Every finding on record at Willow Crossing Health & Rehabilitation Center

Based on record and interview, the facility failed to follow physician's orders related to hold parameters and obtaining vital signs for cardiac medications for 7 of 21 residents reviewed for quality of care. (Residents 44, 62, 30, 10, 3, 8, and 104) Findings include:1.The clinical record for resident 44 was reviewed on 03/10/2026 at 10:30 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/01/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, hypertension. An open-ended physician's order, with a start date of 12/22/2025, indicated the resident was to be given midodrine 10 milligrams (mg) twice a day for orthostatic hypertension. The staff were to hold, not give, the medication, if the resident's systolic blood pressure (top number) was greater than 130. The January, February, and March 2026 Electronic Medication Administration Record (EMAR) indicated the resident had received the medication on the following days and times when the resident's systolic blood pressure was greater than 130: -On 01/03/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 139, -On 01/21/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 133, -On 02/09/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 144, -On 02/19/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 133, -On 02/21/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 160, -On 02/25/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 144, and -On 03/04/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 145. 2. The clinical record for Resident 62 was reviewed on 03/06/2026 at 11:56 A.M. A Quarterly MDS assessment, dated 01/02/2026, indicated the resident was severely cognitively impaired. The resident's diagnosis included, but was not limited to, hypertension. An open-ended physician's order, with a start date of 11/21/2025, indicated the resident was to be given metoprolol succinate 25 mg, once a day, for hypertension. The staff were to hold the medication if the resident's pulse was less than 60 beats per minute, or the resident's systolic blood pressure was less than 100. The January and February 2026 EMARs lacked documented resident blood pressure values at the time the medication was administered. The March 2026 EMAR lacked documented resident blood pressure values at the time the medication was administered from 03/01/20226 through 03/06/2026. Starting on 03/07/2026, the resident's blood pressure values were documented on the EMAR at the time the medication was administered. 3. The clinical record for Resident 30 was reviewed on 03/10/2026 at 9:48 A.M. An admission MDS assessment, dated 02/27/2026, indicted the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension and diabetes. A physician's order, dated 02/21/2026 through 03/07/2026, indicated the resident was to be given hydralazine 25 mg, twice a day for chronic kidney disease. The staff were to hold the medication if the resident's systolic blood pressure was less than 170. The February and March 2026 EMAR indicated the resident had received the medication on the following dates and times when the resident's systolic blood pressure was less than 170: -On 02/22/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 122 and at 6:30 P.M. to 10:30 P.M, when the resident's systolic blood pressure was 121, -On 02/23/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 104 and 110, -On 02/24/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 121, -On 02/25/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 146 and at 6:30 P.M. to 10:30 P.M., the resident's systolic blood pressure was 139, -On 02/26/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 113 and at 6:30 P.M. to 10:30 P.M., the resident's systolic blood pressure was 112, -On 02/27/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 132 and at 6:30 P.M. to 10:30 P.M., the resident's systolic blood pressure was 125, -On 02/28/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 129, -On 03/01/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 133, -On 03/02/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 130 and at 6:30 P.M. to 10:30 P.M., the resident's systolic blood pressure was 133, -On 03/04/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 119 and at 6:30 P.M. to 10:30 P.M., the resident's systolic blood pressure was 122, -On 03/05/2026 from 6:30 P.M. to 10:30 P.M., when the resident's systolic blood pressure was 102, -On 03/06/2026 from 6:30 A.M. to 10:30 P.M., when the resident's systolic blood pressure was 118 and at 6:30 P.M. to 10:30 P.M., the resident's systolic blood pressure was 121, and -On 03/07/2026 from 6:30 A.M. to 10:30 A.M., when the resident's systolic blood pressure was 101. 4. The clinical record for Resident 10 was reviewed on 03/10/2026 at 11:50 A.M. A Quarterly MDS assessment, dated 01/12/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included but was not limited to, diabetes. An open-ended physician's order, with a start date of 12/11/2025, indicated the resident was to receive 6 units of Admelog (a rapid acting insulin) with meals. The staff were to hold the medication for blood sugars that were below 150 or if the resident didn't eat. The January, February, and March, 2026 EMAR indicated the resident had received the medication when the resident's blood sugar was less than 150 on the following dates and times: -On 01/01/2026 at 7:00 A.M., when the resident's blood sugar was 118, -On 01/08/2026 at 4:00 P.M., when the resident's blood sugar was 143, -On 01/18/2026 at 7:00 A.M., when the resident's blood sugar was 143, -On 01/25/2026 at 7:00 A.M., when the resident's blood sugar was 148 and at 11:00 A.M., the resident's blood sugar was 136, -On 02/08/2026 at 7:00 A.M., when the resident's blood sugar was 134 and 11:00 A.M., the resident's blood sugar was 122, -On 02/12/2026 at 7:00 A.M., when the resident's blood sugar was 145, and -On 03/09/2026 at 7:00 A.M., when the resident's blood sugar was 132. 5. Resident 3's clinical record was reviewed on 03/10/2026 at 2:26 P.M. A Quarterly MDS assessment, dated 01/10/2026, indicated the resident's diagnoses included, but were not limited to, heart failure, hypotension, and end stage kidney disease. The resident received dialysis treatments. A current, open-ended physician's order, with a start date of 09/05/2025, indicated the resident was to receive midodrine 10 mg, three times a day for hypotension. Staff were to hold the medication if the resident's systolic blood pressure was greater than 120. The February and March 2026 EMARs indicated the resident received the medication on the following dates and times when the resident's systolic blood pressure was greater than 120: - On 02/04/2026 at 8:00 P.M., when the resident's systolic blood pressure was 122, - On 02/10/2026 at 12:00 P.M., when the resident's systolic blood pressure was 135, - On 02/12/2026 at 12:00 P.M., when the resident's systolic blood pressure was 149, - On 02/15/2026 at 12:00 P.M., when the resident's systolic blood pressure was 126, - On 02/16/2026 at 5:30 A.M., when the resident's systolic blood pressure was 121, - On 02/25/2026 at 12:00 P.M., when the resident's systolic blood pressure was 141, - On 03/04/2026 at 5:30 A.M., when the resident's systolic blood pressure was 180, - On 03/05/2026 at 5:30 A.M., when the resident's systolic blood pressure was 123 and at 8:00 P.M., when the resident's systolic blood pressure was 126,- On 03/07/2026 at 5:30 A.M., when the resident's systolic blood pressure was 121, and - On 03/08/2026 at 8:00 P.M., when the resident's systolic blood pressure was 129. 6. Resident 8's clinical record was reviewed on 03/10/2026 at 10:47 A.M. A Significant Change MDS assessment, dated 01/01/2026, the resident's diagnosis included, but was not limited to, coronary artery disease and hypertension. A current, open-ended physician's order, with a start date of 09/18/2025, indicated the resident was to receive metoprolol succinate, 25 mg, once a day for hypertension. The medication was to be held if the resident's SBP was less than 120 or their heart rate was less than 60. The February and March 2026 EMARs indicated the resident received the medication on the following dates when the resident's systolic blood pressure was less than 120: - On 02/15/2026, when the resident's systolic blood pressure was 103, - On 02/27/2026, when the resident's systolic blood pressure was 94, and - On 03/06/2026, when the resident's systolic blood pressure was 116. 7. Resident 104's clinical record was reviewed on 03/10/2026 at 2:00 P.M. A Comprehensive MDS assessment, dated 02/11/2026, indicated the resident's diagnoses included, but were not limited to, heart failure, hypertension, and end stage renal disease. The resident received dialysis treatments. A current, open-ended physician's order, with a start date of 01/23/2026, indicated the resident was to receive midodrine 5 mg, once a day on Monday, Wednesday, and Friday at 6:00 A.M. for hypotension. The medication was to be held if the resident's SBP was greater than 130 or if their heart rate was greater than 80. The February and March 2026 EMARs indicated the resident received the medication on the following dates and times when the resident's systolic blood pressure was greater than 130: - On 02/04/2026, when the resident's systolic blood pressure was 133. - On 02/09/2026, when the resident's systolic blood pressure was not assessed, - On 02/16/2026, when the resident's systolic blood pressure was 132, - On 03/02/2026, when the resident's systolic blood pressure was 143, and - On 03/04/2026, when the resident's systolic blood pressure was 132. During an interview, on 03/11/2026 at 10:56 A.M., RN 2 indicated when a resident had hold parameters for a medication, she would obtain the required vital signs (blood pressure or heart rate) before she administered the medication. If the resident's blood pressure or heart rate was out of range, she would not administer the medication and she would indicate in the EMAR the medication was held due to the resident's condition. The current facility policy, revised on 09/2025 and titled MEDICATION ADMINISTRATION was provided by the Assistant Director of Nursing on 03/11/2026 at 1:30 P.M. The policy indicated, '.To safely administer medications as per physicians' orders. Always take pulse and B/P as indicated if ordered prior to giving certain cardiac or antihypertensive drugs. Notify the physician if the vital signs are not within the acceptable range. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(6)

Based on observation and interview, the facility failed to maintain resident records in a private manner related to computer screens being left open with resident information visible for 3 random observations. (Residents 32 and 33)Findings include:During an observation, on 03/09/2026 at 10:18 A.M., the computer screen on the 100 Hall Medication Cart 1 was observed to have Resident 32's personal and medical information visible and was left unattended. - On 03/09/2026 at 10:18 A.M., a staff member walked by the medication cart,- On 03/09/2026 at 10:19 A.M., a resident walked by the medication cart, - On 03/09/2026 at 10:19 A.M., a Certified Nurse Aide (CNA) walked by the medication cart,- On 03/09/2026 at 10:20 A.M., RN 3 returned to the medication cart. During an observation, on 03/09/2026 at 11:58 A.M., the computer screen on the 100 Hall Medication Cart 2 was observed to have resident information visible and was left unattended. - On 03/09/2026 at 11:59 A.M., the Administrator and the Assistant Director of Nursing (ADON) walked by the medication cart,- On 03/09/2026 at 12:00 P.M., a CNA walked by the medication cart. - On 03/09/2026 at 12:01 P.M., RN 2 returned to the medication cart. During an interview at that time, she indicated the resident information shouldn't be left visible and she was sorry. During an observation, on 03/09/2026 at 1:13 P.M., the computer screen on one of the 100 Hall Medication Cart 2 was observed to have Resident 33's personal and medical information visible and was left unattended. - On 03/09/2026 at 1:13 P.M., a CNA walked by the medication cart. - On 03/09/2026 at 1:14 P.M., a visitor walked by the medication cart. - On 03/09/2026 at 1:15 P.M., RN 2 returned to the medication cart. During an interview, on 03/10/2026 at 11:30 A.M., Licensed Practical Nurse (LPN) 5 indicated the computer screen should not be left with resident information visible. There was a walk away button on the computer to hide resident information without closing the computer lid. The Current HIPPA (Health Insurance Portability and Accountability Act) policy was provided by the ADON on 03/09/2026 at 2:19 P.M. The policy indicated .All staff members are responsible for safeguarding the privacy of resident health information.410 IAC (Indiana Administrative Code) 16.2-3.1-3(o)

Based on interview, record review, and observation, the facility failed to ensure appropriate procedure was followed during providing care for a suprapubic urinary catheter replacement for 1 of 2 residents reviewed for urinary catheters. (Resident 78) Findings include:The clinical record for Resident 78 was reviewed on 03/09/2026 at 9:46 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/30/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, neurogenic bladder (dysfunction of the urinary bladder caused by nervous system damage), and obstructive uropathy (structural or functional blockage of urine flow anywhere along the urinary tract). The resident had an indwelling urinary catheter. The Electronic Medication Administration Record (EMAR) for February and March 2026, indicated the resident had received the antibiotic Ciprofloxacin 250 milligrams twice a day from 02/25/2026 through 03/03/2026 for a urinary tract infection. The procedure for changing the resident's indwelling suprapubic urinary catheter was observed on 03/09/2026 at 2:18 P.M., with RN 3. The nurse entered the resident's room, washed her hands, adjusted the resident's bed, placed supplies on an over-bed table, draped the resident with a clean towel, and donned clean gloves. The nurse took her gathered supplies and placed them on the over-bed table. She then peeled the resident's brief back and attached an empty syringe to the port to deflate the retention balloon. The nurse pulled out 30 cubic centimeters (cc) of clear fluid, squirted it in the trash, tried pulling more fluid, squirted it in the trash, and removed her gloves. The nurse then opened the sterile kit box and dropped the paper wrapped sterile gloves on the over-bed table. She opened the paper wrapper, donned the sterile gloves, took the paper drape out of the package and placed it over the insertion site of the suprapubic catheter. She removed a syringe from the box and placed it on the paper the gloves had been wrapped in, using the paper for a sterile field. She opened the betadine swabs and placed them on the paper. She squirted lubricant from the kit out on the paper, removed the new catheter tubing from the plastic bag/wrapper, just the end, and placed the open end in the lube on the paper. She picked up the betadine swabs and cleaned around the insertion site of the catheter on the resident's abdomen, pulled out the old catheter tubing, and placed it on the towel on the bed. She continued to clean around the insertion site. There was some black residue in the crease of the resident's abdomen where the insertion site was located. The nurse squirted some normal saline from a syringe onto a gauze pad and cleaned around the insertion site to remove the black residue. Then the nurse inserted the new catheter tubing into the insertion site, pulling the plastic off the tubing as she fed the tubing into the resident's abdomen, using both gloved hands. There was no visible urine return coming out of the tubing. The tubing was open with no catheter bag attached. The RN inflated the 30 cc balloon to anchor the catheter, then attached the urinary catheter drainage tubing and bag, applied a split gauze pad around the catheter tubing at the insertion site, threw the old drainage bag away, pulled up the resident's brief, attached the tubing to the Velcro anchor, hung the drainage bag on the side of the bed, covered the resident up with her blankets, gathered trash from the table and floor, threw the trash away, removed the sterile gloves, and tied the trash bag up. When asked if the resident had urine return, the RN indicated, Well, she had just peed. The resident had a sign on her closet door in her room stating she was in Enhanced Barrier Precautions. The nurse did not don a gown prior to changing the resident's catheter. During an interview immediately following the procedure, RN 3 indicated if a resident was on Enhanced Barrier Precautions there would normally be a cart outside of the resident's room with supplies. When asking the RN if she normally would don a gown before performing invasive procedures, she replied, Not normally with this resident. During an interview, on 03/09/2026 at 3:15 P.M., the Assistant Director of Nursing (ADON) indicated, for residents in EBP, staff were to don appropriate Personal Protective Equipment (PPE) including a gown and gloves. The procedure for changing a suprapubic indwelling urinary catheter was to first get supplies, then gown up, go in, ask permission, and set up the sterile field. She had always put a drape over the table and used a clean towel. She would clean the table, cover it with a clean towel, open the equipment, it's all in one bag that included the drainage bag, the tubing, the insertion kit, and sterile gloves. Clean the resident, remove the old suprapubic catheter, clean the site, remove your gloves and gown, perform hand hygiene, don a clean gown, don the sterile gloves, prepare the site, cleanse the site with the betadine swabs, insert the catheter tubing, ensure there was urine return, then anchor the catheter. Make sure there was urine return before you inflate the catheter anchoring balloon. You should get urine return; if you didn't, there was a problem. The current CATHETER REINSERTION, SUPRAPUBIC policy, dated 10/2014, was provided by the Director of Nursing on 03/11/2026 at 1:06 P.M. The policy indicated, .Wash abdominal area above the pubis with soap and water .Open sterile catheter package .Put on sterile gloves .Lubricate tip of catheter .Insert the catheter slowly until urine begins to flow . 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on record review and interview, the facility failed to have medications available to residents for 2 of 24 residents reviewed for pharmacy services. (Residents 10 and 104)Findings include: 1.The clinical record for Resident 10 was reviewed on 03/10/2026 at 11:50 A.M. A Quarterly MDS assessment, dated 01/12/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, non-Alzheimer's dementia (mental decline). An open-ended physician's order, with a start date of 09/09/2025, indicated the resident was to be given Aricept (a dementia medication) 10 mg at bedtime. The January, February, and March, 2026 EMAR indicated the resident did not receive the medication on the following dates due to the medication being unavailable: 01/03/2026, 01/04/2026, 01/11/2026, 01/17/2026, 01/18/2026, 01/25/2026, 01/31/2026, 02/05/2026, 02/07/2026, 02/08/2026, 02/14/2026, 02/15/2026, 02/16/2026, 02/19/2026, 02/21/2026, 02/22/2026, 02/28/2026, 03/01/2026, 03/07/2026, and 03/08/2026. 2. Resident 104's clinical record was reviewed on 03/10/2026 at 2:00 P.M. A Comprehensive MDS assessment, dated 02/11/2026, indicated the resident's diagnosis included, but was not limited to, end stage renal disease. The resident received dialysis treatments. A current, open-ended physician's order, with a start date of 01/13/2026, indicated the resident was to receive Renvela (phosphate binding medication used to manage high phosphate levels in patients with chronic kidney disease on dialysis) 800 mg with meals due to dependence on renal dialysis. The January and February 2026 EMARs indicated the resident did not receive the medication on the following dates and times due to the medication being unavailable: On 01/13/2026 at 5:00 P.M.; 01/14/2026 at 5:00 P.M.; 01/15/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 01/16/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 01/17/2026 at 8:00 A.M., and 12:00 P.M.; 01/18/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 01/19/2026 at 5:00 P.M.; 01/20/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 01/21/2026 at 12:00 P.M., and 5:00 P.M.; 01/22/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 01/23/2026 at 8:00 A.M., and 12:00 P.M.; 01/24/2026 at 8:00 A.M., and 5:00 P.M.; 01/26/2026 at 8:00 A.M., and 12:00 P.M.; 01/27/2026 at 5:00 P.M.; 01/28/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 02/02/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 02/03/2026 at 12:00 P.M., and 5:00 P.M.; 02/04/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 02/05/2026 at 8:00 A.M., and 12:00 P.M.; 02/06/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 02/07/2026 at 8:00 A.M., and 12:00 P.M.; 02/08/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 02/09/2026 at 8:00 A.M., and 12:00 P.M.; 02/10/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 02/11/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; 02/12/2026 at 8:00 A.M., and 12:00 P.M.; 02/14/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; and 02/15/2026 at 8:00 A.M., 12:00 P.M., and 5:00 P.M. During an interview, on 03/11/2026 at 10:46 A.M., RN 2 indicated the last five doses of a medication were highlighted in blue on the medication cards so nursing staff would know to re-order the medication. Medications were able to be ordered by clicking a button in the resident's Electronic Health Record (EHR) that would notify the pharmacy to send a new supply. If a medication was not available in the medication cart, she would look in the Emergency Drug Kit (EDK) and pull it from there. If the medication wasn't available in the EDK, she would notify the MD or Nurse Practitioner (NP) and see if there was a substitute medication they wanted administered. If not, she would get a Hold order from the provider. If a medication was unavailable, she would contact the pharmacy to re-order the medication. Medications were usually delivered within 48 to 72 hours of being ordered. She would document notes in the resident's EMAR and progress notes regarding unavailable medication. There was an issue between the dialysis center and the pharmacy with obtaining Resident 104's medication. She was unsure if the facility MD or NP were aware that the medication had been unavailable. The current facility policy, revised on 09/2025 and titled MEDICATION ADMINISTRATION was provided by the Assistant Director of Nursing on 03/11/2026 at 1:30 P.M. the policy indicated, '.Should the medication be out of supply, the nurse or QMA must consider the type of medication and whether significant or non-significant for timely administration. If significant, the EDK should be assessed to verify if the medication is available and could be accessed immediately per use of the EDK. If not in the EDK, upon completion of the medication pass, the pharmacy should be contacted and notified of the medication out of supply. If significant, the pharmacy should be notified of the urgent need for delivery. If not significant, the pharmacy may deliver upon next normally scheduled delivery day. Should there be a delay in delivery of a significant medication which could pose risk to the resident's plan of care, the physician must be contacted to ensure he/she is aware of the delay and provide opportunity for an alternative, available treatment to be ordered or to provide further directive due to lack of availability of the medication. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on record review and interview, the facility failed to track infections for 3 of 12 residents reviewed for antibiotic stewardship. (Residents 10, 22, and 78)Findings include:1.The clinical record for Resident 10 was reviewed on 03/10/2026 at 11:50 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/12/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, urinary tract infection. A physician's order, dated 09/19/2025 through 09/24/2025, indicated the resident was to be given Avycaz (an antibiotic medication) 2.5 grams, every 8 hours for resistance to carbapenem (an antibiotic medication), for a urinary tract infection. The Electronic Medication Administration Record (EMAR) indicated the resident had received the medication. The September 2025 Infection Control Tracking Log lacked indication the resident had received an antibiotic in September 2025. A physician's order, dated 11/14/2025 through 11/21/2025, indicated the resident was to be given Cipro (an antibiotic) 250 milligrams (mg), twice a day for history of urinary tract infections. The November 2025 Infection Control Tracking Log lacked indication the resident had received an antibiotic in November 2025. The Electronic Medication Administration Record (EMAR) indicated the resident had received the medication. During an interview, on 03/11/2026 at 10:37 A.M., the Assistant Director of Nursing indicated she ran an antibiotic report daily to add residents who started on a new antibiotic to the tracking log. If a resident was admitted from the hospital on an antibiotic, then she checked the start and stop dates and tracked them also. She would track and trend infections to see if there needed to be more education or training for resident care. 2. The clinical record for Resident 22 was reviewed on 03/09/2026 9:15 A.M. A Quarterly MDS assessment, dated 01/14/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, chronic respiratory failure. A physician's order, dated 02/19/2026 through 02/26/2026, indicated the resident was to be given Amoxicillin (an antibiotic medication) 500 milligrams (mg), three times each day for acute cough. The EMAR indicated the resident had received the medication. A physician's order, dated 02/26/2026 through 03/06/2026, indicated the resident was to be given Augmentin (an antibiotic medication) 875-125 mg, twice a day each day for acute cough. The EMAR indicated the resident had received the medication. The February 2026 Infection Control Tracking Log lacked indication the resident had received an antibiotic in February 2026. 3.The clinical record for Resident 78 was reviewed on 03/09/2026 at 9:46 A.M. A Quarterly MDS assessment, dated 01/30/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, obstructive uropathy (structural or functional blockage of urine flow anywhere along the urinary tact). The resident had an indwelling urinary catheter. The resident had not been discharged from the facility in over 90 days. A physician's order, dated 02/25/2026 through 03/03/2026, indicated the resident was to be given the antibiotic Ciprofloxacin 250 mg, twice a day for a Urinary Tract Infection (UTI). The EMAR for February and March 2026 indicated the resident had received the medication. The February 2026 Infection Control Tracking Log lacked indication the resident had received an antibiotic in February 2026. The current ANTIBIOTIC STEWARDSHIP PROGRAM policy, with a revised date of 06/2018, was provided by the Assistant Director of Nursing on 03/11/2026 at 1:43 P.M. The policy indicated, .The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections.and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(1)(A)

Based on observation, interview, and record review, the facility failed to ensure a resident was free of physical and mental abuse by a staff member purposely and forcefully causing a resident to fall from the wheelchair onto the floor. This resulted in the staff member leaving the resident lying on the floor with no assistance, she walked away from the resident going into other resident rooms, while another resident was maneuvering their wheelchair around the resident, and the staff member failed to provide accurate details related to the fall for assessment and follow-up care for 1 of 6 residents reviewed for abuse (Resident B). Using the reasonable person concept, it is likely this would lead to fear, confusion, anxiety, and intimidation for Resident B. Findings include:The clinical record for Resident B was reviewed on 02/17/2026 at 11:22 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, depression, anxiety, and unspecified dementia (decline in mental ability). The resident had not exhibited any behaviors during the assessment time frame. The resident utilized a wheelchair and walker for mobility. A Facility Reported Incident, dated 02/10/2026, indicated the Assistant Director of Nursing (ADON) was conducting a root cause analysis of a fall when she reviewed video footage related to a fall for Resident B. Upon review of the video footage, it was noted that Certified Nurse Aide (CNA) 2 was observed forcefully pulling the residents wheelchair backwards causing the resident to fall from the wheelchair. During an interview, on 02/17/2026 at 9:27 A.M., the Regional Nurse Consultant indicated that after a resident had a fall in the facility, they would conduct root cause analysis to determine what caused the fall. While reviewing the hallway recorded video, the morning after it was reported, related to Resident B falling out of his wheelchair in a common area, it was determined a CNA was aggressive with the resident and caused him to fall. There were no other staff members on the unit at the time of the incident. On 02/17/2026 at 10:08 A.M., during an observation of the recorded video footage from 02/09/2026 at 4:20 A.M., with the Regional Nurse Consultant, Resident B was observed sitting in his wheelchair in the hallway on the facility's locked dementia unit. He was in front of the central nurse's station, removed linens from the facility linen cart, and threw the linens on the ground. The resident flipped the linen cart on top of himself, dumping more linens on the floor, and the open linen cart landed on the ground in front of the resident. CNA 2 exited a resident's room directly next to the linen cart where Resident B was sitting. CNA 2 aggressively grabbed the back of Resident B's wheelchair using both handles and proceeded to purposely, forcefully, pull Resident B backwards towards the central nurse's station with two separate jerking, pulling motions. After the second forceful pull Resident B fell out of his wheelchair landing on his buttocks and then fell backwards onto his back to the left of the nurse's desk. The resident's legs were visualized laying in the center of the floor to the left of the nurse's station, with the top half of the resident hidden out of camera view by the nurse's station counter. CNA 2 then stands over Resident B looking down at him and proceeds to walk back to the linen cart in the hallway. CNA 2 standing approximately two feet away from Resident B's feet then flips the linen cart back onto its wheels and proceeded to put the dropped linens, lying on the floor, back into the linen cart. She then moved the linen cart further down the hallway and proceed back into a resident's room directly in front of the nurse's station that she had exited from prior to the interaction. At 4:22 A.M., CNA 2 wheeled a female Resident out of the resident's room towards the dining walking around Resident B, as the resident was still laying on the floor. At 4:23 A.M., CNA 2 walked back past Resident B as he was laying on the floor on his left side, and leaned against the front of the nurse's station counter on her left elbow looking down at Resident B. She then points back at the linen cart and continues looking down at Resident B. CNA 2 then enters another resident's room directly in front of the nurse's station leaving Resident B lying on his left side next to the central nurse's station. At 4:24 A.M., Resident H attempted to wheel around Resident B lying on the floor. Resident B attempted to scoot his body out of the way so that Resident H could get past him. Resident B then rolled over and after a few attempts the resident sits up on his buttocks on the floor. At 4:27 A.M., Resident B appears to be yelling towards the nurse's station throwing his hands in the air while sitting on the floor. At 4:29 A.M., CNA 2 walked around Resident B and to the linen cart. The CNA then pretended to tip the linen cart over and made the movement of throwing linens on the ground without touching the linens in the cart. The recorded video ended at 4:30 A.M., with Resident B on the floor directly next to the end of to the nurse's station counter with CNA 2 standing in the hallway at the linen cart looking at the resident and another resident sitting in their wheelchair in the hallway beside Resident B. During an interview, on 02/17/2026 at 2:23 P.M., RN 3 indicated she was the nurse working with CNA 2 on the facility's locked dementia unit on 02/09/2026. She was on her lunch break and was off the unit when Resident B had fallen on 02/09/2026. When she walked onto the unit Resident B was sitting on the floor next to the nurse's station with his wheelchair in front of him. CNA 2 told her Resident B had flipped the linen cart on top of himself and then slid himself out onto the floor. Resident B wasn't in any distress and never mentioned anything about the situation at all, so she followed the facility's fall protocol. She did not know the exact time she came back onto the unit, but she had clocked back in when she did. A Facility Clock in Form for RN 3 was provided by the Administrator on 02/17/2026 at 2:40 P.M. The document indicated RN 3 clocked back in from her lunch break on 02/09/2026 at 4:42 A.M. During an interview, on 02/17/2026 at 9:03 A.M., Resident B indicated that he had no memory of falling or sitting on the floor. The current facility policy titled, Abuse Prohibition, Reporting and Investigation with a revision date of 06/2023, was provided by the Administrator on 02/17/2026 at 3:40 P.M. The policy indicated, .This facility shall prohibit abuse . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Mental Abuse - Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation . The past noncompliance deficiency was corrected, on 02/11/26, prior to the start of the survey after the facility implemented a systemic plan that included the following actions: the CNA was removed from the work force, an audit was completed for all residents on the unit, education was provided to all staff related to resident abuse and behaviors, and continued abuse audits and monitoring of residents. This citation relates to Intake 2740223. 3.1-27(a)

Based on interview and record review, the facility failed to ensure a resident with a major mental illness was appropriately supervised during a physical/mental outburst for 1 of 6 residents reviewed for behavior health services. (Resident B). Findings include:The clinical record for Resident B was reviewed on 02/17/2026 at 11:22 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, depression, anxiety, unspecified dementia (mental decline), and a history of visual hallucinations. The resident utilized a wheelchair and walker for mobility. An Incident Report, dated 02/11/2026 at 11:23 P.M., indicated Resident B had grabbed a stationary chair that Resident F was sitting in, and made negative comments towards them. The staff intervened to separate the two residents. Resident B continued to go towards the staff and Resident F in an intimidating manner. A Progress Note, dated 02/11/2026 at 11:30 P.M., indicated Resident F sat next to RN 3 at the nurse's station when a male resident came from behind and stated, I'm going to kill you tonight. I don't need anything to do it; I will strangle you. Staff intervened and moved Resident F away from the other resident. The male resident attempted to grab Resident F's shirt and staff responded, you're not allowed to do that. The male resident replied, Watch me, I can do whatever I want. The male resident then proceeded to grab a colored pencil from behind the desk and moved towards staff and Resident F. Staff and Resident F went into a resident's room and closed the door. The male resident proceeded back to the nurse's station where he threw various items. During an interview, on 02/17/2026 at 3:52 P.M., RN 3 indicated she was working the nightshift on the facility's locked dementia unit on 02/11/2026. She was sitting at the nurse's station with Resident F next to her when Resident B came up behind them and stated, I'm going to kill you tonight. I don't need anything to do it because I'm going to strangle you. He then tried to grab the back of the chair Resident F was sitting in and pull her backwards. Certified Nurse Aide (CNA) 4 came around the desk and helped RN 3 get Resident F out from behind the desk. Resident B then stood up out of his wheelchair and began walking towards all three of them with a colored pencil in his hand. They went into the room directly in front of the nurse's station and RN 3 closed the door. Resident B attempted to get into the room. Resident B then gave up and sat down at the nurse's station. He threw a drink, the phone, and attempted to throw the computer monitor off the desk. It was only her and CNA 4 working on the locked unit at the time of the incident. The police were called and arrived within a few minutes. The resident was calm at the time the police arrived; and the resident was removed from the facility. A Staff Statement from CNA 4, provided by the Regional Nurse Consultant on 02/17/2026 at 9:30 A.M., dated 02/11/2026, indicated when Resident B continued towards the staff and Resident F. RN 3 closed the door of room [ROOM NUMBER] keeping Resident B out of the room. CNA 4 then called the staff in another location (outside of the locked unit) for additional staff for assistance. The two staff members working on the locked unit went into a resident's room and shut the door. The door lacked a window and the resident was left behind the nurses station without a staff member monitoring the residents actions during the outburst. During an interview, on 02/19/2026 at 11:42 A.M., Qualified Medical Assistant (QMA) 5 indicated that during a resident-to-resident altercation she would separate the residents removing them both from harm's way and then ensure safety for both residents. She would never leave a resident during a behavior outburst, and she would attempt to redirect. A current care plan, with the start date of 02/10/2026, indicated Resident B had experienced delusions (fixed false beliefs) that someone was out to get him. The interventions included, but were not limited to: dated 02/10/2026, ensure resident's safety. Attempt to ascertain the potential for harm to self or others. The current facility policy titled, Dementia Aggression/Anger dated 05/2016, was provided by the Regional Nurse Consultant on 02/19/2026 at 12:00 P.M. The policy indicated, .Caregivers will strive strategies to understand the aggression that can be caused by many factors including physical discomfort, environmental factors, and poor communication and know how to respond to promote comfort to the resident with dementia . Decrease level of danger.Asses the level of danger - for yourself and the resident with dementia. 3.1-45(a)(2)

Based on observation and interview, the facility failed to follow infection control guidelines during dining service for 1 of 2 dining observations. (Residents 102 and 15) Findings include: During a continuous observation on 02/12/25, from 11:49 A.M. to 11:57 A.M., in the Dementia Unit Dining Room, the following was observed: At 11:49 A.M., Activity Aide (AA) 10 sat an empty lunch tray on a table, opened the trash can lid with her bare left hand, threw some trash into the can, went to the meal cart, and moved around several meal trays within the cart that were to be served to the residents. She retrieved a tray from the cart and served it to Resident 102. After serving the tray she sanitized her hands. At 11:54, she sat an empty tray on a table; opened the trash can lid with her bare left hand; threw some trash into the can; went to the meal cart; and moved several resident meal trays within the cart. She retrieved a meal tray and served it to Resident 15. After serving the tray she sanitized her hands. During an interview, on 02/18/25 at 1:31 P.M., Certified Nurse Aide (CNA) 7 indicated when she was serving meal trays to residents, she would sanitize her hands after every tray served and wash her hands after every third tray served. If she ever touched anything besides the tray while serving, then she would immediately wash or sanitize her hands. The current facility policy titled, Meal Service dated 10/2014 was provided by the Administrator on 02/18/25 at 2:00 P.M. The policy indicated, .To ensure that all meals are delivered to resident as per physician's order . 3.1-21(i)(3)

Based on record review and interview, the facility failed to follow physician's orders related to medication hold parameters for 2 of 22 residents reviewed for Quality of Care. (Residents 71 and 5) Findings include: 1. The clinical record for Resident 71 was reviewed on 02/17/25 at 9:00 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/13/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, schizoaffective disorder, heart failure, hypertension, diabetes, and depression. The current open-ended physician's order, with a start date of 09/03/24, indicated the resident was to receive Lisinopril (a blood pressure medication) 10 milligrams (mg), twice a day. The staff were to hold the medication when the systolic blood pressure (SBP) was less than 130 or the heart rate was less than 60. The January and February 2025 Electronic Medication Administration Record (EMAR) indicated the resident had received the medication when the blood pressure was less than 130 or the heart rate was less than 60 on the following dates and times: - On 01/01/25 in the evening, when the resident's blood pressure was 122/67, - On 01/04/25 in the evening, when the resident's blood pressure was 110/71, - On 01/06/25 in the morning, when the resident's blood pressure was 121/70, - On 01/08/25 in the evening, when the resident's blood pressure was 120/73, - On 01/09/25 in the morning, when the resident's blood pressure was 109/81, - On 01/10/25 in the morning, when the resident's blood pressure was 118/67, - On 01/19/25 in the evening, when the resident's blood pressure was 101/69, - On 01/22/25 in the morning when the resident's blood pressure was 118/76, - On 01/23/25 in the evening when the resident's blood pressure was 124/71, - On 01/24/25 in the morning when the resident's blood pressure was 120/76, - On 01/26/25 in the evening when the resident's blood pressure was 94/72, - On 01/27/25 in the morning when the resident's blood pressure was 108/69, and in the evening when the blood pressure was 113/65, - On 02/01/25 in the evening when the resident's blood pressure was 127/71, - On 02/02/25 in the morning when the resident's blood pressure was 122/67, and in the evening when the blood pressure was 126/65, - On 02/03/25 in the morning when the resident's blood pressure was 126/68, - On 02/05/25 in the evening when the resident's blood pressure was 122/67, - On 02/06/25 in the evening when the resident's blood pressure was 122/75, - On 02/07/25 in the morning when the resident's blood pressure was 128/74, - On 02/08/25 in the evening when the resident's blood pressure was 126/76, - On 02/09/25 in the evening when the resident's blood pressure was 124/73, - On 02/11/25 in the evening when the resident's blood pressure was 126/71, - On 02/12/25 in the evening when the resident's blood pressure was 126/77, - On 02/13/25 in the evening when the resident's blood pressure was 124/76, - On 02/14/25 in the evening when the resident's blood pressure was 123/78, - On 02/15/25 in the evening when the resident's blood pressure was 127/63, and - On 02/17/25 in the morning when the resident's blood pressure was 90/86, and in the evening when the blood pressure was 112/67. The HEART DISEASE Care Plan included, but was not limited to, an intervention to monitor the resident's vital signs as ordered and as needed, and administer medications as ordered. 38239 2. The clinical record for Resident 5 was reviewed on 02/14/25 at 2:00 P.M. A Quarterly MDS assessment, dated 11/22/24 indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, coronary artery disease, hypertension, and dementia. The resident's current MD orders included, but were not limited to the following: An open-ended order, with a start date of 11/07/24, to administer amlodipine (a cardiac medication) 5 mg, twice a day. The medication was to be held if the resident's SBP was less than 120. The January and February 2025 EMARs were reviewed and indicated the medication was administered when the resident's SBP was less than 120 on the following dates and times: - On 01/01/25 the morning the resident's blood pressure was 118/77, - On 01/02/25 the morning the resident's blood pressure was 115/75, - On 01/06/25 the morning the resident's blood pressure was 101/64, - On 01/07/25 the morning the resident's blood pressure was 93/66, - On 01/08/25 the morning the resident's blood pressure was 105/60 and the evening blood pressure was 107/66, - On 01/09/25 the evening the resident's blood pressure was 111/69, - On 01/11/25 the morning the resident's blood pressure was 110/60, - On 01/12/25 the morning the resident's blood pressure was 104/73 and the evening blood pressure was 111/71, - On 01/22/25 the morning the resident's blood pressure was 109/77, - On 01/26/25 the morning the resident's blood pressure was 112/67, - On 02/04/25 the morning the resident's blood pressure was 98/64 and the evening blood pressure was 112/76, - On 02/05/25 the morning the resident's blood pressure was 94/60, - On 02/06/25 the morning the resident's blood pressure was 105/70, - On 02/08/25 the morning the resident's blood pressure was 104/80, and - On 02/11/25 the morning the resident's blood pressure was 102/60 and the evening blood pressure was 110/78. During an interview on 02/18/25 at 10:17 A.M., RN 3 indicated if a resident had a cardiac medication withhold parameters, she would check the resident's blood pressure and heart rate before administering the medication. If the resident's blood pressure or heart rate was out of range, she would hold the medication. She would document in the EMAR that the medication was held. The current facility policy titled PHYSICIAN ORDERS, dated 10/2014, was provided by the Assistant Director of Nursing (ADON) on 02/18/25 at 1:15 P.M. The policy indicated, .Physician's orders are administered .Ensure any follow through is completed . The current facility policy titled MEDICATION ADMINISTRATION, dated 04/2017, was provided by the ADON on 02/18/25 at 1:15 P.M. The policy indicated, .Always take pulse and B/P as indicated in ordered prior to giving certain cardiac or antihypertensive drugs .Notify the physician if the vital signs are not within the acceptable range . 3.1-37(a)

Based on observation and interview, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (Back 200 Medication Cart and Front 100 Medication Cart) Findings include: 1. The Back 200 Medication Cart was observed, on 02/18/25 at 2:33 P.M, with Qualified Medication Aide (QMA) 9. The medication cart contained the following loose pills laying loose in the bottom of the drawers: - two small round white tablets, - one small oval white tablet, and - one small oval blue tablet. The medication cart had several bits of debris/paper that were scattered heavily throughout the cart. During an , on 02/18/25 at 2:35 P.M., QMA 9 indicated she didn't clean the medication cart; she just passed the medications. 2. The Front 100 Medication Cart was observed, on 02/18/25 at 2:39 P.M., with QMA 8. The medication cart contained the following loose pills laying loose in the bottom of the drawers. - one small round white tablet, - one medium round white tablet, and - one large round white tablet. The medication cart had several bits of debris/paper that were scattered throughout the cart. During an interview, on 02/18/25 at 2:42 P.M., the Assistant Director of Nursing (ADON) indicated there should not be any loose pills in the medication carts. The current Storing Drugs policy, dated 4/2021, was provided by the ADON on 02/18/25 at 3:06 P.M. The policy indicated .Drugs and biologicals will be stored in a safe, secure, and orderly manner . 3.1-25(j)

Based on record review and interview, the facility failed to document meal consumption values for 2 of 4 residents reviewed for nutrition. (Residents 55 and 62) Findings include: 1. A Quarterly Minimum Data Set (MDS) assessment, dated 01/29/25, indicated Resident 55 was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, urinary tract infection, seizure disorder, anxiety, depression, and bipolar. The resident had experienced weight loss. A Weight Loss Care Plan, with a start date of 01/18/25, included, but was not limited to, the following intervention: Monitor meal consumption and encourage resident to consume 100% (percent) of meals. The January and February 2025 Meal Consumption Record for the resident lacked documented meal intake values for the following dates: - 01/18/25 at dinner, - 01/26/25 at lunch, - 02/03/25 at breakfast, - 02/10/25 at dinner, and - 02/17/25 at breakfast. 2. A Quarterly MDS assessment, dated 11/27/24, indicated Resident 62 was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, hypertension, Alzheimer's disease, seizure disorder, malnutrition, anxiety, and depression. A Potential for Weight Loss Care Plan, with a start date of 10/01/24, included, but was not limited to, the following intervention: Monitor intake of each meal. The December 2024, January and February 2025 Meal Consumption Record for the resident lacked documented meal intake values for the following dates: - 12/01/24 at lunch, - 12/07/24 at breakfast, lunch, and dinner, - 12/11/24 at lunch, - 12/12/24 at breakfast and lunch, - 12/13/24 at breakfast, - 12/14/24 at dinner, - 12/22/24 at breakfast and lunch, - 12/28/24 at breakfast and lunch, - 01/18/25 at lunch, - 01/19/25 at lunch, - 01/25/25 at lunch, - 02/01/25 at lunch, - 02/05/25 at lunch, and - 02/12/25 at breakfast and lunch. During an interview, on 02/18/25 at 1:07 P.M., Qualified Medication Aide (QMA) 6 indicated residents' meal consumption values should be documented in the computer system after every meal. The current facility policy titled, Meal Consumption Record, dated 10/2014, was provided by the Assistant Director of Nursing (ADON) on 02/18/25 at 1:55 P.M. The policy indicated, .To provide a means to monitor the resident's daily intake .At the end of each meal, resident trays should be observed and percentage of food consumed recorded on Meal Consumption Record . 3.1-46(a)(1)

Based on record review and interview, the facility failed to obtain a urinalysis in a timely manner for 1 of 4 residents reviewed for laboratory services. (Resident 36) Findings include: A Quarterly Minimum Data Set assessment, dated 11/06/24, indicated Resident 36 was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, vascular dementia, diabetes, and stroke. A progress note, dated 01/02/25 at 1:47 P.M., indicated the resident had a new physician's order to obtain a urine dip (a rapid urine test performed in the facility). If the urine dip was positive, nursing staff were to obtain a urine sample to send to the lab for urinalysis (UA) and a Culture and Sensitivity (C&S). The resident's family member was notified. The lab report from the urinalysis indicated the urine sample was collected on 01/07/25 and resulted on 01/08/25. The report indicated there were greater than 100,000 CFU/ml (colony forming units per milliliter) of Streptococcus beta hemolytic Group B bacteria. The bacteria were universally susceptible to Penicillins (a type of antibiotic). Susceptibility testing was not routinely performed. A progress note, dated 01/09/25 at 2:18 P.M., indicated the resident was to receive Amoxicillin (an antibiotic) 500 mg (milligrams) by mouth four times a day for a UTI. During an interview, on 02/18/25 at 10:17 A.M., RN 3 indicated if there was an order to obtain a UA, she would put the order in the computer. She would fill out a lab requisition form and fax the form to the lab, so they were aware. She would collect the urine sample and place it in the designated refrigerator. If she was having a hard time obtaining a sample, she would document that in the computer. The lab technicians came every day, and staff could call the courier to pick up a sample as well. UA C&S results were usually available within 48 to 72 hours of the sample arriving at the lab. During an interview, on 02/18/25 at 10:11 A.M., the ADON indicated the lab came in every morning to collect specimens to take to the local hospital. The order for the UA was given on 01/02/25. The sample was not collected until 01/07/25. It did not usually take five days to obtain a urine specimen. The current facility policy, titled SPECIMEN COLLECTION ROUTINE URINE, dated 10/2014, was provided by the ADON on 02/18/25 at 1:15 P.M. The policy indicated, .obtain a fresh urine specimen for lab analysis .Routine urine specimens are collected as per physician's orders . 3.1-49(a)

Based on observation, interview, and record review, the facility failed to prevent and ensure a resident's wound was identified prior to the resident developing a Stage III pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 64) Findings include: The resident's clinical record was reviewed on 02/18/25 at 1:29 P.M. A Quarterly Minimum Data Set assessment, dated 07/16/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hemiplegia affecting the right dominate side, malnutrition, dementia, peripheral vascular disease, and neuromuscular dysfunction of the bladder. The resident was always incontinent of bowel and had an indwelling urinary catheter. The resident was dependent on staff for toileting, hygiene, and mobility, including rolling left to right. The resident was at risk for pressure ulcers but had no pressures at the time of the assessment. The resident utilized pressure reducing devices for the bed and chair. The clinical record lacked documentation the resident had been absent from the facility for any services for an extended period of time during the month of August. A shower sheet, dated 08/24/24, indicated the resident had a red open area above her buttocks. During an interview on 02/18/25 at 10:30 A.M., the Director of Nursing (DON) indicated when the resident's wound was identified on 08/24/24 he would have assessed it and obtained a physician's order for treatment. He didn't document an assessment of the wound. If he documented a wound's severity or wound stage in the computer, and then the wound specialist came in and staged the wound as less severe, they wouldn't be able to change the wound staging. The wound specialist that came into the facility documented the initial wound assessment on 08/29/24. The resident's physician orders included an order, with a start date of 08/25/24, for a daily treatment to the sacral (base of the spine) wound. The wound was to be cleansed with normal saline. A skin protectant was to be applied to the skin around the wound. An antimicrobial wound gel and calcium alginate was to be applied to the wound bed. The wound was to be covered with a gauze dressing. The Wound Specialist documentation, dated 08/29/24, indicated the wound was a Stage III (full thickness skin loss that may extend into the subcutaneous tissue) pressure ulcer that measured 1.2 centimeters (cm) x (by) 1 cm, with a depth of 0.1 cm. There was a moderate amount of serous (watery, clear, or slightly yellow/tan/pink fluid) exudate. The wound was 70% granulation (new, pink/red moist) tissue and 30% slough (non-viable, dead) tissue. During an observation, on 02/17/25 at 10:09 A.M., Resident 64's sacral wound was observed with RN 3 and the Director of Nursing (DON). The wound was about 3 cm in diameter, with a depth of 1 cm. There was an area of undermining (a separation of the wound edge from the surrounding healthy tissue) along one side of the wound approximately 2 cm long. The wound bed was reddish/pink. There was no drainage or sign of infection. During an interview, on 02/18/25 at 1:45 P.M., Qualified Medication Aide (QMA) 4 indicated the resident required extensive assistance from two staff members for care. Staff would provide catheter care and incontinence care multiple times each day. The current facility policy, titled SKIN MANAGEMENT PROGRAM, dated 10/2013, was provided by the DON on 02/18/24 at 2:40 P.M. The policy indicated, .Residents who receive assistance with bathing and/or pericare will be observed daily by nursing staff and any observance of red areas, open areas .will be reported to the licensed nurse for further assessment . The current facility policy, titled PRESSURE ULCERS, dated 10/2014, was provided by the DON on 02/18/24 at 2:45 P.M. The policy indicated, .assure that residents with pressure ulcers will receive necessary care and treatment to promote healing, prevent new ulcers from developing and prevent infection . 3.1-49(a)(2)

Based on interview and record review, the facility failed to ensure a resident with a urinary tract infection received antibiotic treatment in a timely manner for 1 of 3 residents reviewed for urinary tract infections. (Resident B). Findings include: The clinical record for Resident B was reviewed on 08/28/24 at 2:00 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/05/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, diabetes, renal insufficiency, and neurogenic bladder. The resident was incontinent of bowel and bladder. A progress note, dated 07/10/24 at 9:00 A.M., indicated the resident's family member requested the resident's urine be tested for a UTI (urinary tract infection). The NP (Nurse Practitioner) was in the facility and ordered a UA (urinalysis) with a C&S (Culture and Sensitivity, an additional test used to determine the appropriate antibiotic to use if infection was present) if indicated. A progress note, dated 07/12/24 at 4:50 P.M., indicated the results of the C&S were still pending at that time. A progress note, dated 07/15/24 at 7:30 A.M., indicated the UA C&S results were called in to the NP and ceftriaxone (an antibiotic) was ordered to treat the infection. During an interview on 08/28/24 at 1:09 P.M., RN 2 indicated the lab (laboratory) faxed results to the facility throughout the day. If the lab values were normal, the labs were placed in a binder for the NP to review the next time they were in the facility. If the labs were abnormal, the nurse would contact the NP, inform them of the results, and then implement any new treatment orders. She received the resident's C&S results the evening of Saturday, July 13, 2024. She checked the resident's profile, saw that the resident was currently receiving Macrodantin (nitrofurantoin, an antibiotic) and figured if the NP wanted to change the antibiotic they would do so on the following Monday. If the resident hadn't already been on an antibiotic she would have called and got something started. She didn't review the C&S results, so she didn't know the bacteria present in the resident's urine was resistant to the Macrodantin the resident was currently receiving. The resident's UA C&S results were reviewed. A urine specimen was collected on 07/10/24 and the results indicated a C&S would be required. The final results of the C&S were available on 07/13/24 and indicated the bacteria present in the resident's urine was resistant to treatment with a nitrofuran antibiotic (Macrodantin) the resident was currently taking. The current facility policy, titled LABORATORY ORDERS/RESULT REPORTING, with a revised on date of 11/2016, was provided by the Corporate Nurse on 08/29/24 at 1:56 P.M. The policy indicated, .To ensure laboratory tests ordered by the physician are drawn and results are received by the facility and reported to the attending physician .The facility shall then be responsible to forward the results to the applicable care provider . The deficient practice was corrected on 07/16/24 after the facility reviewed all residents' lab results for timeliness, educated staff, and implemented a process to monitor labs and lab results. This citation relates to Complaint IN00438759. 3.1-41(a)(2)

Based on observation and interview, the facility failed to ensure food was served in a sanitary manner for 2 of 4 dining observations and 4 of 5 staff observations. (CNA 3, CNA 17, QMA 16, and CNA 5) Findings include: 1. During a dining observation in the Memory Care Unit on 04/14/24 the following occurred: - At 12:20 P.M., CNA (Certified Nurse Aide) 3 delivered Resident 70's meal. She removed the plate and cups from the tray and placed them on the table. She removed a dinner roll from the clear plastic package with her bare hand, placed the package on the table, and placed the roll on top of the package. - At 12:23 P.M., CNA 17 delivered Resident 159's meal. She removed the plate and cups from the tray and placed them on the table. She removed a dinner roll from the plastic package with her bare hand and set the package on the table. She sat the roll on top of the package. - At 12:26 P.M., CNA 3 delivered Resident 90's meal. She removed the plate and cups from the tray and placed them on the table. She removed a dinner roll from the plastic package with her bare hand and set the package on the table. She sat the roll on top of the package. - At 12:29 P.M., CNA 17 took Resident 94's dinner roll out of the package with her bare hand, buttered the roll and then placed the roll on the resident's plate. - At 12:33 P.M., QMA (Qualified Medication Aide) 16 removed Resident 45's dinner roll from the package with her bare hand, placed the package on the table and placed the roll on top of the package. 38769 2. During an observation on 04/14/24 in the Main Dining Room, the following was observed: - At 1:09 P.M., CNA 5 applied gloves and served a tray to Resident 13, she touched the tray and all the resident's bowls of food, she retrieved the bread from a bowl and applied butter to the bread. She removed her gloves after giving the resident all her food. - At 1:13 P.M., CNA 5 applied gloves and served a tray to Resident 27, she touched the tray and the resident's plate. She retrieved the bread and touched it with both hands. During an interview on 04/19/24 at 3:08 P.M., QMA 9 indicated if she were to touch a resident's food then she would don gloves. She wouldn't touch anything else after putting on the gloves. The current facility policy titled, Glove Use & Meal Service, dated 05/2018, was provided by the Administrator on 04/19/24 at 3:41 P.M. The policy indicated, .Employees may not touch ready-to-eat foods with bare hands, gloves must be worn . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed and for 6 of 15 resident medications reviewed. (Residents 41, 88, 36, 91, 23, and 13) Findings include: 1. During an observation on 04/14/24 at 9:53 A.M., the back 200 Hall medication cart had the following residents' controlled medications preset for the noon medication pass: - Resident 41's Oxycodone 7.5/325 mg (milligrams) and lorazepam 1 mg, - Resident 88's hydrocodone-acetaminophen 7.5-325 mg, - Resident 36's Lyrica 50 mg and hydrocodone-acetaminophen 7.5-325 mg, - Resident 91's tramadol 50 mg, and - Resident 23's hydrocodone-acetaminophen 10-325 mg. During an interview on 04/14/24 at 9:55 A.M., LPN (Licensed Practical Nurse) 8 indicated she usually preset resident medications for the next medication pass by placing them in a medication cup and labeling them with the resident's name. She placed the cup in the top drawer of the medication cart. 2. During an observation on 04/14/24 at 9:58 A.M., the front 200 Hall medication cart had the following controlled medication preset for the 10:00 A.M. medication pass: - Resident 13's tramadol 50 mg. During an interview on 04/14/24 at 9:59 A.M., QMA (Qualified Medication Aide) 9 indicated she usually preset her next medication pass after the previous medication pass. During an interview on 04/18/24 at 10:32 A.M., the DON (Director of Nursing) indicated controlled medications should not be preset. 38769 3. During a continuous observation on 04/14/24 from 12:02 P.M. to 12:04 P.M., an unlocked medication cart on the 200 Hall was parked outside room [ROOM NUMBER]. The door to room [ROOM NUMBER] was closed and there was no staff around. At 12:03 P.M., QMA 9 came out of room [ROOM NUMBER] and prepared medications. At 12:04 P.M. she locked the medication cart and returned to room [ROOM NUMBER] with the prepared medications. During an interview on 04/19/24 at 3:36 P.M., the DON indicated medication carts are to remain locked when unattended. The current STORING DRUGS policy, with a date of 12/2017, was provided by the Clinical Consultant on 04/18/24 at 10:08 A.M. The policy indicated, .Controlled medications must be stored by a double- lock in a separate area from all other medications . 3.1-25(m)

Based on record review and interview, the facility failed to prevent and follow physician's orders related to a pressure ulcer for 1 of 4 residents reviewed for pressure ulcers. (Resident 48) The clinical record for Resident 48 was reviewed on 04/16/24 at 1:35 P.M. A Quarterly Minimum Data Set assessment, dated 01/20/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, heart failure, hypertension, stroke, diabetes, anxiety, and depression. A physician's order with a start date of 03/11/24 and discontinue date of 04/18/24, indicated the resident was to wear Blue Prevalon boots at all times. An Initial Pressure Ulcer Assessment form, dated 03/14/24, indicated a suspected deep tissue injury (a purple or maroon area of discolored intact skin due to damage of underlying tissue) was discovered on the right medial heel. On 04/16/24 at 11:27 A.M., the resident was observed in bed without her blue boots on. On 04/16/24 at 2:54 P.M., the resident was observed in bed without her blue boots on. The blue boots were observed on the top self of her closet. On 04/17/24 at 8:59 A.M., the resident was in her bed without her blue boots on. On 04/17/24 at 02:30 P.M., the DON (Director of Nursing) and LPN (Licensed Practical Nurse) 22 were observed providing wound care to the resident. The resident did not have her blue boots on prior to the start of the wound care. the non skid sock was removed, the purple area on the right medial heel was cleansed, and skin prep applied as ordered. The non skid sock was placed back on the resident's foot. Neither the DON or LPN 22 placed the blue boot on the resident's foot after the wound care. During an interview on 04/18/24 at 9:28 A.M., the facility wound physician indicated the resident should have some kind of off loading either a pillow or boots. During an interview on 04/18/24 at 2:01 P.M., QMA (Qualified Medication Aide) 2 indicated if a resident had an order for off loading of their heels it would be the responsibility of all nursing staff and if the resident refused a behavior sheet should be filled out. The resident's clinical record lacked documentation the resident refused to wear her blue boots. The current facility policy titled, PRESSURE ULCER PREVENTION dated 10/2014, was provided by the Regional Director on 04/19/24 at 2:45 P.M. The policy indicated, .To prevent pressure ulcers and promote healing .reposition resident approximately every two hours .float heels, as appropriate . 3.1-40(a)(3)

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a blood pressure medication for 1 of 23 residents reviewed for quality of care. (Resident 48) Findings include: The clinical record for Resident 48 was reviewed on 04/16/24 at 1:35 P.M. A Quarterly Minimum Data Set assessment, dated 01/20/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, heart failure, hypertension, stroke, diabetes, anxiety, and depression. A current physician's order, with a start date of 03/29/24, indicated the resident was to get losatan 100 mg (milligrams), one time a day, for hypertension. The staff were to hold the medication if the resident's systolic blood pressure (the top number) was less than 110 or the heart rate was less than 60. The clinical record that included the March and April 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked indication the resident's blood pressure and heart rate had been obtained prior to the administration of the medication. The resident received his medication daily and no resident blood pressure or heart rate values were document from 3/29/24 to 4/18/24. During an interview on 04/17/24 at 10:55 A.M., RN 11 indicated if a medication had hold parameters they should be documented on the EMAR. During an interview on 04/18/24 at 2:57 P.M., QMA (Qualified Medication Aide) 12 indicated if a resident had hold parameters for a blood pressure medication, the blood pressure should be documented on the EMAR. During an interview 04/18/24 at 3:01 P.M., the Clinical Consultant indicated if there are parameters for a medication it should be documented on the EMAR. The current facility policy titled, Medication Administration with a revised date of 04/2017, was provided by the Regional Director on 04/19/24 at 2:45 P.M. The policy indicated, .To safely administer medications as per physicians' orders .Always take pulse and B/P (blood pressure) as indicated if ordered prior to giving certain cardiac or antihypertensive drugs . 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was free from mental and physical abuse for 1 of 23 residents reviewed for abuse. (Resident 203) Findings include: A facility reported incident, dated 12/30/23, indicated CNA (Certified Nurse Aide) 20 had became agitated and had spoken to Resident 203 inappropriately during care. The resident's clinical record was reviewed on 04/19/24 at 12:37 P.M. A Quarterly Minimum Data Set assessment, dated 10/18/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, diabetes, Alzheimer's disease, stroke, anxiety, and stage 4 chronic kidney disease. During an interview on 04/19/24 at 10:46 A.M., CNA 21 indicated on 12/30/23 she was providing care to the roommate of Resident 203 when she heard CNA 20 become agitated with Resident 203. She stepped around the curtain and assisted CNA 20 with the residents care. CNA 20 told Resident 203 if you hit me again I'll hit you back, CNA 20 then took a wet wipe and smacked at the resident's face, and pushed her head down to the pillow when she attempted to sit up. CNA 21 asked CNA 20 to leave the room while she finished care to the resident. CNA 21 told the QMA (Qualified Medication Aide) on the hall what she had witnessed. The QMA phoned the ADON (Assistant Director of Nursing). During an interview on 04/19/24 at 11:19 A.M., the Administrator indicated on 12/30/23, she received a phone call from the ADON explaining what had been reported to her. CNA 20 had been asked to clock out and leave the building pending the facility's investigation of abuse. Written statements were taken from CNA 21 and two CNA students who also witnessed the abuse. The ADON assessed each resident for verbal and physical abuse. The Social Service Director came to the facility and interviewed resident who could be interviewed. Resident 203 was unable to be interviewed and had no recollection of the incident because of her low cognition. The abuse was substantiated and CNA 20 was terminated from employment with the facility. Abuse education was provided to each employee. The incident was reported to the state department of health. The current facility policy, titled Abuse Prohibition, Reporting, and Investigation, with a most recent revision date of January 2015, was provided by the Administrator on 04/14/24. The policy indicated, .The facility shall prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation . The Past noncompliance began on 12/30/23 and the deficient practice was corrected prior to the start of the survey. On 01/01/24, the facility implemented a systemic plan that included the following actions: The facility completed education on the Abuse for all staff members. 3.1-27(a)(1)

Based on observation and interview, the facility failed to to protect resident information related to unlocked computer screens for 4 of 6 random observations for personal privacy. Findings include: During an observation on 04/14/24 at 10:02 A.M., a 200 Hall medication cart had a computer screen opened to resident names and list of medications. The opened computer screen was in the resident hallway on top of the medication cart. There was no staff with in 20 to 30 feet of the medication cart. The DON (Director of Nursing) closed the computer screen as he was walking down the hall passed the cart at 10:03 A.M. During an continuous observation on 04/14/24 at 12:15 P.M. to 12:17 P.M., the front 200 Hall medication cart had a computer tablet on top of the cart. The screen was opened to the resident names and pictures. QMA (Qualified Medication Aide) 9 was in room [ROOM NUMBER] talking with a resident, at 12:17 P.M. she came out of room [ROOM NUMBER] and picked the tablet up off of the medication cart. On 04/15/24 at 10:49 A.M., the front 200 Hall medication cart computer screen was up to show resident names and medication lists, at 10:51 A.M., with no staff in view. The DON was walking past the medication cart and pushed the tablet closed. On 04/18/24 at 8:30 A.M., the computer tablet on top of the medication cart at beginning of the 200 Hall was opened to resident names and medication lists. There was no staff present in the hallway or near the medication cart. During an interview on 04/18/24 at 10:32 A.M., the DON indicated the computer screens should be closed when staff were not present. Resident information should not be visible when staff are not at their medication cart. The current Employee Handbook, dated April 2022, was provided by the Regional Director on 04/19/24 at 12:25 P.M. The Handbook indicated .Health Insurance Portability and Accountability Act (HIPAA) .HIPAA's Privacy Rule requires that all identifiable health information be protected from unauthorized access, use, or disclosure . 3.1-3(o)

Based on observation, record review and interview, the facility failed to ensure the necessary treatment and services were provided related to pain assessment and pain control, resulting in the resident yelling out in pain during treatment. This deficient practice affected 1 of 4 residents reviewed for pain control of 4 residents who met the criteria for pain. (Resident # B) Finding includes: On 04/21/2015 at 2:18 P.M., Resident #B was observed with facial grimacing. During an interview on 04/21/2015 at 2:20 P.M., Resident #B indicated the pain medication does not control the pain level for the duration between medication doses. On 04/22/2015 at 10:11 A.M., Resident #B was observed yelling repetitively, "it hurts", while Certified Nursing Aide (CNA) #8 and CNA #9 repositioned the resident on to the left side. During an interview on 04/22/2015 at 10:11 A.M., Certified Nurse Aide (CNA) #8 indicated Resident #B's medication does not appear to last long enough. The resident complained frequently of pain in between pain medication doses. CNA #8 indicated Resident #B states, "it hurts", every time the resident was touched for provision of care. During an interview on 04/23/2015 at 9:32 A.M., Resident #B indicated the pain level was an 8 on a pain scale of 0 to 10 and the pain was all over, from head to toe. On 04/24/2015 at 10:52 A.M., Resident #B was observed yelling out, "my bottom hurts", loud enough to be heard from the hallway. During an interview on 04/27/2015 at 9:29 A.M., Licensed Practical Nurse (LPN) #2 indicated Resident #B had received a pain pill at 8:00 A.M. and Resident #B had an order for [REDACTED]. On 04/27/2015 at 9:38 A.M., Resident #B was observed being placed in the sling for the Hoyer lift by CNA #5 and CNA #8. The resident complained of pain throughout the procedure. During an interview on 04/27/2015 at 9:44 A.M., CNA #5 and CNA #8 indicated the resident had received a pain pill prior to use of the Hoyer lift and always complains of pain . During an interview on 04/27/2015 at 1:17 P.M., Resident #B indicated after returning from the wound clinic, where additional pain medications were administered, the pain level was not too bad. At that time, the resident indicated the pain level was a 3 on a pain scale of 0 to 10. Record review on 04/27/2015 at 2:00 P.M., for Resident #B indicated the following: Resident #B's physician's orders [REDACTED]. If the pain medication was ineffective, the physician was to be notified. Resident #B's physician's orders [REDACTED]. The current Medication Administration Record [REDACTED]. Resident #B's Medication Administration Record [REDACTED] April 21, 2015 at 04:00 A.M. April 22, 2015 at 11:00 A.M. April 24, 2015 at 12:30 P.M. April 26, 2015 at 01:30 A.M. The Significant Change Minimum Data Set (MDS) assessment, dated 02/19/2015, indicated the resident was moderately impaired cognitively with a Brief Interview for Mental status (BIMS) score of 12. The resident's functional status was extensive assistance with mobility. The resident was incontinent of bowel and had an indwelling catheter for urine output. The unhealed coccyx pressure ulcer was measured at 5.8 centimeters in length, 3.6 centimeters in width and a depth of 4.3 centimeters. The resident's care plan for pain, dated 2/25/2015, indicated Resident #B had a goal of pain to be less than 3 on a scale from 0 to 10. The interventions included, but were not limited to, monitor for signs of pain, such as facial grimacing, moaning, and restlessness. Pain medications were to be administered as ordered and monitored for efficacy. The physician and the resident's responsible party were to be notified of changes. The current policy and procedure for Pain Assessment, provided by the Director of Nursing (DON) on 04/24/2015 at 3:42 P.M., indicated the purpose was to "identify those residents who utilized routine medications for pain or who utilized frequent PRN pain medications in an effort to ensure adequate pain control was achieved... 3. Any change in condition affecting pain and/or pain medication shall be evaluated by the interdisciplinary team during care plan review and notification shall be made to the physician accordingly. 4. Should, following admission, the resident exhibit pain which was not sufficiently controlled by current pain medication ordered, a pain Assessment shall be completed and any necessary interventions implemented accordingly." 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure the necessary treatment and services were provided related to pain assessment and pain control, resulting in the resident yelling out in pain during treatment. This deficient practice affected 1 of 4 residents reviewed for pain control of 4 residents who met the criteria for pain. (Resident # B) Finding includes: On 04/21/2015 at 2:18 P.M., Resident #B was observed with facial grimacing. During an interview on 04/21/2015 at 2:20 P.M., Resident #B indicated the pain medication does not control the pain level for the duration between medication doses. On 04/22/2015 at 10:11 A.M., Resident #B was observed yelling repetitively, "it hurts", while Certified Nursing Aide (CNA) #8 and CNA #9 repositioned the resident on to the left side. During an interview on 04/22/2015 at 10:11 A.M., Certified Nurse Aide (CNA) #8 indicated Resident #B's medication does not appear to last long enough. The resident had complained frequently of pain in between pain medication doses. CNA #8 indicated Resident #B states, "it hurts", every time the resident was touched for provision of care. During an interview on 04/23/2015 at 9:32 A.M., Resident #B indicated the pain level was an 8 on a pain scale of 0 to 10 and the pain was all over, from head to toe. On 04/24/2015 at 10:52 A.M., Resident #B was observed yelling out, "my bottom hurts", loud enough to be heard from the hallway. During an interview on 04/27/2015 at 9:29 A.M., Licensed Practical Nurse (LPN) #2 indicated Resident #B had received a pain pill at 8:00 A.M. and Resident #B had an order for [REDACTED]. On 04/27/2015 at 9:38 A.M., Resident #B was observed being placed in the sling for the Hoyer lift by CNA #5 and CNA #8. The resident complained of pain throughout the procedure. During an interview on 04/27/2015 at 9:44 A.M., CNA #5 and CNA #8 indicated the resident had received a pain pill prior to use of the Hoyer lift and always complains of pain. During an interview on 04/27/2015 at 1:17 P.M., Resident #B indicated after returning from the wound clinic, where additional pain medications were administered, the pain level was not too bad. At that time, the resident indicated the pain level was a 3 on a pain scale of 0 to 10. Record review on 04/27/2015 at 2:00 P.M., for Resident #B indicated the following: Resident #B's physician's orders [REDACTED]. If the pain medication was ineffective, the physician was to be notified. Resident #B's physician's orders [REDACTED]. The current Medication Administration Record [REDACTED]. Resident #B's Medication Administration Record [REDACTED] April 21, 2015 at 04:00 A.M. April 22, 2015 at 11:00 A.M. April 24, 2015 at 12:30 P.M. April 26, 2015 at 01:30 A.M. The Significant Change Minimum Data Set (MDS) assessment, dated 02/19/2015, indicated the resident was moderately impaired cognitively with a Brief Interview for Mental status (BIMS) score of 12. The resident's functional status was extensive assistance with mobility. The resident was incontinent of bowel and had an indwelling catheter for urine output. The unhealed coccyx pressure ulcer was measured at 5.8 centimeters in length, 3.6 centimeters in width and a depth of 4.3 centimeters. The resident's care plan for pain, dated 2/25/2015, indicated Resident #B had a goal of pain to be less than 3 on a scale from 0 to 10. The interventions included, but were not limited to, monitor for signs of pain, such as facial grimacing, moaning, and restlessness. Pain medications were to be administered as ordered and monitored for efficacy. The physician and the resident's responsible party were to be notified of changes. The current policy and procedure for Pain Assessment, provided by the Director of Nursing (DON), on 04/24/2015 at 3:42 P.M., indicated the purpose was to, "identify those residents who utilized routine medications for pain or who utilized frequent PRN pain medications in an effort to ensure adequate pain control was achieved... 3. Any change in condition affecting pain and/or pain medication shall be evaluated by the interdisciplinary team during care plan review and notification shall be made to the physician accordingly. 4. Should, following admission, the resident exhibit pain which was not sufficiently controlled by current pain medication ordered, a pain Assessment shall be completed and any necessary interventions implemented accordingly." This Federal tag relates to the Investigation of Complaint IN 810. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure the necessary treatment and services were provided related to pain assessment and pain control, resulting in the resident yelling out in pain during treatment. This deficient practice affected 1 of 5 residents reviewed for pain control. (Resident # D) Findings include: On 3/30/2015 at 9:20 A.M., Resident # D was observed yelling out in pain during a dressing change and treatment of [REDACTED]. The resident asked the Registered Nurse (RN) # 1 why the treatment had to hurt so much. RN # 1 advised the resident that the pain medication ([MEDICATION NAME]) did not have enough time to take effect and indicated the resident should start to feel better soon. During an interview, on 3/30/2015 at 9:34 A.M., RN # 1 indicated she knew the resident's pain medication ([MEDICATION NAME]) was not strong enough to control the resident's pain. She indicated the resident had an order for [REDACTED].# 1 was not able to explain why the medication was not available for the past month for Resident # D. She indicated no pain scale assessment sheets were completed for the resident. Resident # D's clinical record was reviewed on 3/30/2015 at 9:50 A.M. A physician's orders [REDACTED]. Medication Administration Record [REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 2/17/2015, indicated the resident was not cognitively intact with a Brief Interview for Mental status (BIMS) score of 06. The care plan for pain, dated 3/03/2015, indicated Resident # D had a goal of pain to be less than 3 on a scale from 0 to 10. The interventions were to monitor for signs of pain, such as facial grimacing, moaning, and restlessness. Pain medications were to be administered as ordered and monitored for efficacy. No pain scale assessment sheets were located for Resident # D. The current policy and procedure for Pain Assessment provided by the Director of Nursing (DON), on 3/30/2015 at 3:11 P.M., indicated the purpose was to identify those residents who utilized routine medications for pain or who utilized frequent PRN "as needed" pain medications in an effort to ensure adequate pain control was achieved... "3. Any change in condition affecting pain and/or pain medication shall be evaluated by the interdisciplinary team during care plan review and notification shall be made to the physician accordingly. 4. Should, following admission, the resident exhibit pain which was not sufficiently controlled by current pain medication ordered, a pain Assessment shall be completed and any necessary interventions implemented accordingly." This Federal tag relates to the Investigation of Complaint IN 820. 3.1-37(a)

Based on record review and interview, the facility failed to ensure specialized services were provided to prevent infection leading to hospitalization , related to central line care and treatment. This deficient practice affected 1 of 2 residents reviewed for venous access care. (Resident # G) Findings include: During an interview, on 3/30/2015 at 9:04 A.M., Complainant # 1 indicated that on 3/17/2015, Resident # G's central line was contaminated with matted hair and showed symptoms of infection (insertion site was red and dressing was loose and soiled). Resident # G's clinical record was reviewed on 3/30/2015 at 9:00 A.M., and indicated the following: The Vital Sign Record, dated 3/05/2015, temperature of 97.4 degrees Fahrenheit. The Vital Sign Record, dated 3/07/2015, temperature of 99.7 degrees Fahrenheit. On 3/17/2015, the clinical documentation indicated Resident # G was lethargic and unable to speak. The Emergency Department (ED) Triage and Assessment, dated 3/17/2015, indicated the resident arrived with a temperature of 104.5 degrees Fahrenheit. The resident's central line-insertion site appearing red with a noted yellow drainage. The hospital Clinical Document, dated 3/17/2015, indicated the resident's central line was removed in the emergency department. The resident was noted to have some purulent (milky; sometimes green) drainage from the opening. Hospital records indicated the central line tip was cultured on 3/17/2915, the Central Line Culture report indicated a growth of Proteus mirabilis. Resident # G's hospital discharge [DIAGNOSES REDACTED]. Resident # G's clinical record contained no documentation that central line assessments and care were being performed as ordered. This Federal tag relates to the Investigation of Complaint IN 820. 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure the specialty left foot pedal was in place on the wheelchair of a resident with left [DIAGNOSES REDACTED] prior to transporting the resident down the hallway in the wheelchair, resulting in the resident's left foot dropping down onto the floor and then causing the resident to be propelled forward onto the floor which resulted in the resident sustaining a fracture to the left clavicle (collarbone), a sprain to the left ankle and a hematoma to the head. This deficient practice affected 1 of 3 residents reviewed for accidents in a total sample of 3. (Resident #A) Findings include: Resident #A's clinical record was reviewed on 7-17-12 at 11:05 a.m. Her [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 6-21-12, indicated she has moderate cognitive impairment, requires extensive assistance of 1 person with ambulation and transfers and uses a walker or wheelchair for mobility. In interview with Resident #A on 7-17-12 at 10:55 a.m., she indicated, "Not long ago, my aide was pushing me down the hall to the dining room...She forgot the foot pedals of my wheelchair. My (left) foot drug on the floor and I pitched forward. Hurt my shoulder; showed me the xray of my collarbone (in the emergency room )...(and) my left ankle got sprained. I had a stroke about 5 years ago and have little use of my left side. My shoulder aches all the time." In interview with CNA #1 on 7-18-12 at 10:50 a.m., she indicated she was providing care to Resident #A on the evening of 6-16-12. She indicated she assisted her in transferring from the recliner into the wheelchair without any difficulty. She indicated she was unaware the resident required the extension and foot pedal added to the wheelchair. She indicated she had recently switched from the night shift to the evening shift. She indicated she could not recall if the aide assignment sheet had anything about the foot pedal on it prior to the accident. She indicated the resident did not say anything to her in regard to putting the foot pedal on the wheelchair. She indicated she was in the process of pushing the resident down the hall toward the dining room, "No problems until got near the DON's (Director of Nursing) office. Her foot dropped and she just went forward. I screamed and she screamed. All kinds of people showed up. Her head hit and you could hear it hit. First thing I did was check her head...She said her arm and leg or knee hurt. A nurse and 2 or 3 CNA's responded. (Name of resident) seemed to be alert and oriented." In interview with LPN #2 on 7-18-12 at 11:34 a.m., she indicated she did not witness the accident, but "heard it happen." She indicated she had seen CNA #1 walk past the nurse's station with Resident #A. She indicated she did not recall the CNA's walking pace to be unusually fast, "Just a normal pace." She indicated that "Right after she went by, I heard it." She indicated she found the resident lying on her left side with her legs entangled in the wheelchair and, "Generally, she had a pedal on the left side (of the wheelchair) and I immediately noted it was missing." She indicated she assessed the resident and the resident was sent to the local emergency room . She indicated after the resident was sent to the emergency room , she then spoke with CNA #1. She indicated CNA #1 "Told me she was new to the evening shift from nights and didn't know the pedal was suppose to be there. She thought the pedals weren't being used anymore." She indicated, "I don't think the aide assignment sheets said anything about her foot pedal." In interview with the DON on 7-17-12 at 12:17 p.m., she indicated, "Wheelchair pedals should have been on the wheelchair prior to the accident." She indicated she was unsure why the foot pedal was not in place. In interview with the DON on 7-18-12 at 8:12 a.m., she indicated she was not sure if the CNA assignment sheet for Resident #A would have reflected the need for the foot pedal prior to her accident on 6-16-12. She indicated, "Typically, I wouldn't necessarily put things like foot pedals or a leg extension (for a wheelchair) on there unless it would be new or as a result of an incident. On 7-18-12 at 9:35 a.m., the DON provided a copy of the CNA assignment sheet which indicated it had been updated on 6-15-12 for Resident #A. It did not include any information about a foot pedal or leg extension for her wheelchair. Review of the emergency room visit documentation indicated Resident #A arrived via ambulance at 7:05 p.m. on 6-16-12 with a large "lump (to the) left side (of) head starting to bruise" with the left shoulder painful and swollen. The findings of the emergency room physician, upon discharge the same evening, were a left clavicle fracture, a contusion to the left ankle and a left scalp hematoma. These findings were based upon physical examination, a CT scan of the head and xray's of the shoulder and ankle. The recommendations included a follow up appointment with an orthopedist and to wear a left arm sling until seen by the specialist. Review of the orthopedist's recommendations on 6-26-12 was consistent with the emergency room findings. He advised the sling to be worn for comfort and to treat conservatively. He recommended a follow up appointment and xray of the clavicle in 4 weeks. On 7-18-12 at 9:35 a.m., the DON provided a copy of "Occupational Therapy Progress Notes," dated 9-4-09 through 9-11-09. This document indicated Resident #A's wheelchair has a left foot "Box-trough" type of foot pedal/leg extension for the wheelchair. The DON indicated this foot pedal/leg extension had not changed since this note was written in 2009. This Federal tag relates to Complaint IN 334. 3.1-45(a)(2)