25 a.m., the housekeeping closet, on the main hallway, leading to the 3 resident units and across from the main dining room, was unlocked. The closet contained 2 gallon jugs of a chemical called Vertex, 2 containers of Glance NA, 2 boxes of Vectra, and 2 bottles of Virex TB. B5. On 1/21/16 at 11:30 a.m., The soiled utility room door on the 100 hall was unlocked and contained a bottle of Virex, bottle of biological liquid odor control, and a spray bottle of blue liquid (identified as glass cleaner). On 1/21/16 at 11:30 a.m. the 100 hallway soiled utility room was observed unlocked with three bottles of cleaning chemicals in spray bottles on the hopper. With the Maintenance Supervisor the chemicals were identified as Virex, Biological Liquid Odor Control/Cleaner, and an unlabeled bottle of blue liquid, later identified by the Administrator as glass cleaner. B6. On 1/21/16 at 11:55 a.m., the door to the 300 hall housekeeping closet was observed to be unlocked. Several chemicals were observed sitting in the unlocked closet. The chemicals present in the closet included, but were not limited to, Lemon Furniture Polish, Virex, Tackle Rust, Calcium and Lime Deposit Remover, Good Sense Odor Counteractant, Snapback and Vertex. Residents were observed participating in a supervised activity near the area. On 1/21/16 at 3:00 p.m., during an environmental tour of the 300 hall, with the Administrator and the Maintenance Supervisor present,the housekeeping closet was observed to be unlocked. Several chemicals were observed sitting in the unlocked closet. The chemicals present in the closet included, but were not limited to, furniture polish, Virex, Tackle, Good Sense, Snapback and Vertex. During an interview on 1/13/16 at 12:18 p.m., the Administrator indicated the housekeeping closet doors should have been locked at all times. During an interview on 1/21/16 at 11:30 a.m., QMA (Qualified Medication Aide) #12 indicated the soiled utility door on the 100 hall had a keypad to unlock it, but the door was not shut all the way which allowed the door to open without using the keypad. On 1/21/16 at 11:20 a.m., copies of the warning labels for the chemicals located in the 300 hall housekeeping closet were provided by the Administrator. The current warning labels indicated the potential hazards of the chemicals included, but were not limited to: a. Lemon Furniture Polish: Hazard identification included, but were not limited to, inhalation and eye contact hazards. b. Virex: Hazard identification included, but were not limited to, skin and eye contact hazards. c. Tackle. Rust, Calcium and Lime Deposit Remover: Hazard identification included, but were not limited to, Skin irritant and swallow hazard. d. Good Senses Odor Counteractant: Hazard identification included, but were not limited to, explosion and fire hazard. e. Snapback: Hazard identification included, but were not limited to, skin and eye irritant. f. Vertex: Hazard identification included, but were not limited to, eye irritant, inhalation and swallowing hazard. g. Vectra: Hazard identification included, but were not limited to, skin and eye irritant. h. Glance NA: Hazard identification included, but were not limited to, skin and eye irritant. i. DfE B.L.O.C.: Hazard identification included, but were not limited to, eye and skin irritant, inhalation and swallowing hazard. j. Glass Cleaner: Hazard identification included, but were not limited to, eye and skin irritant. On 1/21/16 at 4:20 p.m., the Administrator provided a current policy titled, Storage and Security of Items Potentially Hazardous to Residents, dated 1/2016. The policy indicated, Policy: This facility shall provide each resident an environment that is as free as possible from hazards over which the facility has control, .safe storage of toxic chemicals .Procedure: 2. Chemicals must be secured when not in use . 3.1-45 (a)(1)

Based on observation, interview, and record review; the facility failed to ensure a clean and sanitary environment was maintained for 59 of 59 residents as evidenced by widespread signs of rodent activity in the kitchen food storage room. This deficient practice had the potential to affect 59 of 59 residents. The immediate jeopardy began on 09/04/13 when numerous areas of rodent activity were identified in the kitchen. The Administrator was notified of the immediate jeopardy at 4:18 p.m. on 09/04/13. The immediate jeopardy was removed on 09/05/13, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: a. Based on observation on 09/04/13 between 2:50 p.m. and 3:00 p.m. with the administrator and dietary manager trainee, multiple mouse droppings were observed : 1. In the bottom of six dry food filled storage totes located on metal shelving; 2. On the floor under the shelving; 3. Inside an opened cookie package stored in one plastic tote. 4. Inside cardboard cartons located on shelving in the dry food storage room and on the floor in the kitchen. b. Based on observation on 09/04/13 between 2:50 p.m. and 3:00 p.m. with the administrator and dietary manager trainee, evidence of rodent activity in the dry food storage room was found inside a plastic tote filled with single serving packets of ketchup. At least twenty packets found in the top layer had holes chewed in them. Another plastic food storage tote had a biscuit package which had a hole identified by the dietary manager trainee at the time of observation as chewed by a rodent. c. Based on interview with the administrator on 09/04/13 at 3:45 p.m., evidence of rodent activity had been identified by staff and a pest control contractor was in the facility twice per month and when called for additional occurrences. A Log of Insect Activity to be addressed by pest provider was reviewed with the administrator on 09/04/13 between 3:30 p.m. and 4:30 p.m. noted two insect sightings in August 2013. The administrator said on 09/05/13 at 12:30 p.m. this log was also to be used for reporting any rodent activity. d. Based on review of the Service and Inspection invoice from the pest control contractor Service Inspection Reports of 08/14/13 and 08/28/13 with the administrator on 09/04/13 at 4:45 p.m., conditions noted: holes in walls, gaps around penetrations, unsealed doors (pest points of entry), mouse caught in kitchen storage room and traps reset. On 09/04/13 at 5:00 p.m. two pest control contractors were in the facility, they identified the kitchen and it's storage room as a point of concentration for control of mice. They had captured a mouse at this visit and reset another trap. The contractors explained the inspection report carried forward issues identified affecting pest control results until their resolution was identified by the pest control technician. Bimonthly Service Inspection Reports since 12/19/12 repeatedly identified wall voids and gaps which could harbor pests and the identified a need for cleaning in the kitchen each month. e. Based on a review of a kitchen inspection report by the registered dietitian dated 09/03/13 with the administrator on 09/04/13 at 4:30 p.m., the report identified mouse droppings in the food storage room and noted no boxes were to be stored on shelves, the storeroom needed deep cleaning, food needed to be checked for possible contamination and discarded as necessary, ensure tight fitting tote lids, and call the pest control contractor ASAP. Upon inspection of the kitchen with the administrator and dietary manager trainee on 09/04/13 between 3:00 p.m. and 4:00 p.m., cardboard cartons containing food were stored on shelves in the food storage rooms. Two cardboard cartons filled with potatoes were located on the floor. Plastic tote lids were loose fitting and the floor, shelves and totes were soiled. Food debris was noted inside totes along with rodent dropping. The administrator said at the time of observation, the issues identified were being addressed by staff. f. Based on observation during a tour of the facility kitchen and food storage area on 09/05/13 between 9:00 a.m. and 10:00 a.m., these kitchen areas had been cleaned and sanitized. Food storage totes where rodent activity was identified were sanitized and damaged food packets were discarded. All cardboard boxes were discarded. There was no evidence of rodent activity. The administrator reported at the time of observations, the pest control contractor had added ten additional rodent control baits and identified areas of concern where gaps and missing seals might harbor pests. Areas under the dishwashing machine at the based board were observed to have a buildup of grime, the tops of overhead ceiling pipes and refrigerators and freezers were dirty. Based on interview with the registered dietician on 09/05/13 at 11:00 a.m., all dietary staff were inserviced on pest control measures for dry storage and cold storage areas. The facility policies for using cleaning compounds, cleaning the refrigerators and freezers, use of sanitation buckets and equipment dated 11/12/08 were reviewed during the Inservice. The administrator said on 09/05/13 at 11:30 a.m., a registered dietitian was monitoring the status of the kitchen sanitation practices and will continue to do so with twice weekly sanitation rounds until the staff have mastered all practices to ensure the protection of food supplies and kitchen equipment. The immediate jeopardy which began on 09/04/13 was removed on 09/05/13 after observation, record reviews, and interviews determined the facility had implemented the plan of action to remove the immediacy of the problem. The noncompliance remained at a lower level scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy at the facility since ongoing monitoring and follow up by the facility and pest control company was needed to guarantee the complete eradication of rodent problems. 3.1-19(f)(4)

1. Based on observation, interview and record review; the facility failed to ensure a clean and sanitary kitchen was maintained for 59 of 59 residents as evidenced by widespread signs of rodent activity in the kitchen. This deficient practice affects all residents receiving food served from the only kitchen. The immediate jeopardy began on 09/04/13 when numerous areas of rodent activity were identified in the kitchen. The Administrator was notified of the immediate jeopardy at 4:18 p.m. on 09/04/13. The immediate jeopardy was removed on 09/05/13, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: a. Based on observation on 09/04/13 between 2:50 p.m. and 3:00 p.m. with the administrator and dietary manager trainee, multiple mouse droppings were observed : 1. In the bottom of six dry food filled storage totes located on metal shelving; 2. On the floor under the shelving; 3. Inside an opened cookie package stored in one plastic tote. 4. Inside cardboard cartons located on shelving in the dry food storage room and on the floor in the kitchen. b. Based on observation on 09/04/13 between 2:50 p.m. and 3:00 p.m. with the administrator and dietary manager trainee, evidence of rodent activity in the dry food storage room was found inside a plastic tote filled with single serving packets of ketchup. At least twenty packets found in the top layer had holes chewed in them. Another plastic food storage tote had a biscuit package which had a hole identified by the dietary manager trainee at the time of observation as chewed by a rodent. c. Based on observation on 09/04/13 between 2:50 p.m. and 3:00 p.m. with the administrator and dietary manager trainee, individual syrup packets, sugar packets, cereal, dirt and debris littered the areas under the shelves in the food storage room with a thick layer of dirt and grime blackening the floor under the food storage shelves. Food debris littered the kitchen floor under and around food prep tables, the range, oven, refrigerators and freezers. A sticky residue was evident on the food prep table. A four by six inch area of a dried food was observed under the table behind the "walk in" freezer. Debris and grime coated the floor under the dishwashing machine. The administrator said at the time of observations, the registered dietician had visited and directed special "cleaning projects" on 08/19/13 for each dietary staff employee. The tasks were to be completed and noted with a date and signature. Not all tasks were completed. d. Based on interview with the administrator on 09/04/13 at 3:45 p.m., evidence of rodent activity had been identified by staff and a pest control contractor was in the facility twice per month and when called for additional occurrences. A Log of Insect Activity to be addressed by pest provider was reviewed with the administrator on 09/04/13 between 3:30 p.m. and 4:30 p.m. noted two insect sightings in August 2013. The administrator said on 09/05/13 at 12:30 p.m. this log was also to be used for reporting any rodent activity. e. Based on review of the Service and Inspection invoice from the pest control contractor Service Inspection Reports of 08/14/13 and 08/28/13 with the administrator on 09/04/13 at 4:45 p.m., conditions noted: holes in walls, gaps around penetrations, unsealed doors (pest points of entry), mouse caught in kitchen storage room and traps reset. On 09/04/13 at 5:00 p.m. two pest control contractors were in the facility, they identified the kitchen and it's storage room as a point of concentration for control of mice. They had captured a mouse at this visit and reset another trap. The contractors explained the inspection report carried forward issues identified affecting pest control results until their resolution was identified by the pest control technician. Bimonthly Service Inspection Reports since 12/19/12 repeatedly identified wall voids and gaps which could harbor pests and the identified a need for cleaning in the kitchen each month. f. Based on a review of a kitchen inspection report by the registered dietitian dated 09/03/13 with the administrator on 09/04/13 at 4:30 p.m., the report identified mouse droppings in the food storage room and noted no boxes were to be stored on shelves, the storeroom needed deep cleaning, food needed to be checked for possible contamination and discarded as necessary, ensure tight fitting tote lids, and call the pest control contractor ASAP. Upon inspection of the kitchen with the administrator and dietary manager trainee on 09/04/13 between 3:00 p.m. and 4:00 p.m., cardboard cartons containing food were stored on shelves in the food storage rooms. Two cardboard cartons filled with potatoes were located on the floor. Plastic tote lids were loose fitting and the floor, shelves and totes were soiled. Food debris was noted inside totes along with rodent droppings. The administrator said at the time of observation, the issues identified were being addressed by staff. g. Based on observation during a tour of the facility kitchen and food storage area on 09/05/13 between 9:00 a.m. and 10:00 a.m., these kitchen areas had been cleaned and sanitized. Food storage totes where rodent activity was identified were sanitized and damaged food packets were discarded. All cardboard boxes were discarded. There was no evidence of rodent activity. The administrator reported at the time of observations, the pest control contractor had added ten additional rodent control baits and identified areas of concern where gaps and missing seals might harbor pests. Areas under the dishwashing machine at the base board were observed to have a buildup of grime, the tops of overhead ceiling pipes and refrigerators and freezers were dirty. Based on interview with the registered dietician on 09/05/13 at 11:00 a.m., all dietary staff were inserviced on pest control measures for dry storage and cold storage areas. The facility policies for using cleaning compounds, cleaning the refrigerators and freezers, use of sanitation buckets and equipment dated 11/12/08 were reviewed during the Inservice. The administrator said on 09/05/13 at 11:30 a.m., a registered dietitian was monitoring the status of the kitchen sanitation practices and will continue to do twice weekly sanitation rounds until the staff have mastered all practices to ensure the protection of food supplies and kitchen equipment. The immediate jeopardy which began on 09/04/13 was removed on 09/05/13 after observation, record reviews, and interviews determined the facility had implemented the plan of action to remove the immediacy of the problem. The noncompliance remained at a lower level scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy at the facility since ongoing monitoring and follow up by the facility and pest control company was needed to guarantee the complete eradication of rodent problems. 3.1-21(i)(2) 3.1-21(i)(3) 2. Based on observation, interview and record review, the facility failed to store food under sanitary conditions and safe temperatures for 59 of 59 residents. This deficient practice affects all residents receiving food served from the only kitchen. Findings include: a. Based on observation on 09/04/13 between 2:50 p.m. and 4:00 p.m. with the administrator and dietary manager trainee, refrigerator temperatures were measured at 50 degrees F on three facility thermometers located at various levels in the refrigerator. Two trays of full milk glasses were stored in the refrigerator. The milk glasses were uncovered, undated, and measured at 47.4 degrees F with a facility thermometer by the administrator. She immediately directed staff to discard the glasses of milk. b. Based on observation on 09/04/13 between 2:50 p.m. and 4:00 p.m. with the administrator and dietary manager trainee, four institutional size food condiment containers had been opened and were undated. A shredded institutional size cheese package was open and undated. The administrator acknowledged the containers' date of use could not be determined at the time of observation and ordered them discarded. c. A metal pan with two, two to three pound portions of plastic wrapped ground meat were observe in the bottom of one refrigerator. The ground meat was undated and thawed, the dietary manager trainee said at the time of observation, he thought the meat had been thawing two days but could not say for sure. The administrator ordered it's disposal immediately. d. Two metal containers were observed atop the grill with the administrator and dietary manager trainee on 09/04/13 at 3:45 p.m., aluminum foil covering the containers was open with the contents identified at the time of observation by the cook as baked chicken and cheesy potatoes from the lunch meal. He said the covering had been opened to provide a resident with more food after he came on duty "around 2:00 p.m." He said he prepared a plate and reheated the food in the microwave. He acknowledged at the time of interview, the food should not have been stored at room temperature since the noon meal. e. At 3:50 p.m. on 09/05/13 a loaf of bread was stored on the food prep table unopened with two slices of bread lying on the table. No food preparation was underway although the cook said at the time of observation he was "planning to use that." He acknowledge the bread should be properly covered and sealed when not in use. Based on interview with the registered dietician on 09/05/13 at 11:00 a.m., all dietary staff were inserviced on dry storage and cold storage measures. The facility policies for Storage of Leftovers and Proper Thawing of and Storage of Meats dated 11/12/08 were reviewed during the Inservice. The administrator said on 09/05/13 at 11:30 a.m., a registered dietitian was monitoring the status of the kitchen food storage practices and will continue to do twice weekly rounds until the staff have mastered all practices to ensure the protection of food supplies and kitchen equipment. The immediate jeopardy which began on 09/04/13 was removed on 09/05/13 after observation, record reviews, and interviews determined the facility had implemented the plan of action to remove the immediacy of the problem. The noncompliance remained at a lower level scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy at the facility since ongoing monitoring and follow up by the facility was needed to guarantee the practices were being followed. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure interventions to prevent a fall with injury for a resident who was noncompliant with fall prevention alarms for 1 of 3 sampled residents reviewed for falls (Resident B). Findings include: Resident B's record review on 02/25/13 at 12:55 p.m., indicated the resident had [DIAGNOSES REDACTED]. Resident B's most recent admission Minimum Data Set (MDS) assessment, dated 12/12/12, indicated Resident B was moderately cognitively impaired, had poor decision making skills, and needed cues/supervision regarding tasks of daily life, and wandered at significant risk of getting to a potentially dangerous place daily. The resident needed supervision to limited assistance of one person with mobility. The MDS assessment indicated the resident had no impairment with range of motion and used a wheelchair. Medicare Charting, dated 12/04/12, indicated, ".. Res (Resident) noted per therapy being unsafe c (with) ambulation. Res noted being unsteady when stands et (and) has blood levels that are low which will cause dizziness...." Resident B's most recent Fall Risk Assessment, dated 01/26/13 indicated the resident was at risk for falls due to history of falls, confusion, weakness, unsteady gait, non-compliance issues, and history of pacing without regard of need for rest. Resident B's clinical record indicated numerous falls. The following indicates the fall dates: 01/04/13 - unwitnessed fall, ambulating in the hall and fell , wheelchair alarm not on, resident non-compliant and was ambulating without assist; resident very lethargic, had been up all night and half the day before. New intervention -assist to lay down during the day/evening 01/09/13 - unwitnessed fall, resident transferred himself, had been incontinent, - placed sensor alarm/floor mat at bedside 01/16/13 - unwitnessed fall, resident tripped from moving to one wheelchair to another which was in his room - removed other wheelchair 01/17/13 - unwitnessed fall, resident transferred himself out of wheelchair to ambulate, resident had removed alarm, - applied auto lock brakes to wheelchair, 15 minute checks, monitor closely, and x-ray to head. 01/21/13 - attempted to sit down in chair at nurse's station, resident missed judged distance, lost balance and sat on bottom - ensure chairs in lobby have arms on them and offer assistance when noticeably tired 01/21/13 - unwitnessed fall, ambulating, states he tripped over rug, no rug, - assist resident with attending activities of choice 02/07/13 - unwitnessed fall, resident indicated he was going fishing - landing strips beside bed 02/14/13 - unwitnessed fall, ambulating in hall - placed on 15 minute checks, checked every 2 hours for incontinence often, and assistance to bathroom 02/15/13 - unwitnessed fall, resident was in bed prior, had removed alarm, resident lost balance attempting to dress self - staff will now assist, stand by assist, resident with dressing. Nurse's Notes, dated 02/15/13 at 7:45 a.m., indicated CNA #1 found resident lying on his left side on the floor in his room. The notes indicated the resident complained of pain in the left groin area. The physician was notified and x-rays were ordered. The x-ray results, dated 02/15/13, indicated a subacute complete displaced subcapital left hip fracture and the resident was sent to the hospital that evening. Post Fall Investigation, dated 02/15/13, indicated the resident was trying to dress self for breakfast, lost balance and fell . The report indicated the resident had removed the bed alarm. Interview with LPN #2, on 02/27/13 at 11:08 a.m., indicated she mostly witnessed Resident B during meals in the dining room. LPN #2 indicated the resident was very difficult to keep in a chair, propelled his wheelchair throughout the dining room and wouldn't remain in the dining room for long. Interview with CNA #1,on 02/27/13 at 11:15 a.m., indicated she saw the resident sitting in his wheelchair inside the doorway of his room when she picked up breakfast trays and when she returned she found him on the floor. CNA #1 indicated the fall was unwitnessed and the resident did not complain of pain right away and kept saying, "Get me up off the floor." CNA #1 indicated the resident was assessed by the nurse and he was put back into his wheelchair and it was later he complained of pain in his left groin area. Interview with LPN #3, on 02/27/13 at 11:58 a.m., indicated Resident B wandered a lot, was confused, combative, and at other times, was calm and able to sit with other residents at the nurse's station and carry on a conversation. Interview with the Director of Nursing (DoN) and the Administrator on 02/27/2013 at 12:45 p.m. indicated Resident B was non-compliant with alarms and removed/disconnected his alarms and folded them at the end of his bed. Review of the facility's "FALL MANAGEMENT PROCEDURE", dated 02/2005, indicated, "...PURPOSE: To assess all residents for risk factors that may contribute to falling. To provide planned interventions identified by the team, as appropriate, for resident use in maintaining or returning to the highest level of physical, social, and psychosocial functioning as possible. PROCEDURE: 1. Complete the fall risk assessment and care plan upon admission, readmission, quarterly and with significant change in status. 2. The interdisciplinary health care plan team will review the risk factors and determine if further assessment is needed. 3. The interdisciplinary health care plan team will determine which interventions are most appropriate for reducing the risk of falls and/or injuries related to falls. 4. Update the plan of care each time there is a change in intervention and communicate to staff...." This federal finding is related to Complaint IN 882. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision or use of assistive devices to prevent accidents for 2 of 9 residents reviewed for falls in a sample of 15. This deficient practice resulted in Resident B sustaining fractures and Resident A a hematoma. Findings include: 1. During initial tour on 11/1/12 at 10:30 a.m., with LPN #3, Resident B was observed in bed with a Foley catheter. The LPN indicated the resident had returned from the hospital the previous evening. The LPN indicated the resident sustained [REDACTED]. Resident B's clinical record was reviewed on 11/1/12 at 11:40 a.m. A nursing note, dated 10/25/12 at 7:20 a.m., was noted of "Called to res (resident) room et (and) res was sitting beside bed with legs underneath her. CNA was attempting to transfer res to w/c (wheelchair) from bed. ...When legs brought out from underneath her (L) (left) leg was noted to have outward rotation et (and) res c/o (complained of) pain. ...MD called order received to send to ER (emergency room .)." A report of the incident, provided by the Administrator on 11/1/12 at 11:25 a.m., included, but was not limited to "(name) CNA was transferring (Resident B's name) from the bed to the resident's wheelchair. The caregiver was utilizing a gait belt and the resident was wearing tennis shoes for non-skid footwear. CNA could not execute the transfer prior to the resident's legs buckling under her. The CNA lowered the resident to the floor. ...Type of injury/injuries: Fractured left tibia and fractured left fibula. ..." Further investigation of the incident included in the report included, but was not limited to, "(CNA's name) was helping (resident's name) to get dressed. The CNA assisted the resident with her pants, brief, socks & (and) shoes while the resident sat on the bed. From the edge of the bed, the resident then stood up by herself. The CNA held on to the resident's gait belt while she pulled the resident's brief and pants the rest of the way up. The CNA then assisted the resident to sit back down on the bed. The CNA rechecked the gait belt to ensure it was still in place appropriately. The CNA then asked the resident to stand again so that the CNA could assist to transfer the resident to the wheelchair. As the resident stood, the resident grabbed the wheelchair that was positioned beside the bed, and did a turn. The resident stated she heard her leg 'pop.' The CNA had hold of the gait belt on the resident and felt the resident lowering herself to the floor. ... Type of Injury/injuries: Spiral fracture of the left distal tibia with lateral displacement of the distal fragment and an oblique nondisplaced fracture of the proximal fibula. Preventive measures taken: Post fall investigation was conducted and revealed the ADL (Activities of Daily Living) documentation/grid and staff interviews confirmed one caregiver transfer of this resident the majority of the time, with only a few episodes when two caregivers were necessary." An "Inservice Record," provided by the Administrator on 11/1/12 at 12:45 p.m., was noted of the CNA receiving 1 to 1 training to always use correct number of assist with all transfers. always use gait belt. Wait for help! Ask for help! Always have the resident's safety in mind. Notify charge nurse or DON/ADON (Assistant Director of Nursing) if other staff refuse to assist with transfers. Look at CNA assignment sheet prior to transfer. The CNA assignment sheet, dated 10/26/12, provided by the ADON on 11/1/12 at 11:20 a.m. included, but was not limited to, transfers X 2. LPN #3 was interviewed on 11/1/12 at 12:30 p.m., the LPN indicated the resident always required assistance of two for transfers. The LPN indicated the other CNA working on the unit was in a resident's room, feeding the resident. Resident B's Minimum Data Set (MDS) assessment, dated 9/11/12, reviewed on 11/1/12 at 11:40 a.m., had coded the resident with no cognitive impairment. Required extensive assistance of two for transfers. Assistance of one for ambulation in the room. Only able to stabilize balance with staff assistance. A Physical Therapy Evaluation, dated 9/4/12, provided by the DON on 11/1/12 at 12:45 p.m., included, but was not limited to decreased mobility, pain to both knees and left hip. The assessment indicated the resident required assistance of one for sit to stand, and assistance of two for transfers. The assessment indicated the resident was currently demonstrating decline in transfers, balance, safety awareness, physical functioning, strength, and gait. A plan of Care that addressed "ADL Assist Required" dated 8/21/12 and 10/25/12 addressed the problem of the resident requires up to extensive assistance to total assistance of two in performing ADL's due to decrease in mood, said yes to little pleasure/interest in doing things, feeling down depressed, feeling tired/having little energy having poor appetite half or more of the previous 14 days of assessment period. (8/7/12.) The DON was interviewed on 11/1/12 at 2:25 p.m. The DON indicated therapy had reported assistance of one for sit to stand was appropriate, but required assistance of two for surface to surface transfers. 2. During initial tour on 11/1/12 which began at 10:30 a.m., with LPN #3, Resident A was identified as having had falls. The resident was out of the facility for an appointment. The DON was interviewed on 11/1/12 at 2:25 p.m. The DON indicated Resident B had a fall on 10/20/12 at 3:30 a.m. The resident was found on the floor in the bathroom. The DON indicated the resident had transferred self from the bed to wheelchair and gone into the bathroom. The DON indicated a pressure pad alarm was in place on the resident's bed but was not turned on. The DON indicated she did not know why the alarm was not on. During the interview, the DON indicated the resident had a fall on 10/24/12 at 9:00 a.m. The resident was on the floor beside the bed and the pressure pad alarm on the bed had not sounded. The DON indicated when the alarm was pushed on it sounded and was replaced. The DON indicated she did not know why it had not sounded. During the same interview, the DON indicated the resident fell on [DATE] at 9:55 a.m. The resident was seated in the wheelchair in the hallway. A staff person was near by heard a thud looked up and found the resident on the floor. The resident sustained [REDACTED]. The resident was on Coumadin (blood thinner medication) and was taken to the hospital for a CT scan. The DON indicated the resident had a hematoma from the fall. The DON indicated she did not know if an alarm had been in place or sounded at the time of the fall. On 11/1/12 at 3:00 p.m., the resident was observed in her room. The resident was asleep in a personal recliner. A pressure pad alarm was observed under the resident. The wire to the alarm was draped over the arm of the chair and the alarm box was lying on the floor beside the resident. A pressure pad alarm was observed on the resident's bed. The alarm box was hanging on a cable under the bed rail towards the head of the resident's bed, and would have been within reach of the resident when in bed. At 3:45 p.m., with the ADON the alarm was again observed. The telephone type cord from the pressure pad to the alarm box was observed not to be connected. The cord was also observed to be wrapped around part of the side rail on the resident's bed which was in the down position. The resident's clinical record was reviewed on 11/1/12 at 4:00 p.m., A Minimum Data Set (MDS) assessment, dated 9/5/12, coded the resident with short and long term memory impairment, severely impaired cognition. The assessment coded the resident as requiring extensive assistance of two for bed mobility and transfers, and ambulation in the room. Balance unsteady without staff assistance. A plan of care, dated 8/28/12 and 9/15/12, addressed the problem of resident required use of safety alarm sensor alarm in chair and bed due to high fall risk. Interventions included, but were not limited to, place alarm appropriately per manufacturer's instructions. Observe for signs of low battery and replace as needed, notify the charge nurse of attempts to remove the device check replacement and function every shift. Manufacturer's directions for the type of alarms utilized for the resident, (Deluxe Bed and Chair Sentry Fall Monitoring Systems User Instructions) provided by the ADON on 11/1/12 at 4:05 p.m., included, but was not limited to, "How to Use the Deluxe Sentry Monitors" 2. Attach the Sentry monitor to a wheelchair, chair or bed using the attached metal clip. Other mounting options include an optional bracket extender and a chair strap for large side chairs. 4. Place the UMP pad on the chair or bed so that the bulk of the patient's weight (buttocks area) will be resting on it. Plug the end of the pad cable into the PAD jack on the bottom of the monitor. For added safety from accidental pulls on the cord, route the cable through the strain relief slot on the bottom of the monitor. NOTE: If the UMP pad is disconnected from the PAD jack while in operating mode, the alarm will be activated. Under the section titled "Caution" information was noted to make sure the monitor is held securely to the bed or chair and that the bracket mount is secure. Documentation was noted on the Medication Administration Record of the alarms being checked daily. This Federal tag relates to Complaint IN 753 3.1-45(a)(2)