Every finding on record at Willows of Greensburg

Based on interview and record review, the facility failed to follow appropriate safety measures when assisting a resident in their wheelchair, resulting in the resident falling for 1 of 3 residents reviewed for accident hazards. (Resident B)Findings include: Resident B's clinical record was reviewed on 08/25/2025 at 10:35 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/29/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes (a chronic condition where your body either cannot produce enough insulin or cannot effectively use the insulin it makes), and kidney failure. The resident's range of motion was impaired in one of his arms and in both of his legs. The resident used a wheelchair and required partial/moderate staff assistance to wheel himself short distances and substantial/maximal staff assistance to wheel himself long distances. The resident had not experienced a fall since the last assessment review period. A Health Status Note, dated 07/06/2026 at 9:45 P.M., indicated the resident was self-propelling in his wheelchair down the hall. The resident indicated he was leaving the facility. RN 4 stopped the resident in the hall and discussed staying in the facility. RN 4 was pushing the resident in his wheelchair back to his room. The resident put his feet on the floor and the RN stopped pushing the resident. The resident tried to stand and fell forward before the nurse was able to get to him, and the resident landed on the floor.During an interview, on 08/26/2026 at 11:30 A.M., RN 4 indicated on the evening of 07/06/2026 she observed the resident in the hall, propelling himself in his wheelchair. He told her he was leaving the building. She talked to him, determined he needed to use the restroom and started to push him back to his room. She pushed him about ten feet, he put his feet down and his feet caught on the ground. She stopped and he stood up and was falling forward. It was all one fluid motion. She tried to get to him, but he fell and hit the floor face first. His nose was bleeding and he had a gash on his forehead and another across the bridge of his nose. She assessed his injuries, stopped the bleeding, and called Emergency Medical Services (EMS) to send him to the hospital. As far as she knew he was able to propel himself around the building, but he was usually in his room in his recliner when she worked with him. It was uncommon for him to be out of his room in his wheelchair. She did not think the aides assisted him into the wheelchair, she thought he got into it himself. If you were pushing a resident in a wheelchair, their feet should be up on footrests. She did not think he had footrests on his wheelchair at the time; the nursing intervention that was put into place after the fall was that the resident was to have footrests on his wheelchair. Best practice would be to ensure resident's feet were placed on footrests when you were pushing a resident in a wheelchair. During an interview, on 08/26/2026 at 1:50 P.M., Certified Nurse Aide (CNA) 3 indicated not all residents that used wheelchairs had footrests; the Therapy Department evaluated residents and let nursing staff know which residents were to utilize footrests. Several residents propelled themselves, so they didn't have footrests on their wheelchairs. If nursing staff were pushing a resident in their wheelchair, they should have footrests in place. The current facility policy, titled Accidents and Supervision, dated 07/2023, was provided by the Administrator on 08/26/2026 at 2:21 P.M. The policy indicated, .Each resident will receive adequate supervision and assistive devices to prevent accidents.The current Indiana State Department of Health Nurse Aide Curriculum, revised on November 19, 2015, was reviewed on 08/26/2026 at 2:45 P.M. The curriculum indicated, .TRANSFERRING TO WHEELCHAIR.Align resident's body and position footrests.Unlock wheels.transport resident forward.The citation relates to Intake 3095936.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on record review and interview, the facility failed to accurately document wound care treatments for 1 of 3 residents reviewed for documentation. (Resident B)Findings include:Resident B's clinical record was reviewed on 08/25/2026 at 10:35 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/29/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes (a chronic condition where your body either cannot produce enough insulin or cannot effectively use the insulin it makes), and peripheral vascular disease (a blood circulation disorder that narrows, blocks, or spasms blood vessels outside the heart and brain, most commonly affecting the arteries in the legs and feet). The resident had an arterial ulcer (an open skin wound caused by a severe lack of blood flow and oxygen to the lower legs and feet). The resident was hospitalized on [DATE] and returned to the facility on [DATE]. The resident was evaluated on readmission and observed to have the following new skin impairments in addition to the left heel ulcer that was present before he discharged from the facility. - A Wound Assessment, dated 07/22/2026, indicated the resident had an arterial ulcer on the anterior ankle of the left foot that measured 3 centimeters (cm) x 5 cm. The treatment orders were to cleanse the wound and apply calcium alginate (a water-insoluble, wound treatment made from acid found in brown seaweed) and wrap with a woven gauze bandage daily, and- A Wound Assessment, dated 07/22/2026, indicate the resident had an arterial ulcer on the lateral distal side of the left foot that measured 1 cm x 2 cm. The treatment orders were to cleanse the wound, apply calcium alginate, and a woven gauze dressing daily.The July 2026 Electronic Treatment Administration Record (ETAR) was reviewed. The wound treatment orders for the anterior ankle and lateral distal side of the left foot were not documented as administered until 07/29/2026, seven days after the treatment was ordered.During an interview, on 08/26/26 at 10:54 A.M., the Facility Wound Nurse (FWN) indicated she observed the resident's wounds and documented the assessments when he readmitted to the facility on [DATE]. She contacted the Wound Nurse Practitioner (WNP) for treatment orders. The WNP came into the facility once a week and had already been in the facility the day before the resident was readmitted , so she wouldn't see him until the following week. The ordered treatments should have shown up on the ETAR on 07/22/2026, she was not sure why they were not on the ETAR until 07/29/2026. The treatments were administered daily as ordered. When nursing staff administered the treatment to the heel, they did the other areas too. During an interview, on 08/26/2026 at 12:49 P.M., RN 2 indicated when the resident returned to the facility he had some new areas on his left foot. She was not sure if there was an issue with the ETAR, but she administered the treatments to the new areas on the resident's foot when she administered the treatment to his left heel. The current facility policy, titled Documentation of Wound Treatments, dated 07/2023, was provided by the Administrator on 08/26/2026 at 2:17 P.M. The policy indicated, .The facility completes accurate documentation of wound assessments and treatments.Additional documentation shall include, but is not limited to.Treatments.The citation relates to Intake 3095936.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained and the kitchen was free of mouse droppings. This deficient practice had the potential to affect 71 of 71 residents residing in the facility. Findings include:During the initial kitchen tour with the Dietary Manager (DM), on 05/14/2026 at 10:45 A.M., the following was observed in the dry storage room: -Scattered mouse droppings in a case box of cans of evaporated milk that was sitting on a wire shelf rack,-Scattered mouse droppings in a metal tray under the furnace, and-Scattered mouse droppings in an open clear rectangular bin full of plastic lids that was sitting on a wire shelf rack. During an observation and interview with the DM, on 05/15/2026 at 2:04 P.M., the DM indicated the pest control company had been to the facility for treatment a couple of weeks ago. During an interview, on 05/15/2026 at 2:07 P.M., the Administrator indicated the facility used a local pest control company and last date of service was 05/01/2026 when they provided the monthly treatment along with the spring treatment. During an interview, on 05/18/2026 at 9:30 A.M., the Administrator indicated a local pest control company supplied and installed mice bait boxes at the facility in February 2026. The pest control company came to the facility every other month to check the boxes and add bait to them. The current Food Safety Requirements policy, with an implemented date of 07/2023, was provided by the Administrator on 05/14/2026 at 12:00 P.M. The policy indicated, .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)(4)

Based on record and interview, the facility failed to follow the physician's hold parameters for a cardiac medication for 1 of 19 residents reviewed for quality of care. (Resident 63)Findings include:Resident 63's clinical record was reviewed on 05/19/2026 at 1:20 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/17/2025, indicated the resident's diagnosis include, but were not limited to: hypertension (high blood pressure).The resident's current physician's orders, with a start date of 03/31/2023, indicated the resident was prescribed amlodipine (hypertension), 10 milligrams every morning. The medication was to be held if the resident's systolic blood pressure (the top number) was below 110. The April and May 2026 Electronic Medication Administration Record (EMAR) indicated the medication was administered on the following days when the resident's blood pressure was below 110:- On 04/01/2026, the resident's systolic blood pressure was 90,- On 04/02/2026, the resident's systolic blood pressure was 90,- On 04/04/2026, the resident's systolic blood pressure was 103,- On 04/06/2026, the resident's systolic blood pressure was 108,- On 04/08/2026, the resident's systolic blood pressure was 107,- On 04/09/2026, the resident's systolic blood pressure was 106,- On 04/13/2026, the resident's systolic blood pressure was 105,- On 04/16/2026, the resident's systolic blood pressure was 108,- On 04/23/2026, the resident's systolic blood pressure was 105,- On 04/24/2026, the resident's systolic blood pressure was 108,- On 04/27/2026, the resident's systolic blood pressure was 104, and- On 05/02/2026, the resident's systolic blood pressure was 106.During an interview, on 05/20/2026 at 10:21 A.M., Licensed Practical Nurse (LPN) 2 indicated if a resident had hold parameters for a cardiac medication, she would assess the resident's blood pressure before she administered the medication. If anything was out of range, she would notify the Nurse Practitioner. She would not administer the medication, and she would document the reason in the EMAR. The current facility policy, titled Physician Medication Orders, revised on 07/2023, was provided by the Administrator on 05/19/2026 at 1:19 P.M. The policy indicated, .Medications should be administered only upon the signed order of a person lawfully authorized to prescribe .IAC (Indiana Administrative Code) 3.1-48(a)(6)

Based on observation, record review, and interview, the facility failed to ensure wound treatments were completed as ordered for 2 of 3 residents reviewed for pressure ulcers. (Residents 54 and 63)Findings include:1. During an observation, on 05/19/2026 at 10:18 A.M., the Assistant Director of Nursing (ADON) prepared supplies to complete Resident 54's wound treatment. She placed a towel on the overbed table, arranged the supplies on top of it, washed her hands, and donned gloves. She elevated the resident's bed to waist level, rolled the resident to her left side, removed the resident's pants, and unfastened her brief. She then removed her gloves, sanitized her hands, and donned new gloves. The ADON removed the resident's dressing from the right ischium, which had drainage present and was dated for the previous day. She cleansed the wound with Dakin's solution. The wound was approximately tennis ball size, and had measurable depth. The wound contained slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) and was a gray color. The exterior skin around the wound was pink. The ADON removed her gloves, donned a gown, and new gloves. She applied the treatment per the physician's orders. The resident's clinical record was reviewed on 05/18/2026 at 2:21 P.M. A Significant Change Minimum Data Set (MDS) assessment, dated 04/25/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included but were not limited to, dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life) and diabetes (a chronic condition where your body either cannot produce enough insulin or effectively use the insulin it makes). The resident had an unstageable (Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer that was not present on admission. A Facility Wound Assessment, dated 01/19/2026, indicated the resident had a Stage 1 (Non-blanchable erythema of intact skin with a localized area of non-blanchable erythema (redness) pressure ulcer to the right ischium that was acquired in house on 01/19/2026. The wound was dry without drainage. The wound measured 1 cm (centimeter) X (by) 1 cm. An order was obtained to apply skin protectant daily and cover with a foam dressing. A Facility Wound Assessment, dated 02/17/2026, indicated the resident had a Stage 1 pressure ulcer to the right ischium. The wound was dry with serous (is watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) drainage. The wound had worsened and measured 2.5 cm X 2.6 cm X 0.1 cm. A new treatment order was obtained to cleanse the wound with wound cleanser, pat dry cover, with calcium alginate, then cover with bordered gauze. A Wound Nurse Practitioner (NP) Assessment, dated 02/23/2026, indicated the resident had an unstageable pressure ulcer to the right ischium. The wound had a light amount of serous drainage. The wound had 80% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound), 10% slough, and 10% granulation (new, pink-to-red, bumpy connective tissue and microscopic blood vessels that form at the base of a wound during the healing process). The wound measured 3.5 cm X 3.5 cm X 0.1 cm. A new order was obtained to cleanse the wound with wound cleanser or normal saline, apply medical grade honey, and cover with bordered gauze, daily. Physician's wound treatment orders in February 2026 for the right ischium included: - An order dated 01/19/2026 through 02/25/2026, the staff were to apply skin protectant to the right ischium every day, - An order with a start date of 02/17/2026, indicated the staff were to cleanse the right ischium with wound cleanser, pat dry, cover with calcium alginate and bordered gauze until 02/23/2026, and - An order dated 02/25/2026 through 03/12/2026, indicated the staff were to cleanse the right ischium with wound cleanser, apply medical grade honey, and cover with bordered gauze every night shift. The clinical record including the February 2026 Electronic Medication Administration Record (EMAR)/Electronic Treatment Administration Record (ETAR) lacked documentation that the wound treatment for the calcium alginate was completed from 02/17/2026 through 02/23/2026. During an interview, on 05/19/2026 at 10:38 A.M., the ADON indicated the resident had a stage 1 pressure ulcer that started 01/19/2026. It was just some sheering when it started. The resident had a rapid decline in her health. When the wound worsened it worsened fast. She was following the wound in the facility from 01/19/2026 through 02/17/2026. When she assessed the wound on 02/17/2026 it had worsened. She obtained new orders from the Facility NP until the resident would be see by the Wound NP the following week. She transcribed the new order on 02/17/2026. When the nurses completed the treatment, they would check it off on the EMAR/ETAR or some nurses would put in a progress note. The treatments should have been checked off in the EMAR/ETAR. 2. Resident 63's wound was observed on 05/19/2026 at 9:40 A.M., with the ADON and Facility Wound NP. The wound was on the resident's right buttock/lower back area. The wound was around 5 cm in diameter, with a depth of 2 cm. The wound bed was pink in color with no drainage or signs of infection. During an interview, on 05/19/2026 at 9:26 A.M., the ADON and Wound NP indicated the wound started out as Incontinence Associated Dermatitis (IAD) (a painful, inflammatory skin condition caused by prolonged contact with urine or stool). The resident had a rapid overall decline. The ADON indicated she became frequently incontinent and slept a lot. Initially, she resisted interventions to alleviate pressure on her backside. She insisted on sleeping in her recliner and refused to use an alternate pressure-reducing cushion in her chair. The Wound NP indicated the wound was considered unavoidable and the resident was currently receiving hospice services. A Skin and Wound Progress Note, dated 01/06/2026, indicated the resident had an area of IAD on her right buttock. The resident had a history of intermittent incontinence and refused to sleep in her bed. She only slept in her recliner and was noted to have a gel cushion in place. The wound measured 4 cm x 4 cm, with a depth of 0.1 cm. The wound bed was 100% epithelial tissue (pink tissue with a shiny, pearl appearance). The treatment was to cleanse the skin, dry the skin, and apply a barrier paste daily and as needed. A Skin and Wound Progress Note, dated 01/27/2026, indicated the resident had an area of IAD on her right and left buttocks that measured 1 cm x 0.2 cm x 0.1 cm. The wound bed was 100% epithelial tissue. The treatment was to cleanse the skin, dry the skin, and apply a barrier paste twice a day and as needed. A Progress Note, dated 01/28/2026 at 9:19 A.M., indicated a new skin issue was identified on the resident's right buttock. A small abrasion area was cleansed, and cream was applied while on rounds with the Wound NP. Nursing staff were to continue with barrier cream. A Skin and Wound Progress Note, dated 02/03/2026, indicated the resident had new, unstageable pressure ulcer to her right buttock as evidenced by thick slough and eschar noted to the proximal aspect of the wound. She continued to have IAD to the left buttock that was not full thickness and only involved dermis. The wound on her right buttock measured 5 cm x 3 cm x 0.3 cm. The wound base was 30% epithelial tissue, 30% granulation tissue, and 40% eschar. The treatment plan was to cleanse the wound and apply medical grade honey and a dressing daily. A Skin and Wound Progress Note, dated 02/10/2026, indicated the unstageable wound on the resident's right buttock measured 4 cm x 3 cm x 0.3 cm. The wound base was 60% granulation tissue, 20% slough, and 20% eschar. The treatment plan was to continue to cleanse the wound and apply medical grade honey and a dressing daily. A Skin and Wound Progress Note, dated 02/17/2026, indicated the wound on the resident's right buttock measured 3 cm x 3 cm x 0.3 cm. The wound base was 60% granulation tissue, 20% slough, and 20% eschar. The treatment plan was to continue to cleanse the wound and apply medical grade honey and a dressing daily. The resident's February 2026 EMAR/ETAR was reviewed and indicated the treatment to cleanse the wound and apply honey was initiated and administered daily from 02/06/2026 until it was discontinued on 02/11/2026. A new treatment to cleanse the wound and apply a zinc oxide-based hydrophilic paste mixed with collagen particles twice a day was administered from 02/11/2026 until 02/18/2026, when it was discontinued and the honey wound treatment was restarted. The resident's record lacked indication the treatment should have been changed from medical grade honey to the collagen/paste mixture on 02/11/2026. The current facility policy, titled Pressure Injury Prevention and Management, revised on 07/23, was provided by the Administrator on 05/19/2026 at 1:19 P.M. The policy indicated, .This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present . IAC (Indiana Administrative Code) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to follow infection control guidelines related to enhance barrier precautions for 1 of 2 residents reviewed for urinary tract infections. (Resident 25)Findings include:During an observation on, 05/19/2026 at 1:26 P.M., Certified Nurse Aide (CNA) 7 was in Resident 25's room. She donned gloves and pulled the curtain closed. She removed the resident's blankets and brief. She cleansed the resident and the resident's urinary catheter appropriately. She did not don a gown to provide care to the resident. The resident's door contained signs that indicated there was enhanced barrier precautions (infection control measures designed to stop the spread of dangerous germs) in place. The sign listed that the staff were to wear gown and gloves when providing care. The clinical record for Resident 25 was reviewed on 05/18/2026 at 9:52 A.M. The resident was severely cognitively impaired. The resident's diagnosis included but was not limited to neurogenic bladder (a lack of bladder control due to nerve damage in the brain, spinal cord, or surrounding nerves). The resident had a urinary catheter. An open-ended physician's order, with a start date of 03/19/2025, indicated the resident was on enhanced barrier precautions related to the urinary catheter. The resident's record indicated the resident was prescribed and administered Macrobid (antibiotic) for urinary tract infections (UTI) on 05/11/2026 through 05/21/2026. During an interview on 05/19/2026 at 2:19 P.M., CNA 7 indicated when a resident required enhanced barrier precautions, she would wear gown and gloves when providing care. When she had provided urinary catheter care for Resident 25, she had forgotten to wear a gown.The current facility policy titled, Enhanced Barrier Precautions updated 07/2023, was provided by the Administrator on 05/19/2026 at 2:50 P.M. The policy indicated, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions:. An order for enhanced barrier precautions will be obtained for residents with any of the following:.indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO.High-contact resident care activities include:. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes.410 IAC (Indiana Administrative Code) 3.1-40(a)(2)

Based on record review and interview, the facility failed to obtain weights for 1 of 3 residents reviewed for nutrition. (Resident 7)Findings include:The clinical record for Resident 7 was reviewed on 05/18/2026 at 11:41 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 04/22/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure (a chronic condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs) and respiratory failure (occurs when your lungs cannot get enough oxygen into the blood or fail to remove enough carbon dioxide from it). An open-ended physician's order, with a start date of 04/22/2026, indicated the resident was to be given Bumetanide (a diuretic) 2 milligrams, every 24 hours as needed for leg swelling or a weight gain of greater than 3 pounds in one day. The clinical record and the April and May 2026 Electronic Medication Administration Record/Electronic Treatment Administration Record lacked the resident had documented weights from 04/23/2026 through 05/19/2026. During an interview, on 05/19/2026 at 9:48 A.M., Registered Nurse (RN) 6 indicated if a resident had an order for an as needed medication to be given for weight gain, then the resident should have been weighed daily. During an interview, on 05/19/2026 at 11:06 A.M., the Assistant Director of Nursing (ADON) indicated the resident was a daily weight prior to being admitted to hospice. The order for the daily weights must have been discontinued. If the resident had a medication to be given for weight gain, then she should have been a daily weight. The order could not be followed if the resident wasn't weighed daily. The current facility policy titled, Weight Monitoring, updated 07/2023, was provided by the Administrator on 05/19/2026 at 1:19 P.M. The policy indicated, .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. If clinically indicated - monitor weight daily.410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)(1)

Based on observation and interview, the facility failed to ensure multi use insulin pens had the required labeling for 2 of 3 medication carts reviewed (Long Hall Medication Cart and L Hall Medication Cart).Findings include: 1. On 05/20/2026 at 2:31 P.M., the Long Hall Medication Cart was observed with Licensed Practical Nurse (LPN) 2 and contained the following: - A Lantus (a type of long-acting insulin) insulin pen for Resident 1. The pen was around eighty percent full and was not labeled with an opened on date.During an interview, on 05/20/2026 at 2:32 P.M., LPN 2 indicated whoever put the pen in the cart should have dated the pen. She used the insulin pen to administer 50 units of insulin to Resident 1 that morning. The insulin pen should be labeled with the date it was opened. 2. On 05/20/2026 at 2:35 P.M., the L-Hall Medication Cart was observed with LPN 3 and contained the following:- A Basaglar (a type of long-acting insulin) insulin pen for Resident 73. The pen was half full and was not labeled with an opened on date.The current, undated facility policy, titled Labeling of Medications was provided by the Administrator on 05/20/2026 at 3:47 P.M. The policy indicated, .All medications and biologicals will be labeled in accordance with applicable federal and state requirements.Labels for multi-use vials must include.The date the vial was initially opened or accessed.410 IAC (Indiana Administrative Code) 3.1-25(o)

Based on observation and interview, the facility failed to store foods appropriately for 2 of 3 snack refrigerators reviewed. (Memory Care Unit and Station 4) Findings include: During an observation and interview, on 05/20/2026 at 2:46 P.M., with QMA (Qualified Medication Aide) 4, the snack refrigerator on the Memory Care Unit contained a gray plastic grocery bag with a double layer white cake in a plastic container on the top shelf. The container had a best if purchased by, date of 05/18/2026. There was no name on the container or bag. QMA 4 indicated food items brought in by families should be labeled with the resident's name and a date. The snack refrigerator and freezer on Station 4 was observed on 05/20/2026 at 3:08 P.M., with CNA (Certified Nurse Aide) 5 and contained the following: - A gray plastic bag with a plastic container with leftovers was on the second shelf, there was no name on the container or the bag, - In the door was a gray plastic bag with two plastic containers of leftovers, there was no name on the container or the bag, - In the door was an unopened carbonated soft drink, with no name or date, and - In the freezer, a medium sized to go cup with a chocolate frozen treat with a lid and spoon, there was no name or date. During an interview, on 05/20/2026 at 3:10 P.M., CNA 5 indicated if there was no name on the containers, they probably belonged to an employee. The current STORAGE OF FOOD BROUGHT IN FROM THE COMMUNITY policy was provided by the Administrator on 05/20/2026 at 3:34 P.M. The policy indicated, .It is the policy of this facility that proper food handling practices will be followed regarding storage of food brought into the facility by visitors, to prevent foodborne illness.food item is labeled with the resident's name and dated received. 410 IAC (Indiana Administrative Code) 3.1-21(i)(3)

Based on record review and interview, the facility failed to provide appropriate urinary catheter care for 1 of 3 residents reviewed for urinary catheter care. (Resident C)Findings Include:The clinical record for Resident C was reviewed on 8/14/2025 at 11:30 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 5/22/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, atrial fibrillation, End-stage renal disease, and Alzheimer's disease. A Progress Note, dated 8/7/2025 at 8:50 A.M., created by Registered Nurse (RN) 2, indicated the Nurse Practitioner (NP) was made aware of Resident C's increase fatigue. New orders were obtained to anchor a urinary catheter and administer a normal saline bolus of 500 cubic centimeter (cc) over two hours and then decrease to 100cc every hour for 48 hours. A Progress Note, dated 8/7/2025 at 2:30 P.M., created by RN 3, indicated Resident C had a 16 French indwelling urinary catheter with a 15 milliliter (ml) balloon. Upon insertion of the urinary catheter there was no urine return. A Progress Note, dated 8/7/2025 at 8:29 P.M., created by RN 3, indicated a Qualified Medical Assistant from another unit reported to them the presence of blood in Resident C's urinary catheter bag. Bright red blood was noted in the catheter tubing and bag. Emergency Medical Services (EMS) arrived and transported the resident to the hospital.The clinical record lacked documentation to indicate the resident's catheter placement was reassessed prior to the presence of blood in the catheter bag. A Hospital Transfer Report, dated 8/7/2025, indicated Resident C had an Abdomen/Pelvis Computed Tomography (CT) Scan. A Radiology Impression indicated a urinary catheter balloon was inflated within the penile urethra. During an interview, on 8/14/2025 at 3:08 P.M., RN 3 indicated that after inserting a urinary catheter the nurse would need to make sure there was urine return in the tubing. If there was no urine return, the urinary catheter would need to be monitored to ensure urine return began. The current facility policy titled, Validation Checklist Catheterization (Male), dated 2023, was provided by the Director of Nursing (DON) on 8/14/2025 at 3:53 P.M. The policy indicated, .Inserted the catheter gently into the meatus or until urine began to flow from the bladder .if resistance continued, do not force entry . This citation relates to Complaints 2574159 and 2572941. 3.1-41(a)(2)

Based on record review, and interview the facility failed to provide an ordered medication for 1 of 3 resident's reviewed. (Resident B)Findings Include: The clinical record for Resident B was reviewed on 8/14/2025 at 11:18 A.M. The record indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia, atrial fibrillation, and hypertension. A physician's order, dated 6/22/2025, indicated Resident B was to receive Memantine (a cognition medication) 5 milligram (mg), one tablet twice a day.The order was discontinued on 7/7/25 with a note stating, Meds from home no interchange needed. The resident's medication administration record was reviewed. The resident had not received the prescribed Memantine from 7/8/25 through 7/28/25.A Health Status Note, dated 8/08/25 at 3:11 P.M., indicated the family notified the facility of discontinuance of memantine on 7/07/2025. The writer confirmed and notified the Nurse Practitioner (NP). During an interview, on 8/14/2025 at 1:28 P.M., RN 2 indicated that on 7/07/25 she discontinued Resident B's Memantine medication on accident, and the family notified her of the missing medication on 7/28/2025. The medication was restarted on 7/29/2025. A current physician's order, with a start date of 7/29/2025, indicated Resident B was to receive Memantine extended release 14 mg daily. The current facility policy titled, Physician Medication/ Ancillary Order Policy & Procedure, dated 07/2023, was provided by the Director of Nursing (DON) on 8/14/2025 at 3:15 P.M. The policy indicated, .Ensure medications/treatments are provided to residents . in accordance with the order . This citation relates to Complaint 2587102. 16.2-5-6 (l) (2)

Based on record review and interview, the facility failed to document a fall and start neurological assessments in a timely manner for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 07/22/25 at 9:55 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/21/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, heart failure, hypertension, dementia, anxiety, and depression. The resident used a walker for mobility and required partial to moderate staff assistance for Activities of Daily Living (ADLs). During an interview, on 07/23/25 at 10:53 A.M., the Director of Nursing (DON) indicated she was made aware Resident C had a fall through a text message from RN 2 on 06/09/25 at 11:12 P.M. RN 2 sent a second text message on 06/09/25 at 11:47 P.M. that the resident was having hip pain. She sent a text back advising RN 2 to make the Nurse Practitioner (NP) aware. RN 2 sent a third text message on 06/10/25 at 7:19 A.M., that the NP wanted the resident to have an x-ray of her left hip. The x-ray report indicated the resident had a left hip fracture. RN 2 did not complete a risk management for the unwitnessed fall; she had completed the form the next day. During an interview, on 07/23/25 at 11:12 A.M., Certified Nurse Aide (CNA) 3, indicated on 06/09/25 she started her shift at 10:00 P.M. Shortly after she arrived on the unit, she heard a loud thud. She went to Resident C's room and saw she had fallen. She went to the nurse's station and alerted RN 2 that the resident was on the floor. He went to the resident's room, checked her vital signs, and assisted the resident back to bed. A few minutes later the resident turned her call light on and complained of pain. CNA 3 told RN 2 and he went to the resident's room, checked her vital signs, and indicated to her the resident was fine. Around midnight the resident turned her call light on again and complained of pain and said she wanted to go to the local hospital. CNA 3 said she informed RN 2 who went to the medication cart and took something to the resident. The resident slept for the rest of her shift. During an interview, on 07/23/2025 at 11:37 A.M., Licensed Practical Nurse (LPN) 4 indicated when a resident had a fall, she would complete a head-to-toe assessment, check vital signs, range of motion of arms and legs, and if everything checked out fine, she would assist them back to bed or a chair. She would notify the DON, NP, and the resident's representative to alert them of the fall. The NP would either be called or sent a text message for them to call back. Any new orders from the NP were given verbally to the nurse. A risk management fall assessment should be completed in the resident's clinical record and neurological (neuros) assessment were completed on paper. Neurological assessments were completed at the time of the fall, every 15 minutes for the first hour, every 30 minutes for the next two hours, every four hours for five times, and every eight hours for six times. A progress note should also be documented about the fall. An unwitnessed fall assessment form was completed by the DON on 06/09/25 at 11:20 P.M.A Neuro Assessment form was started for Resident C on 06/10/25. The first set of neuros were completed and documented at 12:30 A.M. A current facility policy titled Fall Management, was provided by the DON on 7/23/25 at 11:20 A.M., with a date of 08/01/2023 , indicated .Post Fall 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided.6. The nurse will document the fall, resident and nurse statement, MD/family notification, pain assessment, potential root cause of fall, and immediate intervention.This citation relates to complaint 1294215.3.1-37(a)

Based on record review, observation, and interview, the facility failed to ensure care planned interventions were followed related to fall interventions and care plans were in place for residents with a diagnosis of Post Traumatic Stress Disorder (PTSD) for 6 of 16 residents reviewed for Care Plans. (Residents 48, 18, 260, 51, 22, 7) Findings include: 1. Resident 48's clinical record was reviewed on 04/03/25 at 3:23 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/09/25, indicated the resident was moderately cognitively impaired. The resident used a walker and a wheelchair and required partial to moderate assist from staff for mobility. The resident's diagnoses included, but were not limited to, Parkinson's disease, hypertension, and dementia. The resident experienced two or more falls without injury since the last assessment. An Incident Note, dated 09/04/24 at 8:16 A.M., indicated the resident experienced a fall on 09/4/24 at 1:15 A.M. The resident was observed laying on the floor in his room. The resident was not injured and indicated he was sitting in his recliner and wanted to go over towards his closet. An intervention to hang a sign to remind the resident to use his call light for assistance was added to his plan of care. An Incident Note, dated 02/14/25 at 9:46 A.M., indicated the resident experienced a fall earlier that day. The resident was found by staff sitting next to his bed. An intervention to add non-skid strips to the floor next to the resident's bed was added to his plan of care. The resident's Care Plan for falls included, but was not limited to the following interventions: - An intervention, with a start date of 09/04/24, for call light signage to be hung in the resident's room to remind him to use the call light for assistance, and - An intervention, with a start date of 02/14/25, for non-skid strips to be placed on the floor next to the bed. The resident's room was observed on 04/02/25 at 10:15 A.M. The resident was in his wheelchair in the room. There was no signage hanging in the room related to the call light and no non-skid strips visible on the floor near the resident's bed. The resident's room was observed on 04/02/25 at 1:49 P.M. The resident was in bed. There was no signage hanging in the room related to using the call light. There were non-skid strips on the floor to the left of the bed, but under the bed. The strips were placed in the wrong direction, with only about 5 inches of one strip visible. The resident's room was observed on 04/03/25 at 8:51 A.M. The resident was in his chair. There was no signage hanging in the room related to using the call light. The non-skid strips were under the resident's bed and not visible. The resident's room was observed with Licensed Practical Nurse (LPN) 2 on 04/03/25 at 2:13 P.M. There was no signage noted on the walls and the bed was covering the non-skid strips on the floor. LPN 2 indicated there should be a sign on the wall to remind the resident to use his call light. The sign was face down on the resident's bedside stand. The non-skid strips were on the floor, but the bed was covering them. The strips should be placed parallel to the bed, alongside of it, so the resident would step on them if he got out of bed. These strips were going the wrong way. The bed had always been in the position it was in; it had not been recently moved. 2. Resident 18's clinical record was reviewed on 04/03/25 at 3:11 P.M. A Quarterly MDS assessment, dated 01/04/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, cancer, anemia, and hypertension. The resident used a walker and a wheelchair and required partial to moderate assist from staff for mobility. The resident experienced two or more falls without injury since the last assessment. An Incident Note, dated 10/28/24 at 9:53 A.M., indicated the resident experienced a fall on 10/25/24 at 6:45 P.M. The resident was witnessed by staff standing up from his recliner. The resident began walking when he lost his balance and fell backwards. Staff was unable to reach him before he fell . The resident was not injured. An intervention to place a clip alarm to notify staff when the resident was attempting to stand without assistance was added to the resident's plan of care. An Incident Note, dated 12/23/24 at 8:33 A.M., indicated the resident was observed climbing back into bed from the floor in his room. The resident did have an abrasion to his forehead. The fall alarm was unplugged from the alarm box. Staff were educated on ensuring the alarm was in place, plugged in, and functioning appropriately. The alarm box was placed out of the resident's reach so he couldn't unplug it without staff's knowledge. A Health Status Note, dated 03/07/25 9:39 A.M., indicated the resident experienced a fall on 03/06/25. The resident was on the floor across the room. A Hospice Aide had just given the resident a shower and did not plug in the floor mat alarm. The resident suffered no injuries. Education was to be provided to hospice staff related to fall interventions. The resident's Care Plan for falls included, but was not limited to the following interventions: - An intervention, with a start date of 03/12/25, to use a clip alarm as ordered. The resident was observed on 04/03/25 at 1:16 P.M. The resident was in his room in bed. The resident's wheelchair was in the room near the bed. The resident's clip alarm was attached to the wheelchair and not with the resident in bed. During an interview, on 04/03/25 at 1:20 P.M. Certified Nurse Aide (CNA) 3 indicated the resident's clip alarm should have been moved from the wheelchair to the resident's bed. Hospice staff had assisted him with a shower and put him to bed earlier that day, they should have put the alarm in place. 38769 3. During an observation of Resident 260's room, on 04/02/25 at 11:01 A.M., there were no noticeable non-skid strips in front of the resident's recliner. During an observation of Resident 260's room, on 04/02/25 at 1:52 P.M., there were no noticeable non-skid strips in front of the resident's recliner. During an observation of Resident 260's room, on 04/03/25 at 8:59 A.M., there were no noticeable non-skid strips in front of the resident's recliner. During an observation of Resident 260's room, on 04/03/25 at 12:53 P.M., there were no noticeable non-skid strips in front of the resident's recliner. The clinical record for Resident 260 was reviewed on 04/02/25 at 11:20 A.M. An Admission MDS assessment, dated 01/23/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, and non-Alzheimer's dementia. A Progress Note, dated 03/17/25 at 2:25 P.M., indicated the resident was placed in his recliner to elevate his legs. The resident had slid to the end of the recliner to the floor. The call light was in reach but was not initiated. There were no injuries noted. A Progress Note, 03/18/25 at 9:46 A.M., indicated the IDT had reviewed the resident's unwitnessed fall on 03/17/25. The nurse was called to the resident's room and was found to be sitting on his buttocks in front of the recliner. The resident was unable to describe the fall. All interventions were reviewed and believed the non-skid strips in front of the recliner would be beneficial related to the fall. The current care plan included an intervention, but was not limited to, non-skid strips in front of the recliner related to a fall on 03/17/25. During an interview, on 04/03/25 at 1:41 P.M., Qualified Medication Aide (QMA) 6 indicated if a resident had a fall, she would find new fall interventions on their CNA pocket sheets or in report. During an interview, on 04/03/25 at 1:46 P.M., LPN 5 indicated she would find resident's fall interventions that were new on the home screen of their computer system, and they would stay there for 24 hours. All the other interventions would be found in the resident's orders and were passed on to them during report. The Director of Nursing (DON) and Assistance Director of Nursing (ADON) were responsible for inputting new interventions and making sure the interventions were in place. During an interview and observation of Resident 260's room on 04/03/25 at 1:50 P.M., LPN 5 indicated the resident had lacked non-skid strips in front if the recliner. 4. The clinical record for Resident 51 was reviewed on 04/03/25 at 9:18 A.M. A Quarterly MDS assessment, dated 02/26/25, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, anemia, hypertension, renal insufficiency, diabetes, anxiety, post-traumatic stress disorder (PTSD), sleep terrors, and nightmare disorder. The Complete Care Plan lacked an appropriate care plan and interventions related to the residents PTSD diagnosis. During an interview, on 04/07/25 at 11:11 A.M., the Social Service Director (SSD) indicated she would develop care plans for residents if they had a diagnosis of PTSD. The care plan would have interventions related to the diagnosis and would explain what the resident's PTSD was related to, to help staff with their triggers. 33613 5. Resident 22's clinical record was reviewed on 04/02/25 at 2:02 P.M. A Quarterly MDS assessment, dated 01/17/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, heart failure, hypertension, anxiety, and dementia. The resident used a wheelchair and required partial to moderate assist from staff for mobility. The resident experienced two or more falls without injury and two or more falls with injury since the last assessment. An Incident Note, dated 01/23/25 at 10:01 A.M., indicated the resident experienced an unwitnessed fall on 01/22/25 at 7:20 A.M. The resident fell from his wheelchair in the dining room. The resident was not injured and denied pain. An intervention to place bright colored tape on the brakes of the wheelchair to remind and encourage the resident to lock brakes on the wheelchair when attempting to stand would be beneficial. The resident's Care Plan for falls included, but was not limited to the following interventions: - An intervention, with a start date of 05/09/23, to use anti roll backs on the wheelchair, and - An intervention, with a start date of 01/24/25, to use bright colored tape on the brakes of the wheelchair. The resident was observed on 04/02/25 at 11:09 A.M. The resident was in his room in his recliner. The resident's wheelchair was in the room near the closet. The wheelchair lacked anti roll back tippers on the back of the wheelchair and bright colored tape on the brakes. The resident was observed on 04/02/25 at 1:46 P.M. The resident was in his wheelchair by the nurse's station. The wheelchair lacked anti roll back tippers on the back of the wheelchair and bright colored tape on the brakes. The resident was observed on 04/03/25 at 9:27 A.M. The resident was in his room in his recliner. The resident's wheelchair was in the room near the closet. The wheelchair lacked anti roll back tippers on the back of the wheelchair and bright colored tape on the brakes. During an interview, on 04/03/25 at 1:38 P.M., CNA 8 indicated interventions were passed on in report at the beginning of each shift. The resident had a clip alarm on his person when in the recliner and a floor mat next to his bed. He was unaware of any interventions for the resident's wheelchair. 6. Resident 7's clinical record was reviewed on 04/03/25 at 11:00 A.M. A Quarterly MDS assessment, dated 01/24/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, hypertension, renal insufficiency, depression, anxiety, and PTSD. The Complete Care Plan lacked a care plan related to the residents PTSD diagnosis. During an interview, on 04/07/25 at 11:11 A.M., the SSD indicated there should have been a care plan for the resident related to his diagnoses of PTSD. The current, undated, facility policy titled, Comprehensive Care Plans, was provided by the DON on 04/07/25 at 12:50 P.M. The policy indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 3.1-31(a)

Based on record review and interview, the facility failed to document an appropriate advance directive for 1 of 16 residents' advanced directives reviewed. (Resident 260) Findings include: The clinical record for Resident 260 was reviewed on [DATE] at 11:20 A.M. An Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, and non-Alzheimer's dementia. The resident had a signed Out of Hospital Do Not Resuscitate (DNR) Declaration and Order, dated [DATE], along with a Physician Orders for Scope of Treatment (POST) form that indicated the resident was a DNR signed the same day. A current, open-ended physician's order, dated [DATE], indicated the resident was to receive Cardiopulmonary Resuscitation (CPR). During an interview, on [DATE] at 12:48 P.M., Licensed Practical Nurse (LPN) 2 indicated when a resident admitted to the facility the nurse would complete the POST Forms and the Out of Hospital DNR with the family and transcribe the order to indicate if the resident was to receive CPR or if the resident was a DNR. During an interview, on [DATE] at the Director of Nursing (DON) indicated when a resident admitted the Social Service Director would complete resident's POST Forms. The management staff would complete an admission review to ensure that the POST form matched the resident's orders. If the resident had an Out of Hospital DNR then they should have a physician's order for being a DNR and not for CPR. The current, undated, facility policy titled, Code Status was provided by the DON on [DATE] at 1:18 P.M. The policy indicated, .to adhere to resident's rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information . 3.1-(f)(5)

Based on record review and interview, the facility failed to follow MD orders related to cardiac medication administration order parameters for 1 of 16 residents reviewed for Quality of Care. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 04/03/25 at 2:55 P.M. A Quarterly Minimum Data Set assessment, dated 12/31/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, orthostatic hypotension, and disorders of the autonomic nervous system. The resident's current physician's orders included an open-ended order, with a start date of 01/24/25, to administer midodrine (a medication for low blood pressure) 5 mg (milligrams) two times a day for hypotension. The medication was to be held if the resident's systolic (the top number) blood pressure was greater than 140. The resident's Electronic Medication Administration Record (EMAR) for February and March 2025 indicated the resident received the midodrine medication when their blood pressure was assessed and top number was above 140 on the following dates and times: - The medication was administered on 02/02/25 at 8:00 A.M., when the blood pressure was 141/86, - The medication was administered on 02/11/25 at 8:00 A.M., when the blood pressure was 172/59, - The medication was administered on 02/14/25 at 8:00 A.M., when the blood pressure was 180/68, - The medication was administered on 02/16/25 at 4:00 P.M., when the blood pressure was 147/86, - The medication was administered on 02/17/25 at 4:00 P.M., when the blood pressure was 173/87, - The medication was administered on 02/21/25 at 4:00 P.M., when the blood pressure was 157/78, - The medication was administered on 03/05/25 at 4:00 P.M., when the blood pressure was 161/85, - The medication was administered on 03/06/25 at 4:00 P.M., when the blood pressure was 161/90, - The medication was administered on 03/10/25 at 8:00 A.M., when the blood pressure was 156/88, - The medication was administered on 03/14/25 at 8:00 A.M., when the blood pressure was 154/70, - The medication was administered on 03/27/25 at 8:00 A.M., when the blood pressure was 162/60, and - The medication was administered on 03/27/25 at 4:00 P.M., when the blood pressure was 163/60. During an interview, on 04/04/25 at 11:25 A.M., Licensed Practical Nurse 7 indicated if a medication had hold parameters the nurse would check the resident's blood pressure and would not administer the medication if the blood pressure was out of range (too high or too low). The medication should be documented as held and there was a space to indicate why the medication was not given. The current, undated facility policy, titled Medication Administration Policy was provided by the Director of Nursing on 04/07/25 at 12:50 P.M. The policy indicated, .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters . 3.1-48(a)(6)

Based on record review and interview, the facility failed to document meal consumption for 1 of 1 residents reviewed for nutrition. (Resident 12) Findings include: 1. The clinical record for Resident 12 was reviewed on 04/03/25 at 11:13 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/24/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, hypertension, diabetes, stroke, anxiety, and depression. The resident's meal consumption records lacked documented values on the following dates and times: - On 03/05/25 at breakfast and lunch, - On 03/07/25 at breakfast and lunch, - On 03/09/25 at lunch, - On 03/10/25 at breakfast and lunch - On 03/11/25 at breakfast and lunch, - On 03/12/25 at lunch, - On 03/13/25 at breakfast and lunch, - On 03/15/25 at breakfast and lunch, - On 03/16/25 at breakfast and lunch, - On 03/17/25 at breakfast and lunch, - On 03/18/25 at breakfast and lunch, - On 03/19/25 at breakfast and lunch, - On 03/20/25 at lunch, - On 03/23/25 at breakfast and lunch, - On 03/24/25 at breakfast and lunch, - On 03/25/25 at breakfast, - On 03/26/25 at lunch, - On 03/27/25 at breakfast and lunch, and - On 04/2/25 at breakfast and lunch. During an interview, on 04/03/25 at 3:06 P.M., Certified Nurse Aide (CNA) 10 indicated meal consumption should be recorded in the computer daily at the end of the shift. The current facility policy titled, Meal Service, was provided by the Director of Nursing (DON) on 04/07/25 at 12:50 P.M. The policy indicated, .Staff will document meal consumption in the medical record . 3.1-46(a)(1)

Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) on duty for eight consecutive hours a day for 2 of the 7 days reviewed. Findings include: The as worked nursing schedule, from 04/01/25 to 04/06/25, indicated there had not been an RN on duty for eight consecutive hours on Saturday, 04/05/25 and Sunday, 04/06/25. During an interview, on 04/07/25 at 1:42 P.M., the Director of Nursing (DON) indicated RN 3 worked night shift on Saturday 04/05/25 and Sunday 04/06/25. He was the only RN on the schedule for the weekend. His hours were not eight consecutive hours for each day. During an interview, on 04/07/25 at 2:10 P.M., the DON indicated the facility did not have a policy for RN coverage, they followed State and Federal regulations. 3.1-17(b)(3)

Based on record review and interview, the facility failed to transcribed medications on admission for 1 of 16 residents reviewed for pharmacy services. (Resident 3) Findings include: The clinical record for Resident 3 was reviewed on 04/02/25 at 1:59 P.M. An Annual Minimum Data Set (MDS) assessment, dated 01/22/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, anemia, heart failure, hypertension, seizure disorder, non-Alzheimer's dementia, and depression. A Psychiatry Progress Note, dated 01/07/25, indicated the residents Fluoxetine (an antidepressant) medication was to be increased from 60 milligrams (mg) to 80 milligrams once a day, due to the resident having increased behaviors of increased irritability and being easily angered. The resident was admitted to the local hospital on 01/13/25 and returned to the facility on [DATE]. The hospital discharge instructions, dated 01/15/25, indicated the resident was to receive Fluoxetine 80 mg once a day. A physician's order, dated 01/16/25 through 01/19/25, indicated the resident was to receive Fluoxetine 40 mg once a day. A current physician's order, with a start date of 01/19/25, indicated the resident was to receive Fluoxetine 40 mg once a day. The January, February, March, and April Electronic Medication Administration Record (EMAR) indicated the resident had received 40 mg of Fluoxetine instead of 80 mg each day from 01/16/25 through 04/07/25. During an interview, on 04/03/25 at 12:48 P.M., Licensed Practical Nurse (LPN) 2 indicated when a resident admitted to the facility the nurse would transcribe orders for the residents. During an interview, on 04/07/25 at 9:28 A.M., Licensed Practical Nurse (LPN) 7 indicated if a physician or Nurse Practitioner came to the facility and had new orders for a resident the nurse on the floor or the Assistant Director of Nursing would transcribe the orders. During an interview, on 04/07/25 at 1:39 P.M., the Director of Nursing (DON) indicated the resident had returned from the hospital on 01/15/25. The resident's order was transcribed wrong when she returned. She should have been receiving 80 mg of the Fluoxetine instead of 40 mg each day. The current, undated, facility policy titled, Medication Orders, was provided by the DON on 04/07/25 at 2:03 P.M. The policy indicated, .This facility shall use uniform guidelines for the ordering of medications .Clarify the order .Transcribe newly prescribed medications on the MAR [Medications Administration Record] or treatment record or ensure the order is in the electronic MAR . 3.1-25(b)(9) 3.1-25(e)(3) 3.1-37(a)

Based on observation, interview, and record review, the facility failed to appropriately store medications for 1 of 2 medication rooms reviewed. (Station 4 Medication Room) Findings include: The Medication Room on Station 4 was observed with Licensed Practical Nurse (LPN) 2 on 04/07/25 at 8:56 A.M. The medication refrigerator contained the following items: - A box that contained an opened vial of TB (Tuberculin) serum. The vial was not labeled with an opened on date. The box indicated the serum was received from the pharmacy on 02/06/25, and - A clear plastic bag that contained two boxes of TB serum. One of the vials had been opened and used. The vial was not labeled with an opened on date. The label on the bag indicated the serum was received from the pharmacy on 02/26/25. During an interview, on 04/07/25 at 8:56 A.M., LPN 2 indicated the TB serum should have been dated when it was opened and first used. There had been 3 or 4 residents admitted to Station 4 since the medication was delivered from the pharmacy. The TB serum package insert was provided by the Director of Nursing (DON) on 04/07/25 at 12:50 P.M. The directions for storage indicated, .vials in use more than 30 days should be discarded . The current facility policy, titled VIALS AND AMPULES OF INJECTABLE MEDICATIONS, with a revision date of August 2014, was provided by the DON on 04/07/25 at 12:50 P.M. The policy indicated, .Unopened vials expire on the manufacturer's expiration date .Opening a vial triggers a shortened expiration date that is unique for that product .At a minimum, the date opened must be recorded . 3.1-25(o)

Based on record review and interview, the facility failed to obtain a urinalysis in a timely manner for 1 of 6 residents reviewed for laboratory services. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 04/03/25 at 2:55 P.M. A Quarterly Minimum Data Set assessment, dated 12/31/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, orthostatic hypotension, renal insufficiency, neurogenic bladder, and disorders of the autonomic nervous system. The resident had an indwelling urinary catheter. A Health Status Note, dated 02/18/25 at 6:16 P.M., indicated the resident had a new physician's order to obtain a urinalysis (UA) with Culture and Sensitivity (C&S). A Health Status Note, dated 02/22/25 at 9:48 P.M., indicated the resident had a pending UA at that time. A Health Status Note, dated 02/25/25 at 2:01 A.M., indicated the resident's urine had been collected for a UA. A Health Status Note, dated 03/03/25 at 7:24 P.M., indicated the resident received their first dose of Ceftriaxone (an antibiotic) for a UTI (Urinary Tract Infection). During an interview, on 04/07/25 at 8:48 A.M., Licensed Practical Nurse (LPN) 2 indicated if she received a physician's order to obtain a UA, the sample should be obtained within 24 hours. If she got the order, she would try to get the sample that same day before her shift was over. Samples were placed in the refrigerator for the Laboratory Technicians (Lab Techs) to pick up, they came to the facility every day. Once the sample went to the lab, it would take 48 to 72 hours for the C&S report. The lab faxed the results to the facility. The facility would notify the MD or Nurse Practitioner. During an interview, on 04/07/25 at 10:18 A.M., the Director of Nursing (DON) indicated they received a report from the laboratory that indicated the specimen collection for the UA that was ordered on 02/18/25 was cancelled. The collection date listed on the form was 02/20/25 and the cancellation was reported on 02/24/25. There was no explanation as to why it was cancelled. The facility obtained a new urine sample on 02/25/25, it was received in the lab on 02/26/25, and the results were available on 03/01/25. During an interview, on 04/07/25 at 10:10 A.M., Support staff from the Laboratory indicated the Lab Tech came to the facility to collect the urine sample on 02/20/25, 02/21/25, and on 02/24/25 but each time it wasn't available. They usually tried three times to collect a sample and if it wasn't available they would cancel the lab order. A facility nurse signed off on the cancellation. They did come back on 02/25/25 and collected a new sample. The current, undated facility policy, titled Laboratory Services and Reporting, was provided by the DON on 04/07/25 at 12:50 P.M. The policy indicated, .The facility must provide or obtain laboratory services .The facility is responsible for the timeliness of the services . 3.1-49(a)

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers and follow physician's orders for 4 of 4 residents reviewed for pressure ulcers. (Residents 27, 34, 42, 28). Residents 27 and 34 with decreased mobility related to hip fractures developed unstageable wounds on the heels of their affected legs. Findings include: 1. Resident 27's wound was observed on 04/15/21 at 2:21 P.M. The resident was seated in the recliner and was wearing a pressure relieving boot on her left foot. LPN 5 removed the boot and the dressing on the wound. She indicated this was her first observation of the wound that day. The wound was an unstageable (wound was covered with dead tissue) pressure ulcer, measuring 4.5 centimeters (cm) x (by) 4.5 cm. The wound depth was not measurable. The wound was dark in color, with maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) surrounding and pulling away from the darkened wound bed. There was no drainage, no foul odor, and no signs of infection. The clinical record for Resident 27 was reviewed on 04/14/21 at 10:11 A.M. The Annual Minimum Data Set (MDS) assessment, dated 10/22/20, indicated She was severely cognitively impaired and at risk for developing pressure ulcers. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance from one staff member for bed mobility, transferring, dressing, locomotion, eating, and personal hygiene. The resident required limited assistance with walking. The resident was at risk for pressure ulcers; but had no pressure ulcers during the assessment review period. The assessment indicated the resident utilized a pressure reducing devices for the bed. No skin or ulcer treatments were in place at the time of the assessment. The resident was seen by the wound care clinic on 02/11/21, 03/11/21, 03/29/21, and 04/05/21. A care plan, titled Resident with impaired skin integrity as seen by unstageable ulcer on (L) [left] heel, was initiated on 12/29/20. Interventions included, but were not limited to: Air flow mattress heel protectors, date initiated 12/30/20 provide treatments as ordered encourage resident to wear heel protector on affected foot, date initiated 03/31/21 Check skin daily with care and report any changes to physician Observe and document skin weekly Resident 27 sustained a fall in the facility on 12/11/20 and fractured her left hip. The resident had surgery and was readmitted to the facility on [DATE]. The facility re-admission assessment, dated 12/15/20, indicated there were no skin impairments on the resident's heels when she returned from the hospital. The Skilled Nursing assessments indicated there were no changes to the resident's skin integrity identified on the following dates and times: -12/17/20 at 11:04 A.M., -12/17/20 at 4:24 P.M., -12/18/20 at 1:23 A.M., -12/18/20 at 2:15 P.M., -12/18/20 at 8:53 P.M., -12/19/20 at 1:42 A.M., -12/19/20 at 2:35 P.M., -12/19/20 at 7:03 P.M., -12/20/20 at 9:05 P.M., -12/21/20 at 1:03 A.M., -12/21/20 at 7:44 P.M., -12/22/20 at 3:46 A.M., -12/22/20 at 8:23 P.M., -12/23/20 at 5:28 A.M., -12/23/20 at 9:35 A.M., -12/23/20 at 9:47 P.M., -12/24/20 at 4:45 A.M., -12/24/20 at 10:41 A.M., -12/24/20 at 8:08 P.M., -12/25/20 at 10:45 A.M., -12/25/20 at 8:12 P.M., -12/26/20 at 5:46 A.M., -12/26/20 at 2:14 P.M., -12/26/20 at 8:49 P.M., -12/27/20 at 7:05 A.M., -12/27/20 at 10:19 A.M., -12/27/20 at 6:55 P.M., -12/28/20 at 2:18 A.M., and -12/28/20 3:29 P.M. A Weekly Wound assessment, dated 12/30/20, indicated the resident developed a left heel pressure ulcer. The date the wound was acquired was 12/29/20. The wound was unstageable, and measured 5 cm x 5 cm. The depth was not measurable. The wound was dry. The current treatment plan was skin prep to the left heel daily, dated 12/29/20. A Weekly Wound assessment, dated 01/12/21, indicated the resident had an unstageable pressure ulcer on her left heel measuring 3.5 cm x 4 cm. The depth was not measurable. The wound was dry. no change to the wound. The current treatment plan was Santyl ointment to the left heel daily and cover the wound, dated 01/12/21. A Weekly Wound assessment, dated 02/17/21, indicated the resident had an unstageable pressure ulcer on her left heel measuring 3.5 cm x 4 cm. The depth was not measurable. The area was dark in color, loosened edges, and the edges that are loose are red in color with moisture present. The current treatment plan was Santyl ointment to the left heel daily and cover the wound, dated 01/12/21. A Weekly Wound assessment, dated 03/31/21, indicated the resident had an unstageable pressure ulcer on her left heel measuring 4 cm X 4 cm. The depth was not measurable. The area was dark in color in some areas. There was yellow slough present on 25% of the wound. It had a spongy center that was pulling away from the edges. There was some granulation visible right at edge of wound. The edges had some maceration. The tissue surrounding the wound had some redness. The current treatment plan was Santyl ointment to the left heel daily and cover the wound, dated 01/12/21. During an interview on 04/15/21 at 2:19 P.M., RN 3 indicated nursing interventions for this resident after her hip fracture would have included floating her heels, utilizing heel protectors, encouraging the resident to move or change position every two hours, ensuring the resident had an adequate diet, and was eating more than 50% at meals. The care plan would have been updated to include those interventions after the fall. As a nurse, you would observe that the interventions were in place. The interventions should be on the care plan and the Certified Nurse Aide (CNA) assignment sheets. They don't always have a physician's order for all interventions. Any physician's order for treatments, including heel protectors, would be documented in the Treatment Administration Record (TAR) and the nurse would sign off that the intervention was in place. The resident's December 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. There was no documentation of interventions of floating heels or heel protectors until 12/29/20 when the wound was discovered. A physician's order, dated 12/29/20, indicated the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2021 TAR indicated a treatment with a start date of 01/12/21 for Santyl ointment to the left heel pressure ulcer and cover it daily. The February 2021 TAR lacked documentation indicating the heel protectors had been applied while in her chair or that her heels were floated while in bed for the entire month of February. 2. Resident 34's wound was observed on 04/15/21 at 2:45 P.M. The resident was seated in a recliner, and was wearing a pressure relieving boot on his right foot. LPN 5 removed the boot and noticed there was no dressing on the wound. She indicated this was her first observation of the wound that day, she did not know the dressing was not in place. The wound was an unstageable (wound was covered with dead tissue) pressure ulcer, measuring 3.5 cm x 2.7 cm. The wound depth was not measurable. The wound was black/dark in color, with red granulation tissue surrounding the entire outer edge of the dark tissue. There was no drainage, no foul odor, and no signs of infection. The clinical record for Resident 34 was reviewed on 04/15/21 at 10:30 A.M. A Quarterly MDS assessment, dated 12/04/20, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance from one staff member for bed mobility, transferring, dressing, locomotion, and personal hygiene. The resident required limited assistance with walking and supervision when eating. The resident was at risk for pressure ulcers, but had no pressure ulcers during the assessment review period. The assessment indicated the resident had no skin or ulcer treatments in place and did not utilize pressure reducing devices for the bed or chair. Resident 34 sustained a fall in the facility on 01/22/21 and fractured his right hip. The resident had surgery and was readmitted to the facility on [DATE]. The facility re-admission skin assessment, dated 01/27/21, indicated there were no skin impairments on the resident's heels when he returned from the hospital. A Physical Therapy Daily Note, dated 02/01/21, indicated he resident had a large ulcer on his right heel, and the nurse was aware. The therapy assistant placed an orthotic brace on the resident's right foot for heel protection and to reduce weight bearing during transfers. She placed a heel float cushion in the resident's room to use when the resident was laying in bed. She positioned the resident in his recliner with his legs elevated and a pillow underneath to float his heels She provided staff education on using the brace when the resident was in the recliner or wheelchair and to use the soft heel protector and heel float cushion when the resident was in bed. During an interview on 04/15/21 at 3:13 P.M., PTA (Physical Therapy Assistant) 4 indicated she removed the resident's sock and saw the wound on his right heel on 02/01/21. She remembered the wound was open, but kind of dry, and not bleeding. It was about the size of a half dollar and dark red in color. She did not see any heel protectors in the resident's room, and his heels were not floated. She started telling LPN 8 about the wound, and LPN 8 indicated she heard about the wound earlier that morning. During an interview on 04/16/21 at 2:09 P.M., LPN 8 indicated she noticed the resident's right heel was soft and red, not long after he returned from the hospital. She mentioned to the staff to float his heels in bed, she felt like that was something they just passed along to staff. She applied a skin protectant solution to the heel. She did not document that she applied the protectant in the resident's record. She was not sure when she first noticed the wound, and she was not sure if she documented anything on it. If she did document anything, it would have been in a progress note. Therapy brought a pillow and a boot for the resident. The resident was non-compliant with using them. If a resident were using a boot or a pressure reducing device it would probably be documented on the TAR. Another nurse applied the skin protectant and documented it in the progress notes on 02/06/21. A Progress Note documented on 02/6/2021 at 11:02 A.M. indicated the resident's right foot ulcer was assessed. Skin protectant was applied and the wound was covered with a dressing. A Progress Note documented on 02/6/2021 at 11:02 A.M. indicated a message was left for the physician regarding the wound. A Progress Note documented on 02/8/2021 at 2:49 P.M. indicated new orders were received for routine pain medication and for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The Skilled Nursing assessments indicated there were no changes to the resident's skin integrity identified on the following dates and times: - 01/28/21 at 7:30 A.M., - 01/28/21 at 2:06 P.M., - 01/29/21 at 2:14 A.M., - 01/29/21 at 2:20 P.M., - 01/29/21 at 8:04 P.M., - 01/30/21 at 2:58 A.M., - 01/30/21 at 10:53 A.M., - 01/30/21 at 8:01 P.M., - 01/31/21 at 5:25 A.M., - 01/31/21 at 10:49 A.M., - 01/31/21 at 7:17 P.M., - 02/01/21 at 1:32 P.M., - 02/02/21 at 12:49 A.M., - 02/02/21 at 12:14 P.M., - 02/02/21 at 8:27 P.M., - 02/03/21 at 10:23 A.M., - 02/03/21 at 8:19 P.M., - 02/04/21 at 1:14 A.M., - 02/04/21 at 9:57 A.M., and - 02/04/21 at 7:52 P.M. A Skilled Nursing assessment, dated 02/10/21 at 5:37 A.M., indicated there were no new changes to the resident's skin integrity, but the resident had a pressure ulcer on his right heel. A Weekly Wound assessment, dated 02/10/21, indicated the resident developed a right heel pressure ulcer. The date the wound was acquired was 02/06/21. The wound was unstageable and measured 4 cm x 5 cm. The depth was not measurable. The wound was moist, with a scant amount of serosanguinous (pale red to pink, thin and watery) drainage. There were no signs of infection noted. The current treatment plan was [MEDICATION(S)] with a dressing change daily, dated 02/08/21. A Weekly Wound assessment, dated 03/03/21, indicated the resident had an unstageable pressure ulcer on the right heel that measured 3 cm x 5 cm, the depth was not measurable. There was a small amount of serosanguinous drainage. The wound was moist and dry. There were no signs of infection noted. The area was dark and spongy, and the edges were pulling away leaving red, moist tissue present. The wound was improving. A Weekly Wound assessment, dated 03/17/21, indicated the resident had an unstageable pressure ulcer on the right heel that measured 4 cm x 4.5 cm, the depth was not measurable. There was a small amount of serosanguinous drainage. The wound was moist and dry, with necrotic tissue present. There were no signs of infection noted. The area was dark, dry and spongy. The edges of the wound were slightly moist, with red granulation tissue noted. The was some surrounding tissue with some maceration. There was no change to the wound. A Weekly Wound assessment, dated 04/06/21, indicated the resident had an unstageable pressure ulcer on the right heel that measured 4 cm x 4.2 cm, the depth was not measurable. There was a small amount of serosanguinous drainage. There were no signs of infection noted. The wound was moist, with necrotic tissue present. The area was dark and spongy tissue was covering approximately 90% of the wound bed. There was no bleeding. The resident denied pain at the wound site. There was no change to the wound. During an interview on 04/15/21 at 1:39 P.M., RN 3 indicated nursing interventions for this resident after his hip fracture would have included floating his heels, utilizing heel protectors, encouraging the resident to move or change position every two hours, ensuring the resident had an adequate diet and was eating more than 50% at meals. The care plan would have been updated to include those interventions after the fall. As a nurse, you would observe that the interventions were in place. The interventions should be on the care plan and the CNA assignment sheets. They don't always have a physician's order for all interventions. Any physician's order for treatments, including heel protectors, would be documented in the TAR, and the nurse would sign off that the intervention was in place. A care plan, titled Resident with a fractured right hip, was initiated on 01/28/21. Interventions included, but were not limited to: Apply cryo cuff to hip as ordered, Keep affected body part elevated as ordered, Keep all scheduled appointments, Administer pain medications as ordered, and Report any abnormal findings (increase [CONDITION(S)], cyanosis of fingertips, toenails) to the physician. A care plan, titled Resident is at risk for skin impairment related to decreased mobility, was initiated on 10/6/20. Interventions included, but were not limited to: Encourage fluids with meals and in between as tolerated, Evaluate nutritional status as needed, Observe skin during daily care (hygiene, showers, toileting), Provide incontinence care after episodes of incontinence as needed, Report changes to the physician and obtain treatments as ordered, and Toilet resident per toileting program as needed. A care plan, titled Resident with pressure ulcer unstageable to right heel, was initiated on 02/08/21. Interventions included, but were not limited to: Assist with mobility and transfers, Diet as ordered and observe intake, Encourage fluids with medications and between as tolerated, Ensure proper body alignment when in bed or chair, Evaluate nutritional status as needed, Keep skin clean and dry as possible, Monitor laboratory values as they are available, Observe skin condition with daily care, Pressure reducing mattress on bed, Provide incontinent care for episodes of incontinence, Provide treatments as ordered, and Report changes to physician and obtain treatments as ordered and as needed. There were no interventions to float the resident's heels, or to utilize a heel protector boot on the pressure ulcer care plan. The resident's January 2021 MARs and TARs were reviewed on 04/15/21 at 1:30 P.M. There was no documentation of interventions of floating heels or heel protectors. A physician's order, dated 02/08/21, indicated the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The February 2021 TAR indicated a treatment with a start date of 02/10/21, for [MEDICATION(S)] and a foam dressing to the right heel daily. This physician's order was initialed as completed on the following dates only: - 02/03/21 - 02/10/21 - 02/11/21 - 02/14/21 - 02/15/21 - 02/16/21 - 02/17/21 - 02/24/21 - 02/27/21 There was no documentation related to the physician's order to utilize a pressure relieving boot on the February TAR. The March 2021 TAR lacked documentation that the wound treatment was completed on the following dates: - 03/04/21 - 03/05/21 - 03/06/21 There was no documentation related to the physician's order to utilize a pressure relieving boot on the March TAR. The April 2021 TAR lacked documentation that the wound treatment was completed on 04/08/21. There was no documentation related to the physician's order to utilize a pressure relieving boot. During an interview on 04/14/21 at 1:09 P.M., QMA (Qualified Medication Aide) 2 indicated she was familiar with Resident 34. The resident utilized a chair alarm and a floor alarm. She did not remember if he had any pressure reducing devices prior to the development of the wound on his heel. The CNA assignment sheets would indicate things like if a resident had alarms, pressure relieving boots, or compression hose. She was not sure if floating a resident's heels was on the CNA assignment sheet. That information was usually passed along in report. She remembered the therapy department placed a boot on his foot. She felt like she floated his heels. The CNA assignment sheets that were in place in January 2021 were not provided, but the current CNA assignment sheets for Resident 34 were reviewed. There was no indication staff were to float the resident's heels or ensure the resident was wearing heel protectors. 3. The clinical record for Resident 42 was reviewed on 04/13/21 at 8:40 P.M. A Quarterly MDS assessment, dated 03/11/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers and had a pressure reducing device for the chair. A Weekly Wound assessment, dated 11/25/20, indicated the resident had [CONDITION(S)] to the right buttock that was 3 cm x 3 cm and was acquired in house on 11/24/20. The skin was red, dry, and flaky, with some underlying redness. The current treatment, dated 11/16/20, indicated Magic Butt Paste to the excoriated areas on the right buttock every shift until healed. On 11/24/20 a new order was obtained for [MEDICATION(S)] cream to the right buttock, twice a day for two weeks. Preventative measures included a gel cushion. A physician's order, dated 11/24/20, indicated [MEDICATION(S)] cream to the right buttock, twice a day for 2 weeks. The December 2020 TAR lacked documentation of the Lortrisone cream application for the following dates at 8:00 P.M.: - 12/01/20 through 12/04/20 - 12/08/20 through 12/09/20 A Weekly Wound assessment, dated 12/23/20, indicated the resident had a Stage 2 (loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or open/ruptured serum-filled blister pressure ulcer to the right buttock that was 3 cm x 3 cm, and was acquired in house on 11/24/20. The wound was worsening. On 12/22/20, a new order was obtained for a medicated foam dressing to the right buttock ulcer, change every 3 days, and as needed, and discontinue the Magic Butt Paste. A Weekly Wound assessment, dated 12/30/20, indicated the resident had a Stage 2 pressure ulcer to the right buttock that was 3 cm x 2.5 cm. The wound was irregularly shaped and moist. A Weekly Wound assessment, dated 01/27/21, indicated the resident's Stage 2 pressure ulcer to the right buttock was healed. A Weekly Wound assessment, dated 02/03/21, indicated the resident's Stage 2 pressure ulcer remained healed. The skin was dry, slightly red and blanchable. A Weekly Wound assessment, dated 04/07/21, indicated the resident had a Stage 2 pressure ulcer to the right buttock that was acquired on 03/30/21. The wound measured 2 cm x 2 cm and was dry. A new order was obtained on 03/30/21 for a [MEDICATION(S)] dressing to the right buttock, change every 72 hours and as needed. The March 2021 TAR was reviewed and lacked documenation of [MEDICATION(S)] dressing to the right buttock. The April 2021 TAR lacked documentation that the [MEDICATION(S)] dressing was applied for the following dates: - 04/3/21 - 04/15/21 A Weekly Wound assessment, dated 04/14/21, indicated the resident had a Stage 2 pressure ulcer to the right buttock that was acquired on 03/30/21. The wound measured 2 cm x 2 cm. There was no change in the wound with epithelial tissue present. The wound was pink and dry. During an interview on 04/15/21 at 9:29 A.M., RN 3 indicated the resident was ambulatory. The wound on the resident's bottom was a Stage 2 pressure ulcer. The resident liked to sit in his chair and not lay in the bed, the resident had a cushion to his chair. During an interview on 04/15/21 at 1:48 P.M., RN 3 indicated the resident had the Stage 2 wound on his right buttocks prior and it healed and then reopened. She was unsure if there were any interventions put into place to prevent the wound from reopening. A care plan titled at risk for skin impairment related to history of skin breakdown with a start date of 02/22/18, indicated there were no new interventions in between November 2020 and April 2021. During an interview on 04/15/21 at 1:52 P.M., QMA 6 indicated if there was a blank or empty spot on the MAR/TAR she would assume it was not completed. 4. The clinical record for Resident 28 was reviewed on 04/16/21 at 11:20 A.M. A Quarterly MDS assessment, dated 02/22/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of one staff member for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident was at risk for pressure ulcers and had no unhealed pressure ulcers. The Progress Notes were provided by the MDS Coordinator on 04/16/2112:11 P.M. A Progress Note, dated 04/15/21 at 9:11 P.M., indicated a skin assessment was completed. A stage 2, 1.0 cm x 0.5 cm pressure ulcer was observed on the left gluteal fold and a 1.0 x 1.0 cm scabbed area was observed on the right lateral heel. The resident's wounds were observed with RN 7 on 04/16/21 at 12:44 P.M. The open wound on the buttock was on the left inner buttock cheek. The wound was not dressed at the time of the observation. The wound was pea sized with no odor present. The wound bed was red. The edges were intact. No signs or symptoms of infection were observed. Following the completion of the treatment the resident indicated the wound was no longer painful. The wound on the resident's right heel was the size of a pencil eraser with a red/brown scab. No odor or moisture was present. The resident's ankles were slightly swollen. During an interview on 04/16/21 at 12:48 P.M., Resident 28 indicated she had the area on her buttocks for about a month. Staff applied a treatment to the wound about everyday. She had a wound in that area before. She had not had a wound on her feet in the past. She sometimes had swelling in her feet and legs. During an interview on 04/16/21 at 12:55 P.M., RN 7 indicated nursing staff were to initial the TAR indicating skin assessments were completed. If a resident had any skin issues they were to be documented in a Progress Note and the physician was to be notified. The MARs and TARs were provided by the MDS Coordinator on 04/16/21 at 12:11 P.M. A physician's order, with an active date of 03/09/21, indicated staff were to apply a moisture barrier to the bilateral buttocks after toileting, every shift, three times a day. The March 2021 TAR lacked documentation for the moisture barrier treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - Shift 7:00 A.M. to 3:00 P.M. - 03/07, 03/15, 03/20, 03/21, 03/29, and 03/30. - Shift 3:00 P.M. to 11:00 P.M. - 03/08, 03/22, 03/27, 03/28, and 03/29. - Shift 11:00 P.M. to 7:00 A.M. - 03/31. The April 2021 TAR lacked documentation for moisture barrier treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - Shift 7:00 A.M. to 3:00 P.M. - 04/03, and 04/15. - Shift 3:00 P.M. to 11:00 P.M. - 04/05. A treatment order indicated the nurse was to assess the resident's skin on shower days, Tuesdays and Fridays, report any abnormalities to the physician, and document all new findings in the Nurse's Notes . The March 2021 TAR lacked documentation for the skin assessments on the following dates: - 03/12/21 - 03/16/21 - 03/23/21 The April 2021 TAR lacked documentation for skin assessments on the following dates: - 04/13/21 The complete care plan was provided by the DON on 04/16/21 at 02:50 P.M. A care plan, titled Resident is at risk for skin impairment r/t [related to] incontinence at times and decreased mobility, was initiated on 11/13/17. Interventions included, but were not limited to: Observe skin during daily care (hygiene, showers, toileting). (Date initiated 11/13/2017) Report changes to the physician and obtain treatments as ordered. (Date initiated 11/13/2017) Treatment per MD order, notify MD of changes in area. (Date initiated 04/16/21) Will encourage resident to keep foot elevated off mattress when in be. Prefers to sleep in recliner. (Date initiated 04/16/21) The current PRESSURE ULCER PREVENTION policy, with a reviewed date of 06/18/20, was provided by the DON on 4/16/21 at 2:27 P.M. The policy indicated, .It is the policy of this facility that information will be provided to prevent pressure ulcers and to identify risk factors and appropriate interventions for prevention .Routinely assess and document the condition of the resident's skin. Residents identified to be at risk for pressure ulcer development should have a skin assessment completed at least weekly .When in bed, every attempt should be made to 'float heels' (keep heels off of bed) by placing pillow from knee to ankle or with other devices as recommended by therapy . The current Physician Medication / Ancillary Order Policy & Procedure was provided by the DON on 4/16/21 at 2:27 P.M. The policy indicated, .Ensure medications / treatments are provided to resident upon receipt of supplies in accordance with the order . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to provide supervision to prevent the elopement and subsequent fall with injury to one cognitively impaired resident (Resident B) for one of three residents reviewed for accidents. This deficient practice resulted in harm in that Resident B was found face down on the porch of a private home across the street from the facility and sustained a comminuted, displaced and depressed nasal fracture. Findings include: During an unannounced visit on 12/14/2015, an initial tour was conducted with RN (Registered Nurse) # 1 at 9:30 a.m. The following observations were made about the facility layout: 1. There was no keypad/security inside the front entrance of the facility. 2. The facility was in an H format, with the main entrance being in the middle of the east wing of the facility. 3. Upon entering the facility, the main dining room was to the south, and therapy areas and offices were to the north. 4. There was a long hallway which ran east to west from the main entrance, with staff offices along the east end (near entrance) and resident rooms beginning on the west end (further from entrance). 5. There was a front office located where the three halls intersected, which was open by two sliding glass windows which met at the corner. 6. Station 4, the main and first nurses station encountered after entering the facility, was located on the far end of the west hall, with resident rooms running down a long hall from north to south. Resident B's clinical record was reviewed on 12/14/2015 at 11:10 a.m. [DIAGNOSES REDACTED]. Resident B's quarterly Minimum Data Set (MDS) assessment, dated 11/2/2015, indicated a Brief Interview for Mental Status (BIMS) score of 6 of 15; indicating the resident was moderately cognitively impaired. Resident B ambulated independently, but required setup help and supervision for locomotion on and off the unit (how the resident moved between locations in his/her room and adjacent corridor on the same floor, and how the resident moved to and returned from distant areas, such as dining, activities or treatments, on the floor). A current care plan for Resident B, initiated 8/14/2015, indicated, Resident has impaired decision making skills. Resident requires cues and supervision Interventions: .Gently reorient resident as needed A current care plan for Resident B, initiated 8/14/2015, indicated, Resident has memory problems R/T (related to): long term memory deficit, short term memory deficit as evidenced by: Forgetfulness. Unable to recall three words .Interventions: Assess for UTI if increased cognitive deficit noted A current care plan for Resident B, initiated 8/14/2015, indicated, Resident has a history of making suicidal statements about killing self or wishing they were dead. Resident stated to nurse, 'If I say I'm going to kill myself, can I go out? I just need a break, and want to get out of here.' . A current care plan for Resident B, initiated 11/6/2015, indicated, Resident is at risk for falls R/T (related to) epilepsy, medications, HX (history of), chronic pain, doesn't like to wear shoes .Interventions: .cues/redirect PRN (as needed) .Instruct/remind/encourage resident to call for assist with mobility or transfers as needed .Observe for safety. Placed secure ankle bracelet on pt. (patient) left ankle to alert staff pt. out of facility (Date Initiated: 12/05/2015) A current care plan for Resident B, initiated 12/5/2015, indicated, Resident is at risk for wandering from facility secondary to MR (mental retardation) and schizophrenia. Resident thought she saw her son's motorcycle and went to see him. Goal: resident will not wander/elope from facility through next review An Incident/Accident Report for Resident B, dated 12/5/2015, was provided by RN # 1 on 12/14/2015 at 11:12 a.m. The document indicated, Date of Incident/Accident: 3:30 p.m. Time: 3:30 p.m. Exact Location of Incident/Accident: (checked) Other/Specify: Across street family's porch .Property Involved: concrete porch/step. Was person authorized to be at location of accident/incident (not indicated). Describe exactly what happened .: Dietary (staff) called to (LPN (Licensed Practical Nurse) # 2) ask if pt allowed to go across street. Then 2 CNA's (Certified Nursing Assistants) went over to find pt. lying on front porch face down in pool (of) bl (blood). (RN # 5) over there (resident) brought to nursing home .Indicate on the diagram location of injury: (lines drawn to indicate forehead, face, cheeks, eyes, neck, and bruising to left knee. Additional documentation indicated, Hematoma both eyes .bruising cheeks down neck.) .Was person involved taken to a hospital: Yes. Name/Title .of Witness(es): Dietary (staff) just saw pt across road. Additional Comments and or Steps Taken to Prevent Recurrence: Secure Care Ankle bracelet on (L) (left) ankle Resident B's Elopement Risk Assessment, dated 12/6/2015 at 12:54 p.m., indicated a total score of two; indicating the resident was not an elopement risk. A positive answer to number four (historical behavior patterns) or a score of five or higher would indicate an elopement risk. The document indicated the following: 1. Relevant Diagnoses: [REDACTED]. 2. Cognitive Patterns: b. Memory problem, memory recall impaired, decision-making skills impaired, indicators of delirium: No (Yes would add one point) .4. Historical Behavioral Patterns: d. Purposeful exit seeking, frequently searching for home or something familiar: No (Yes would add two points) 6. Mobility Status: f. Independently mobility with or without assistive devices. Nursing Progress Notes, dated 12/5/2015 at 3:30 a.m., indicated, .Dietary (staff) called to nurse (LPN # 2) and ask if pt. allowed to go across street. Then 2 CNA's went over to find pt lying on front porch face down in pool of blood .Nurse noted nose swollen and bruises on chin neck both eyes were turning black .Pt alert and oriented to time and place and person states she was going over to house to see if her son (name) was there, had seen black motorcycle there and her son has one. When went upon porch fell face first. Porch was concrete and had a step. Called (Physician name) at 4pm and new order received to send pt to ER (emergency room ) .returned with pt at 7:00 p.m. Pt's face more swollen eyes black cheeks now bruising. Chin neck and nose shows bruising .At 9:30 (p.m.) called DON (Director of Nursing) and notified her of incident and broken nose and that pt was off grounds .(Resident) states she was going over to that house because she saw a black motorcycle and thought it was her son's, (name) .called son (name) and explained incident and pt injury - He said he was not even in town Radiology Report, dated 12/6/2015 at 12:33 p.m., indicated, Service Date: 12/05/2015 05:17:37 PM .Exam: CT Maxillofacial .Indication: Reason CT Sinus: Trauma - Fall. Pain in frontal and parietal regions post fall today. Patient was walking and fell face first into the sidewalk. Bruising under both eyes, chin, and on her nose. Patient has blood in her nose and on her lips. Impression: --Comminuted Nasal Fracture .The patient could not cooperate with routine positioning .There is a comminuted (bone is in many pieces/fragmented), displaced (bone snaps in two or more parts and moves so the two (or more ends) are not lined up straight), and depressed (fragment of the bone is depressed) nasal fracture. On 12/14/15 at 10:57 p.m. LPN # 2 indicated she was on duty 12/5/2015 during during the incident. She indicated Dietary Staff # 1 was sitting in the dining room and saw Resident B outside and asked her if Resident B was allowed to walk outside by herself. LPN # 2 indicated, I said 'I don't think so' and I yelled back in and said, 'Where's (Resident B)?' to a CNA and she said, 'She just walked down the hall (toward the main entrance) .My daughter saw her across the street in the neighbor's lawn. LPN # 2 indicated she asked Resident B what she was doing after the incident and Resident B indicated she was looking for her son. On 12/14/2015 at 11:40 a.m. Dietary Staff # 1 indicated she was sitting in the main dining room when she thought she saw Resident B walking outside. She indicated, I said (to LPN # 2), 'I think I just saw (Resident B) walk outside .ran over (across the street) and found her on the porch. It was a mess. There was blood everywhere .They (staff) say she's been confused before. I think she's confused. Dietary Staff # 1 indicated the main entrance doors to the facility are not locked and do not have a key pad. Dietary Staff # 1 indicated, I come in at 4:30 in the morning and the (main entrance) doors are unlocked and I don't see anybody (staff) when I come in these doors On 12/14/2015 at 11:50 a.m., Resident B was observed sitting alone at a table in the main dining room. The resident had dark gray - black - green bruising and swelling throughout her face and chin. Resident B indicated (about the incident 12/5/2015), I was black and blue all over (after the fall) .I was seeing my son and he wasn't there .I like to go outside. On 12/14/2015 at 12:42 p.m., the Director of Nursing (DON) indicated the main entrance to the facility was never locked from the inside. She indicated nursing staff is supposed to lock the door every night after the three (p.m.) to eleven (p.m.) shift. The DON indicated there was no policy or procedure related to hours the facility is locked. The DON indicated the staff was not inserviced or provided education following the incident and the resident was not referred for a psychiatric consultation. On 12/15/2015 at 10:55 a.m., the DON indicated she did not consider Resident B an elopement risk because she walks with purpose. The DON indicated Resident B did not have a [DIAGNOSES REDACTED]. Resident B was interviewed in her room on 12/15/2015 at 11:00 a.m. She indicated she could not recall what happened after she walked out of the facility on 12/5/2015. She indicated, I thought I seen my son .nothing else .no one around (the facility when she exited). Resident B indicated she routinely left the building independently to work at (name of not-for profit organization that provides services for adults and children with mental, physical and emotional disabilities), and indicated, I get on the bus to and from work .no one walks me out, I just know when to go. On 12/15/2015 at 12:20 p.m. the DON was interviewed regarding follow up to the incident and possible interventions to ensure future elopement by Resident B, or other residents, does not occur in the future. The DON indicated, We haven't had a problem so far (with confused residents wandering out of the building). The DON indicated Resident B was not required to sign out as a leave of absence when she left the facility, and staff was not required to document when the resident left the facility. The DON indicated the facility did not have a policy and/or procedure related to leaves of absence. The DON provided the Leave of Absence Log on 12/15/2015. Resident B's had 8 entries (leaves of absence) since 11/28/2013, all with her son listed under Responsible Party or Patient, with the most recent one being 11/27/2015. This Federal tag relates to Complaint IN 212. 3.1-45(a)(2)