Every finding on record at Willows of New Castle

Based on observation, interview, and record review, the facility failed to assist a dependent resident with nail care for 2 of 8 residents reviewed for ADLs (Activities of Daily Living). (Resident D and Resident J) Findings include:1.) The clinical record for Resident D was reviewed on 7/22/26 at 11:50 a.m. The diagnoses included, but were not limited to, aphasia (inability [or impaired ability] to understand or produce speech), dementia (a decline in mental abilities), and contractures (permanent tightening or shortening of muscles, tendons, skin, or other soft tissues that causes joints to become stiff and restricts normal movement). A Quarterly Minimum Data Set (MDS) assessment, dated 5/9/26, indicated Resident D was moderately cognitively intact, and was dependent on staff for personal hygiene. During observations on 7/21/26 at 9:50 a.m. and 7/22/26 at 10:55 a.m., Resident D was sitting in his wheelchair in his room. Resident D's hands were contracted and had long, jagged nails that curled up into both palms due to contractures. During an interview on 7/22/26 at 10:58 a.m. with Certified Nurse Aide (CNA) 2, they indicated they usually would cut nails on shower days and acknowledged Resident D's long nails. A plan of care, dated 8/22/24, indicated Resident D had alteration in functional performance as evidenced by: need from at least one helper to complete self care tasks. The interventions included, but were not limited to, grooming every day and as needed. 2.) The clinical record for Resident J was reviewed on 7/22/26 at 12:12 p.m. The diagnoses included, but were not limited to, Alzheimer's disease (a progressive, irreversible brain disorder that destroys memory) , anxiety, and Type 2 diabetes mellitus. A Significant Change Minimum Data Set (MDS) assessment, dated 7/13/26, indicated Resident J was severely cognitively impaired, had no behaviors for rejection of care, and was dependent on care for personal hygiene. During observations of Resident J on 7/21/26 at 10:05 a.m. and 7/22/26 at 11:08 a.m., they were sitting in a wheelchair in their room. Resident J's left thumb nail was long, thick, and jagged, while all other nails were also long and uncut. During an interview with Qualified Medical Assistant (QMA) 3 on 7/22/26 at 11:08 a.m., indicated they had noticed Resident J's nails being long last week and had thought about placing Resident J on a podiatry list because he was diabetic, but did not attempt to cut or file Resident J's nails at the time. During an interview with Licensed Practical Nurse (LPN) 4 on 7/22/26 at 11:30 a.m., indicated nail care should be done with every shower. If a resident is diabetic, the nurse should be the one cutting them and filing if needed. The CNAs were supposed to report long nails to the nurse, so they knew they needed to be cut. A plan of care, dated 4/2/25, indicated Resident J had alteration in functional performance. The interventions included, but were not limited to, assist Resident J with up to 2 staff to assist with ADLS including personal hygiene. A Nail Care policy was provided by the Executive Director (ED) on 7/22/26 at 1:18 p.m. It indicated .Policy Explanation and Compliance Guidelines: .4. Routine nail care, to include trimming and filing, will be provided on a regular schedule .6. Principles of nail care: .a. Nails should be kept smooth to avoid skin injury .b. Only licensed nurses shall trim or file fingernails of resident's with diabetes . This Federal citation relates to intake 3092756410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(E)

Based on interview and record review, the facility failed to provide catheter care as ordered by the physician for 1 of 4 residents reviewed for catheter care. (Resident C) Findings include:The clinical record for Resident C was reviewed on 7/21/26 at 1:36 p.m. The diagnoses included, but were not limited to, intellectual disabilities, urinary tract infections, and obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward into the kidneys). An admission Minimum Data Set (MDS) assessment, dated 5/9/26, indicated Resident C was severely cognitively impaired and had no behaviors for rejection of care. A physician's order, dated 5/18/26, indicated urinary catheter care every shift. A review of June and July 2026 Treatment Administration Record (TAR) indicated Resident C had missed catheter care on the following dates and shifts: 6/2/26, Evening shift6/4/26, Night shift6/16/26, Morning shift6/23/26, Morning shift6/30/26, Evening and Night shift7/4/26, Morning and Evening shift7/5/26, Evening shift, and 7/6/25, Evening shift. A Catheter Care policy was provided by the Executive Director (ED) on 7/22/26 at 2:24 p.m. It indicated .Policy: It is the policy of this facility to ensure resident's with indwelling catheters receive appropriate catheter care .Policy Explanation: .1. Catheter care will be performed every shift . This Federal citation relates to intake 3092756.410 IAC (Indiana Administrative Code) 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the stove hood was maintained in a clean sanitary manner. This deficiency had the potential to affected 58 of 58 residents who dine in the facility. Findings include:A tour of the kitchen was conducted with the Dietary Manager (DM) on 3/2/26 at 12:30 p.m. During the tour, the stove hood was observed. There was a griddle/stove underneath the left side of the hood. The hood had a significant amount of built-up, greasy debris on the back panels and sprinklers. The back panels appeared furry substance completely covering the panels and sprinklers. There was stringy debris of dark substance hanging from one of the sprinklers above the griddle/stove where food was prepared. The sticker on the front of the stove hood indicated it was last serviced on 11/26/25, and the next service was to be in May of 2026. An interview was conducted with the DM during the above observation on 3/2/26 at 12:30 p.m. She indicated they regularly used the griddle/stove underneath the hood, and she noticed the amount of built-up debris on the stove hood, but she was told not to clean it, because it would void the warranty. After reviewing the next scheduled service visit on the sticker, she indicated perhaps it needed scheduled to be cleaned more often than every six months. The work order for the stove hood cleaning, dated 11/26/25, was provided by the DM on 3/2/26 at 12:47 p.m. It indicated cleaning of the kitchen exhaust system every 180 days for two years. The Sanitation policy was provided by the Administrator on 3/6/26 at 2:06 p.m. It indicated, All food service areas shall be kept clean, sanitary, free from litter, rubbish . 410 IAC (Indiana Administrative Code) 3.1-21(i)(3)

Based on interview and record review the facility failed to ensure a resident who received the wrong medication had a assessment completed, ongoing monitoring and vitals signs completed for 1 of 2 residents reviewed for quality of care (Resident B). Finding include:During an interview with Licensed Practical Nurse (LPN) 1 on 3/03/2026 at 1:05 p.m., the LPN indicated she witnessed RN 4 who no longer works at the facility administered Resident B one of Resident E's morning medication. This occurred months ago and LPN 1 was unsure of the date. The medication error was reported to the Director Of Nursing (DON) who no longer works at the facility. During an interview with the Nurse Practitioner (NP) on 3/4/26 at 2:37p.m., the NP indicated on 10/17/25 at 9:31 a.m., LPN 1 reported to her that Resident B had received Resident E morning medication of rivastigmine 3 milligrams (mg). The medication was used to treat dementia. The medication was not harmful to Resident B and the NP told LPN 1 to monitor the resident's vital signs and to observe for anxiety and tremors every shift for 24 hours. During an interview with the Regional Nurse Consultant 3 on 3/5/26 at 10:55 a.m., the Regional Nurse Consultant indicated on 10/17/26, there was no assessment, no progress note and no vital signs documented in the Electronic Health Record (EHR) for Resident B after she received Resident E's morning medication. The floor nurse was responsibility to ensure this was completed for Resident B. Review of the clinical record of Resident B on 3/4/26 at 1:25 p.m., indicated the resident's diagnoses included, but were not limited to, diabetes, chronic kidney disease, osteoporosis, hypertension, congestive heart failure, depression, anxiety disorder, intellectual disability (below average cognitive function) and cerebral infarction (stroke caused by a blocked or narrow arteries). The annual Minimum Data Set (MDS) assessment for Resident B, dated 1/1/26, indicated the resident was moderately impaired for daily decision making. The Medication error policy provided by the Administrator on 3/6/26 at 10:10 a.m., indicated a medication error means the observed or identified preparation or administration of medications or biologicals which was not in accordance with the prescribers order. If a medication error occurs, the following procedure would be initiated: the nurse assesses and examines the resident's condition, monitor and document the resident's condition, including response to medical treatment or nursing interventions, document actions taken in the medical record. The citation relates to Intake 2665000. 410 IAC(Indiana Administrative Code) 3.1-37(a)

Based on observation, interview and record review, the facility failed to implement a splint for a resident with bilateral hand contractures as ordered by the physician for 1 of 1 resident reviewed for Range Of Motion (Resident 51). Finding include:During an observation on 3/02/2026 2:35 p.m., Resident 51 had bilateral hand contractures (a chronic hand condition where connective tissue in the palms of both hands thicken ) with no splints in place. During an observation on 3/04/2026 at 1:54 p.m., Resident 51 had bilateral hand contractures with no splints in place. During an observation on 3/05/2026 at 11:33 p.m., Resident 51 had bilateral hand contractures, the resident had a splint on his left hand and did not have a splint on his right hand. The splint was observed to be on the resident's bedside table. During an observation on 3/05/2026 at 12:46 p.m., Resident 51 was sitting in the dining room, the resident had a splint on his left hand and did not have one on his right hand. Review of the clinical record of Resident 51 on 3/5/26 at 12:55 p.m., indicated the resident's diagnoses included, but were not limited to, traumatic brain injury (a disruption in normal brain function caused by an external force) and dementia (mental decline). The plan of care for Resident 51, dated 8/22/24, indicated the resident had an alteration in functional performance as evidenced by: Needed assistance from at least one staff member to complete self-care tasks. The intervention included, but was not limited to, bilateral palm protectors per order. The Occupational Therapy assessment for Resident 51, dated 1/21/26, indicated the resident had impaired range of motion of the right and left upper extremities due to contractures. The quarterly Minimum Data Set (MDS) assessment for Resident 51, dated 2/6/26, indicated the resident was severely impaired for daily decision making. The resident had impairment in range of motion of both of the upper extremities. The physician's order for Resident 51, dated March 2026, indicated the resident was to have bilateral palm protector or hand orthoses as tolerated at day time and off at night time and bathing (original 10/20/25). The Medication Administration Record (MAR) for Resident 51, dated March 2026, lacked documentation by the resident of any refusals to wear bilateral palm protector or hand orthoses. During an interview with the Regional Nurse Consultant (RNC) on 3/5/26 at 2:25 p.m., the RNC indicated floor nurses were responsible to ensure Resident 51 had his bilateral splints in place. The assistive device and splint policy provided by the Administrator on 3/6/26 at 10:10 a.m., indicated the purpose of the policy was to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function, dignity and quality of life. The devices included, but were not limited to, orthotic equipment/splints. The nurse would be responsible for the resident and monitor for the consistent use of the device. 410 IAC (Indiana Administrative Code) 3.1-42(a)(2)

Based on interview and record review, the facility failed to adequately monitor and treat a resident's wandering behavior for 1 of 3 residents reviewed for dementia care and services. (Resident C) Findings include:The clinical record for Resident C was reviewed on 3/5/26 at 11:11 a.m. His diagnoses included, but were not limited to, dementia (mental decline) with agitation and anxiety. The nursing admission note, dated 2/17/26 at 4:10 p.m., by Licensed Practical Nurse (LPN) 7 indicated the resident was confused and combative. Within the first five minutes of arrival, he was up, refusing to wait on a physical therapy evaluation. He refused to follow staff direction. He moved over to his roommate's area of the room and started to move items around. He then had contact with the roommate. Verbal redirection by staff failed and Resident C became physical, he lashed out and stroke staff. The nursing note, dated 2/17/26 at 10:06 p.m., by LPN 7 indicated the resident was temporarily moved to another room, because he and his roommate were screaming at each other. He was administered a one-time order which was effective for approximately two hours. Then he was found in another resident's room holding her hand, saying he loved her. He was combative with staff during the redirection at that time. An interview was conducted with LPN 7 on 3/5/26 at 2:27 p.m. The LPN indicated he was the nurse on duty when Resident C was admitted to the facility on [DATE]. Resident C touched his roommate's belongings and touched him on his leg. The two of them argued back and forth. The LPN's solution was to separate them and move Resident C to a different room and let management figure out how to handle things the next day. Resident C would not stay in his room, he kept wandering into other resident's rooms and was physically combative with staff, including the LPN. Resident C's discharge medications were unavailable for administration when he arrived at the facility, so LPN 7 had to get emergency medication for him that night, but it had little to no effect. His scheduled Risperidone was not available for administration. His medications were not available until Resident C's second day there. Several female residents were voicing they wanted him kept away from them. The behavior note, dated 2/18/26 at 3:03 a.m., indicate Resident C was confused and ambulated in the hallways. He refused to stay in his bed in his room with repeated attempts. The Interdisciplinary Team note, dated 2/18/26, indicated a review of Resident C's noted behaviors after arrival was completed. The resident was noted to be wandering with no purpose, difficult to redirect, rummaged through his roommate's belongings, and caused irritation to his roommate. Upon investigation and interviews with staff, the contact made with his roommate was a hand on his roommate's leg as this was Resident C's way of communication. It was not done in a manner of aggression. The family reported that Resident C had a difficult time adjusting at first to new environments. In the past, as needed medications were effective. A new order for intramuscular Haldol and Ativan were obtained. A wander guard was placed for the resident's safety. The Haldol was effective for two hours after administration. Resident C continued with intermittent redirectable behaviors. Resident C was found in another resident's room during the night, sitting next to the other resident's bed, holding hand, having civil conversation. No aggression or inappropriate behaviors were noted. A referral was made for psychiatric services to evaluate and treat Resident C. The behavior note, dated 2/18/26 at 9:34 p.m., indicated Resident C continued to enter other residents' rooms, striking staff as they attempted to redirect him. He spit on the nurse and laid on the floor at the nurse's station. The behavior note, dated 2/19/26 at 9:56 p.m., indicated Resident C continued to be agitated without the ability to be redirected, was exit seeking and striking staff. He walked into other resident's rooms. From 9:00 p.m. to 10:00 p.m. the nurse provided one on one supervision to prevent the behaviors. The behavior note, dated 2/22/26 at 2:09 p.m., indicated Resident C wandered the facility all shift. He entered other residents' rooms multiple times and upset the residents. He sat on a resident's bed and refused to move. Multiple nursing staff attempted to redirect him. He had taken off his pants and socks and was attempting to lay down. The owner of the room was sitting in his recliner, was angry, and told the resident it was not his room and he needed to leave. Resident C eventually got up and staff were able to redirect him out of the room. An interview was conducted with Certified Nursing Assistant (CNA) 8 on 3/5/26 at 12:30 p.m. She indicated she'd worked at the facility for two years and normally worked evening shift on the hallway Resident C resided. She was eventually assigned to provide one on one supervision to him. When Resident C first arrived, he got into a verbal altercation with Resident 7. Resident C was provided one-on-one for a few days, maybe five after arriving. He wandered into other resident's' rooms. She received information in shift report that he climbed in bed with Resident 13. It was chaotic when he wasn't provided one-on-one supervision (one staff member to one resident continuous supervision). Some days he was more on edge than others. An interview was conducted with CNA 9 on 3/5/26 at 12:12 p.m. She indicated she'd worked at the facility for two years. She was familiar with Resident C. He would scream out, was combative if you got too close. He would get outrageous, cussing, wouldn't cooperate. She saw him go into other residents' rooms, randomly. The other residents would put on their call lights for staff to come get him out of their room. She had to assist him out of other residents' rooms, where he was maybe messing with their television remote, going through their closet, messing with clothes, and picking up stuff. She explained to him it wasn't his room, kept coaching him, and eventually he would leave. An interview was conducted with Resident 60 on 3/6/26 at 11:35 a.m. She indicated Resident C came into her room and shut the door, which made her feel uncomfortable. He took her wheelchair foot pedals off of the bed and asked her where to put them. She told him he needed to leave. Eventually he put her foot pedals into the trash can and left her room. Another time he came into her room, he laid on the bed. She told him he needed to leave and it was not his room. A staff member came to the door and redirected him out of her room. He went into other residents' rooms too. An interview was conducted with Resident 25 on 3/5/25 at 2:57 p.m. She indicated Resident C came into her room one night. He closed the door and came to the empty bed and started to turn back the covers. He was sitting on the empty bed and started putting dirty signs up on his hands and told her to 'shut up, just shut up.' She told him he needed to go back to his own room. He eventually left her room and shut the door. It didn't make her feel very good. She was a little scared. She never had anyone speak to her like that before. An interview was conducted with Resident 3 on 3/6/26 at 11:25 a.m. She indicated she and her roommate shared a restroom with Resident C. He came into their room through the restroom one time. An interview was conducted with the Social Services Director (SSD) on 3/5/26 at 12:41 p.m. She indicated when a resident had dementia, it was really looked at, as to whether they were a good fit for the facility admission. They were under the impression Resident C was not able to walk and needed assistance for mobility. They were blown away that he was able to walk everywhere as soon as he was admitted . He started having behaviors right away and was more confused when off of the original hospital medications. She saw him go into other residents' rooms. He was not placed on one-on-one supervision until 2/23/26, and she was unsure as to why. He did not get his medications the first night he was at the facility, because the pharmacy did not deliver them. An interview was conducted with the Administrator on 3/6/26 at 10:41 a.m. She indicated Resident C wandered into other residents' rooms and was aggressive with staff. He wandered everywhere until he was placed on one-on-one supervision. Prior to one-on-one supervision, they tried redirection, all the things, but their facility was not the appropriate setting for him. Other residents were upset about his behaviors, as they were not used to other residents coming into their rooms. The Dementia Care policy was provided by the Administrator on 3/5/26 at 3:02 p.m. It indicated, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines: 1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. 2. The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals. 3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illnesses. 4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. 5. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. 6. If needed, the environment will be modified to accommodate individual resident care needs. 7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary. 8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker). 9. All staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help resident's attain or maintain the highest practicable physical, mental, and psychosocial well-being. This citation relates to Intakes 2787990 and 2794869. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's ordered medication was available for administration upon admission to the facility for 1 of 3 residents reviewed for pharmacy services. (Resident C) Findings include: The clinical record for Resident C was reviewed on 3/5/26 at 11:11 a.m. His diagnoses included, but were not limited to, dementia (mental decline) with agitation and anxiety. The hospital discharge orders, dated 2/17/26, indicated staff were to administrator Resident C's Risperidone one time a day, three 0.5 mg tablets. The resident's next dose was due on 2/17/26 at 4:00 p.m. The resident was to receive Trazadone at bedtime, one 50 mg tablet. The resident's next dose was due on 2/17/26 at bedtime. The nursing admission note, dated 2/17/26 at 4:10 p.m., by Licensed Practical Nurse (LPN) 7, indicated the resident was confused and combative. Within the first five minutes of arrival, he was up, refusing to wait for a physical therapy evaluation. He refused to follow staff direction. He moved over to his roommate's area of the room and started to move items around. He then made contacted with the roommate. Verbal redirection by staff failed and Resident C became physical, lashing out and striking staff. The February 2026 medication administration record (MAR) indicated Resident C's three 0.5 mg tablets of Risperidone were not administered at 4:00 p.m. on 2/17/26. The administration of the Resident C's Risperidone since admission was first administered on 2/18/26 at 4:00 p.m. The February 2026 MAR indicated Resident C's 50 mg tablet of Trazadone was not administered at bedtime on 2/17/26. The administration of Resident C's Trazadone since admission was first administered on 2/18/26 at bedtime. The nursing note, dated 2/17/26 at 10:06 p.m., by LPN 7, indicated Resident C was temporarily moved to another room, because he and his roommate were screaming at each other. Resident C was found in another resident's room. He was combative with redirection by staff. An interview was conducted with LPN 7 on 3/5/26 at 2:27 p.m. The LPN indicated he was the nurse on duty when Resident C was admitted to the facility on [DATE]. Resident C's discharge medications were unavailable for administration when he arrived at the facility, including his scheduled Risperidone. The resident's medications were not available until his second day there. An emergency behavior medication was administered with little to no effect. The resident was having behaviors and difficult to redirect after arrival. The Pharmacy Services policy was provided by the Administrator on 3/6/26 at 12:20 p.m. It indicated, The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. This citation relates to Intakes 2787990 and 2794869. 410 IAC (Indiana Administrative Code) 3.1-25(a)

Based on interview and record review, the facility failed to prevent a resident from eloping (leaving the facility without others being aware or giving permission) through the resident's room window for 1 of 3 residents reviewed for elopement. (Resident B) The deficient practice was corrected on 7-23-25, prior to the start of the survey, and was therefore past noncompliance. The facility had completed a physical assessment of the resident after the elopement, placed her on one-on-one direct supervision by facility staff, began an immediate investigation of the elopement, conducted interviews with facility staff regarding the elopement, conducted education with all staff on elopement policy and what to do in the event of an elopement, conducted an elopement drill, conducted an audit of all exit doors and alarms, ensured all windows were secured to not allow an opening more than six (6) inches and completed new assessments on all residents for wandering and elopement risks. Care plans were updated to reflect any residents which were indicated to be an elopement risk. Resident B remained under direct supervision until she was discharged to an area facility with a secured memory care unit. Findings include:The facility submitted a reportable incident to the Indiana Department of Health's Long-Term Care (IDOH-LTC) division on 7-18-25, which indicated Resident B had been found on 7-18-25, outside facility, on facility grounds at 3:10 p.m. Prior to incident, at 3pm [3:00 p.m.], resident and staff member [were in the resident's] in room attempting to make phone call to daughter. It indicated a therapy staff member had observed the resident outside of the facility. Licensed nurse immediately notified, and head to toe assessment completed. Vital signs within normal limits. Resident was clothed appropriately. Current temp 82 degrees. Resident [NAME] [sic] back inside of facility and offered refreshments. No distress noted. Staff interviews and investigation [were] initiated. Family, MD [medical provider], ED [Executive Director], ombudsman notified of incident. No injuries noted. 1:1 [one-on-one direct supervision] will now be provided by staff. All pertinent information will be added to 5- day follow up. Family and MD in agreement with plan of care. A 5-day follow-up report was sent to the IDOH-LTC division on 7-23-25, which indicated Resident B had been discharged to a local facility with a secured memory care unit. It indicated Resident B had sustained a non-emergent skin tear during her elopement. It indicated the facility had conducted an investigation which included, but was not limited to, staff statements related to the elopement, all staff were educated on the facility's elopement policy, an elopement drill had been conducted successfully, the maintenance department had conducted an audit of all exit doors and alarms with no issues identified, windows were secured to not allow opening more than six (6) inches and the Minimum Data Set (MDS) Coordinator had completed new assessments on all residents for wandering and elopement risks. In an interview on 7-28-25 at 12:15 p.m., with the ED, she indicated Resident B had been experiencing escalating behaviors in the weeks prior to the elopement, for which the facility had involved psychiatric services and her primary care doctor, as well as the resident's family. The ED indicated a urinalysis had been obtained with the results being negative. There were several med changes. At the time she eloped, she was on 15-minute checks and then we advanced those to 1:1 after the elopement out of her window. She had been sent out a time or two [to psychiatric facilities] for behaviors. My guess is that her dementia was advancing and she is now in a safer environment. A social services progress note, dated 7-16-25 at 2:56 p.m., indicated a family member of Resident B had scheduled a tour with a local facility to visit their memory care unit, related to possibly transferring Resident B to that facility's memory care unit. In an interview on 7-28-25 at 2:48 p.m., with the Director of Nursing (DON), she indicated Resident B remained on every 15- minute visual checks prior to the elopement. She indicated on the night shift of 7-17-25 through 7-18-25, the nursing staff had someone sitting with her and I think the reason they had charted she was on 1:1's during the night, was she seemed to need more attention. The morning of 7-18, she was actually on every 15-minute checks. The staff member who had been sitting with her [on the afternoon of 7-18-25] came back to the room and found the screen broken out of the window. Of course, after that, she was [placed] on 1:1's until she was discharged . The clinical record of Resident B was reviewed on 7-28-25 at 11:47 a.m. Her diagnoses included, but were not limited to, early onset Alzheimer's disease, dementia, hallucinations, unspecified psychosis and depression. A review of her most recent MDS assessment, dated 6-18-25, indicated she was moderately cognitively impaired, did display wandering behaviors, which were unchanged from the previous assessment time frame. It indicated she was independently ambulatory with the use of a walker and had no falls since the last assessment time frame. Elopement risk assessments, dated 6-16-25 and 7-18-25, indicated she was at risk for elopement. A care plan for Resident B, developed on 3-31-25 and updated on 7-11-25 and 7-18-25, indicated she wanders aimlessly trying to enter doors.refuses to wear wander guard [security device used to assist in provision of safe boundaries]. Another care plan was developed on 6-9-24 and updated on 8-9-24, indicated Resident B had impaired cognition as evidenced by diagnoses of dementia and Alzheimer's disease and via cognitive assessments. On 7-28-25 at 1:20 p.m., the ED provided a copy of an undated policy entitled, Missing/Wandering Resident. This policy indicated it purpose was to locate the missing or wandering resident as soon as possible. It indicated the administrative team and charge nurse are to be notified immediately when a resident is missing. The administrative team and/or charge nurse will organize a thorough search of the premises. Notification will be made to all staff of the potentially missing resident.[including] the name and description of the missing resident.will include the clothing worn, if the resident is ambulatory or uses a wheelchair/walker, and any other information that may be useful.If the resident is not located on the premises, a more extensive search will be conducted as directed by the Administrator/DON. As appropriate, the Administrator will notify the resident's family, the police authorities, the Indiana State Board of Health, Adult Protective Services and the Ombudsman.Once the resident is located.Administrator/DON will conduct a reassessment of events to determine whether present placement is appropriate for the resident's needs and condition. The resident will have an Elopement Risk Assessment completed to assess his/her current risk.The Care Plan will be updated and reviewed for new interventions initiated related to the elopement. Family, resident, and staff will be notified of the new interventions initiated. This citation relates to Complaint 2566622. 3.1-45(a)(1)3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure residents, including a confidential resident, were treated with dignity during care for 2 of 3 residents reviewed for dignity. (Resident 9 and Confidential Resident) Findings include: 1. During an interview with Resident 9 on 3/10/25 at 1:26 p.m., they indicated it had taken an hour for anyone to come into her room when she turned her call light on to go to the restroom. Resident 9 indicated she had to wait so long for help, that she ended up having incontinent episodes of urine and feces in bed. Resident 9 indicated it made them feel bad and it upset them because it was unnecessary and could have been avoided. Resident 9 indicated this occurrence happens at least once a week. The clinical record for Resident 9 was reviewed on 3/11/25 at 12:09 p.m. Diagnoses included, but were not limited to, generalized anxiety disorder, muscle weakness, and chronic pain syndrome. The Quarterly Minimum Data Set (MDS) assessment, dated 2/5/25, indicated Resident 9 was cognitively intact. The quarterly MDS also indicated Resident 9 was frequently incontinent of bowel and bladder, required a wheelchair for ambulation, and needed substantial/maximal assistance with personal hygiene and required moderate assistance with toilet transferring. A care plan for Impaired/Risk for impaired skin integrity was provided by the Administrator on 3/13/25 at 8:30 a.m. It indicated that incontinent care would be performed every two hours and as needed and to turn and reposition every two hours and as needed. A care plan for Bowel/Bladder Incontinence, initiated 10/23/24, indicated to check resident approximately every two hours. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. During an interview with the Administrator on 3/13/25 at 9:36 a.m., she indicated she was never aware of this occurring and will start Resident 9 on a toileting program and check in with her more often for care needs. 45291 2a. A confidential resident record was reviewed during the survey period. The medical diagnoses included dementia and chronic pain. The last Minimum Data Set (MDS) assessment indicated the confidential resident was cognitively intact. A depression care plan, revised on 1/23/24, indicated the confidential resident was at risk for feeling bad about themselves, and received mental health services. The interventions included listening to the resident and validating their feelings. During a confidential resident interview, the resident indicated they were not treated with respect during care. Staff are often rough and holler at them, have accused them of trying to have someone fired, and did not listen to them when they told them how to provide their care. This resulted in the confidential resident feeling disrespected and bad about themselves. 2b. The medical record for Resident 155 was reviewed on 3/12/25 at 11:45 a.m. The medical diagnoses included depression and Chron's disease. An admission assessment, completed on 2/24/25, indicated Resident 155 was alert and oriented to person, place, time, and situation. During an interview on 3/10/25 at 1:45 p.m., Resident 155 indicated she becomes very upset with the way staff talk and treat the confidential resident. She stated, they [staff] are very unkind to [the confidential resident] at times and should not be in this line of work if they [staff] are going to treat people like that. She indicated that if they were to speak to her in that manner, she would be very upset, and it would make her cry. She had on numerous occasions heard the confidential resident state the staff were hurting her, but they didn't stop care or even acknowledge it. During an interview on 3/14/25 at 12:00 p.m., the Administrator indicated it was the expectation of the facility to treat all residents with respect. 3.1-3(t)

Based on interview and record review, the facility failed to provide a bath and/or shower upon request and as care planned for 1 of 1 resident reviewed for bathing. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 3/11/25 at 12:27 p.m. Diagnoses included, but were not limited to, stress incontinence and osteoarthritis of the left hand. During an interview with Resident 6 on 3/10/25 at 12:32 p.m., she indicated a couple months ago when she had COVID-19, she went several days without a bed bath or shower. Resident 6 indicated she asked staff for a shower, but they told her she could not have one because she had COVID-19 and would have to bathe her in her room. Resident 6 indicated she would have to go into her bathroom and wash up on her own. She indicated no bed baths were offered or given. She also indicated she takes her showers on Tuesdays and Fridays. During an interview with Licensed Practical Nurse (LPN) 2 on 3/12/25 at 11:47 a.m., they indicated when anyone was in isolation, they could take a shower, they are just taken last for the day due to sanitizing afterwards. An Admission Minimum Data Set (MDS) assessment, dated 8/22/24, indicated Resident 6 was cognitively intact, had no behaviors of rejection of care, and it was very important for her to be able to choose from a tub bath, shower, bed bath, or sponge-bath. An Interdisciplinary Team (IDT) follow up note, dated 1/11/25, indicated Resident 6 tested positive for COVID-19. A physician's order, dated 1/11/25, indicated Resident 6 was to be placed in droplet/contact isolation precautions for ten days. Shower sheets were provided by the Administrator, on 3/12/25 at 9:45 a.m., and indicated Resident 6 had a shower, on 1/10/25, and a bed bath given due to isolation documented on 1/14/25. A shower sheet, dated 1/16/25, showed no documentation of a shower or bath being given. The Electronic Health Record (EHR) bathing documentation was provided by the Administrator, on 3/13/25 at 10:25 a.m., and indicated Resident 6 did not receive a shower or bath, on 1/17/25, on her scheduled showering day. The next shower documented for Resident 6 was on 1/21/25. This indicated Resident 6 went seven days without a bath and/or shower being given as documented in her plan of care. During an interview with Resident 6 on 3/12/25 at 11:50 a.m., she indicated she was miserable and crying after she had gone several days without a bath or shower when she was sick. An Activities of Daily Living care plan was provided by the Administrator on 3/12/25 at 9:45 a.m. It indicated Resident 6 would receive tub bath or showers as she preferred, and staff would provide supervision/touching assist of one helper with dressing and grooming. A Resident Showers policy was provided by the Administrator on 3/12/25 at 9:45 a.m. It indicated, .1. Residents will be provided showers as per request .2. Partial baths may be given between regular shower schedules .4. Assist the resident to the shower room 3.1-38(a)(3)(A) 3.1-38(a)(3)(B)

Based on interview and record review, the facility failed to provide routine dental care to residents when an inside source was not available for 1 of 3 residents reviewed for dental services. (Resident 2) Findings include: During an interview on 3/10/25 at 1:16 p.m., Resident 2 indicated she would like to see a dentist. Resident 2 indicated she had not seen the dentist in a long time. The clinical record for Resident 2 was reviewed on 3/11/25 at 12:05 p.m. Diagnoses included, but were not limited to, diabetes mellitus and cerebral infarction. The Annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident 2 was cognitively intact for daily decision making. A Complimentary Dental Assessment consent was provided by the Administrator on 3/12/25 at 9:45 a.m. Resident 2 signed to give consent for dental services on 5/27/21. Resident 2's last dental exam provided by the Administrator, on 3/12/25 at 9:45 a.m., indicated Resident 2 had a dental exam on 9/9/22. During an interview with the Administrator on 3/12/25 at 9:55 a.m., she indicated the facility recently switched dental services to a new company because the facility was having issues with the previous company not providing services. The Administrator indicated the dental company had not seen their residents on a regular basis or conducted annual screenings for everyone enrolled. During an interview with the Social Service Director (SSD) on 3/14/25 at 11:28 a.m., they indicated the dental company, whom they worked with, stopped doing annual dental exams after COVID-19. The SSD indicated the facility did not offer to take residents to an outside provider for an annual screening. They only took residents out of the facility if they had any dental problems. A Dental Services policy was provided by the Administrator on 3/12/25 at 10:30 a.m. It indicated, .It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) . [Routine dental services] means an annual inspection of the oral cavity 3.1-24(a)(1)

Based on interview and record review, the facility failed to ensure 2 of 2 residents diagnosed with Clostridium difficile infection (c-diff) were receiving care which included thorough and accurate assessments on a routine basis and the documentation of the assessments reflected the thorough assessments and resident status. (Residents B and C) Findings include: 1. The clinical record of Resident B was reviewed on 1-7-25 at 2:32 p.m. Her diagnoses included, but were not limited to, a history of urinary tract infections (UTI), systemic inflammatory response syndrome (SIRS), Alzheimer's disease and generalized muscle weakness. A hospital discharge summary, dated 11-12-24, indicated she was diagnosed with a c-diff infection upon admission to the hospital on 11-7-24. She returned to the facility on [DATE]. A review of the progress notes and Nursing Infection Charting ATB [antibiotic] daily assessments, dated 11-12-24 through 11-19-24, was conducted. The documentation failed to address the stooling status, such as the presence of watery type diarrhea, foul-smelling or mucous-type stools or presence of abdominal pain, nausea, vomiting or change in appetite for Resident B on 11-12-24 at 11:03 p.m., 11-13-24 at 1:40 a.m., 11-13-24 at 11:51 a.m., 11-17-24 at 5:19 p.m., 11-18-24 at 1:56 p.m., 11-18-24 at 9:28 p.m., and 11-19-24 at 12:57 a.m. Additionally, the clinical record documentation failed to identify Resident B was in contact isolation, related to c-diff, on 11-13-24 at 1:40 a.m., 11-16-24 at 4:58 p.m., 11-17-24 at 5:19 p.m., 11-18-24 at 6:23 a.m., 11-18-24 at 9:28 p.m. and 11-19-24 at 12:57 a.m. The clinical record failed to identify the date of the initiation of contact isolation or the date it ended. A review of the Infection Control Surveillance, information for November 2024, indicated Resident B was started on an antibiotic for c-diff on 11-13-24, but did not specify she was on isolation of any type. During an interview with the Director of Nursing (DON) on 1-8-25 at 12:18 p.m., she indicated the documentation from the nursing staff, related to Resident B's c-diff, appeared to be put in briefly and was more hit and miss. I would expect the documentation to be detailed. During an interview with the DON on 1-9-25 at 11:19 a.m., she indicated the Infection Preventionist's (IP) notation for Resident B indicated the resident was identified with c-diff, on 11-13-24, upon her return from the hospital and was placed in isolation on that date; isolation was discontinued on 11-18-24, per physician orders. The facility's guidelines for continuation of isolation were until the antibiotic was completed. It is a case-by-case basis from the facility's doctors as to how long the person stays in isolation, based on the status of their stools being solid and their antibiotic. Generally, they error on the side of caution. The DON indicated the former IP left employment about a week before Christmas, with no notice. Additionally, the DON indicated she was out for surgery around the same time the former IP left employment and was trying to get some of the paperwork done from home. In an interview with the DON on 1-9-25 at 3:50 p.m., she indicated her expectations for the assessments for c-diff to be thorough and conducted at least daily. 2. The clinical record of Resident C was reviewed on 1-8-25 at 2:17 p.m. His diagnoses included, but were not limited to, unspecified dementia, ulcerative colitis, diabetes, a history of severe sepsis with septic shock, gastrointestinal hemorrhage, noninfective gastroenteritis and colitis, and prior noncompliance with other medical treatment regimen due to an unspecified reason. A progress note, dated 12-21-24, indicated Resident C had experienced frequent, loose, watery, and foul smelling stools, and a stool sample was sent out to determine if he had c-diff. He was placed in contact isolation, pending the results of the stool sample. A notation the following day, 12-22-24, indicated the stool sample was positive for c-diff and the resident remained in contact isolation. It indicated Resident C was placed on an oral medication for 14 days to treat the c-diff infection. A review of the progress notes and Nursing Infection Charting ATB [antibiotic] daily assessments, dated 12-22-24 through 1-7-25, was conducted. The documentation failed to address the stooling status, such as the presence of watery type diarrhea, foul-smelling, or mucous-type stools, or presence of abdominal pain, nausea, vomiting or change in appetite for Resident C on 12-23-24 and 1-6-25. Additionally, the clinical record documentation failed to identify Resident C was in contact isolation, related to c-diff on 12-23-24. A progress note, dated 1-7-25, indicated the contact isolation had been discontinued. A review of the Infection Control Surveillance, information for December 2024, indicated Resident C's c-diff infection was not located on the Monthly Infection Surveillance Report. In an interview with the DON on 1-9-25 at 11:19 a.m., she indicated Resident C's c-diff diagnosis was not added to the infection surveillance log like it should have been. During an interview with the DON on 1-9-25 at 9:30 a.m., she indicated it appeared as if Resident C's clinical record documentation, related to the c-diff infection started out pretty good, but the quality of the documentation and frequency of the documentation of the assessments went downhill. I would expect the documentation, and assessments should remain of a high quality throughout the resident's care needs. The assessments should be at least twice daily for c-diff and address the number and quality of the stooling, as well as any abdominal pain or discomfort. In an interview with the DON on 1-9-25 at 11:19 a.m., she indicated the facility's guidelines for continuation of isolation was until the antibiotic was completed. It is a case-by-case basis from our doctors as to how long the person stays in isolation, based on the status of their stools being solid and their antibiotic. Generally, they error on the side of caution. The DON indicated the former Infection Preventionist (IP) left employment about a week before Christmas, with no notice. Additionally, the DON indicated she was out for surgery around the same time the former IP left employment and was trying to get some of the paperwork done from home. In an interview with the DON on 1-9-25 at 3:50 p.m., she indicated her expectations for the assessments for c-diff infections are they will be thorough and conducted at least daily. On 1-9-25 at 9:15 a.m., the Administrator provided a copy of an undated policy entitled, Management of C. Difficile Infection. It indicated, This facility implements facility-wide strategies for the prevention and spread of Clostridium difficile (C. difficile) infections .Licensed nurses may implement preemptive contact precautions when C. difficile infection is suspected, pending results of testing. Once confirmed, contact precautions shall be implemented in accordance with a physician order and facility policy for transmission-based precautions . This citation relates to Complaint IN00449670. 3.1-37(a)

Based on interview and record review, the facility failed to ensure 2 of 2 residents reviewed for urinary tract infections (UTI), received prompt treatment for complaints of dysuria (painful urination), urine culture and sensitivity reports be reviewed with the medical provider for accuracy related to the proper medications be ordered to treat the identified organisms, and their daily nursing assessments related to their diagnosis are thorough and accurate. (Resident B and D) Findings include: 1. The clinical record of Resident B was reviewed on 1-7-25 at 2:32 p.m. Her diagnoses included, but were not limited to, a history of urinary tract infections (UTIs), systemic inflammatory response syndrome (SIRS), Alzheimer's disease and generalized muscle weakness. 1.a. A review of the progress notes, dated 12-19-24 at 10:42 p.m., indicated a urinalysis with a culture and sensitivity (C&S) request was obtained from Resident B and sent to the lab for analysis on 12-20-24 at 5:58 a.m. An entry, dated 12-22-24 at 8:49 a.m., indicated the facility had received a new physician's order for Cipro (antibiotic) 500 milligrams (mg) to be administered twice daily for seven days for a UTI. The corresponding urinalysis report, including the C&S report, indicated the urine sample had been received by the laboratory on 12-21-24 at 5:21 a.m. The C&S report indicated the urine sample analysis identified the organisms present were a high level of Escherichia coli (e-coli) and low level of Enterococcus faecalis. It indicated these organisms were resistant to Ciprofloxacin, Levofloxacin and Trimethoprim/Sulfamethoxazole. It indicated these organisms were susceptible to 14 common antibiotics. During an interview with the Director of Nursing (DON) on 1-9-25 at 2:20 p.m., she indicated she was unable to address why the Cipro was started for this resident's UTI when the C&S showed it was resistant to Cipro. She indicated one of the nurses should have caught this and notified the doctor or NP (nurse practitioner) of this. I will check with the doctor to see how he wants to handle this. The DON indicated this occurred around the time she was off work for surgery and the Infection Preventionist (IP) and the Assistant Director of Nursing (ADON) had left employment. 1.b. A hospital discharge summary, dated 11-12-24, indicated Resident B was diagnosed with a UTI upon admission to the hospital on 11-7-24. She returned to the facility on [DATE]. A review of the progress notes and Nursing Infection Charting ATB [antibiotic] daily assessments, dated 11-12-24 through 11-19-24, was conducted. The documentation failed to address the urinary status, such as the color and shade of the urine, any urinary odors, clarity of the urine, presence of blood, mucus, or sediment in Resident B's urine on 11-12-24 at 11:03 p.m., 11-13-24 at 1:40 a.m. and 11-18-24 at 9:28 p.m. During an interview with the DON on 1-9-25 at 3:50 p.m., she indicated her expectations for the assessments for UTI's to be thorough and conducted at least daily. 2. The clinical record of Resident D was reviewed on 1-9-25 at 11:05 a.m. Her diagnoses included, but were not limited to, diabetes with neuropathy, unspecified mild dementia, and a history of urinary tract infections (UTIs). A review of Resident D's progress notes reflected she had completed intravenous antibiotic therapy on 12-22-24 for a UTI. It indicated, on 12-26-24, Resident D was reporting blood in her urine and the attending physician ordered for a urinalysis with culture and sensitivity (C&S) testing to be obtained. A notation, on 12-31-24, indicated a urine sample had been obtained and was awaiting the laboratory to pick up the sample. Another entry, dated 12-31-24, indicated Resident D had tested positive for Covid-19 and was ordered to begin a regimen of the anti-viral medication, Paxlovid. Another entry, dated 1-1-25, indicated a second urine sample had been obtained for this resident and was to be sent to the laboratory for analysis. It did not indicate the reason for a second sample. During an interview with the DON on 1-9-25 at 2:20 p.m., she indicated the attending physician for Resident D, does not like to order any antibiotics when someone is on Paxlovid. That is my guess as to why he wouldn't have ordered an antibiotic for the UA [urinalysis] of 1-1-25. The lab had requested a repeat urine from the 12-31-24 urine sent to them as to why it was repeated on 1-1-24. I can't answer as to why there was a delay in getting her urine, from 12-26-24 until 12-31-24. Again, this was during the time frame that I was out of the office, and we had recently had the ADON [Assistant Director of Nursing] and IP [Infection Preventionist] leave employment. Again, one of the nurses should have caught this and gotten it done. It looks like there was a lapse in documentation, so have no idea if she was having blood in her urine or dysuria. During an interview with the DON on 1-9-25 at 3:50 p.m., she indicated the facility does not have a specified policy on documentation. She indicated her expectations for the assessments for UTI's to be thorough and conducted at least daily. This citation relates to Complaint IN00449670. 3.1-41(a)(2)

A.) Based on observation, interview and record review the facility failed to adequate supervision during care and ensure two staff were providing care for a dependent resident resulting in the resident falling out of bed and sustaining 3 brain bleeds and 5 facial sutures (Resident B). B.) Based on observation, interview and record review the facility failed to have fall interventions of two assistive devices in place and failed to have a call light available for a resident who had sustained a fall with a fracture (Resident D). This affected 2 of 4 residents reviewed for accidents (Resident B and Resident D). Findings include: A.) During an interview with Resident B's Family member 1 on 1/22/24 at 1:21 p.m., indicated on 12/22/23 CNA 2 was attempted to provide incontinent care by herself and the resident rolled out of bed. When CNA 2 rolled the resident on her side, the resident grabbed the privacy curtain and fell out of bed. The family member indicated she visits the resident every day but she was not at the facility when this occurred it happened early in the morning, RN 1 called her and notified her of what had happened. The resident was suppose to have 2 staff provide care. The resident sustained 3 brain bleeds and 5 sutures above her eyebrow. The resident was in the Intensive Care Unit (ICU) for one night. Family member 1 indicated the resident had significantly declined since the fall, the resident was now on hospice, the resident would get up every day and would go to activities, now the resident slept all day. The resident now takes morphine (pain medicine) in the morning and in the evening. The family member pointed to a sign on the wall that said care in pairs and indicated after the fall the facility put the sign up. Resident B was observed to be lying in bed with her eyes closed, the resident had a scab above her right eye brow. During an interview with CNA 2 on 1/24/24 at 11:53 a.m., indicated she was Resident B's CNA on 12/22/23 when she fell out of the bed. CNA 2 indicated the resident was incontinent of urine and was laying on her side. CNA 2 turned around to get clothes out of the resident's closet and when she turned around the resident had grabbed the privacy curtain and her legs were off of the bed. CNA 2 indicated she grabbed the resident's upper body to try to keep her from falling but the resident had a tight grip on the privacy curtain with both hands. The resident went on over the bed and fell on to the floor. During an interview with RN 1 on 1/24/24 at 11:41 a.m., indicated she was Resident B's nurse on 12/22/23 when she fell out of bed. RN 1 indicated CNA 2 came running out and told her she had been providing incontinent care for Resident B and she had fell out of bed onto the floor. The resident had a huge laceration on the right eye brow and she attempted to get the bleeding to stop. RN 1 had CNA 2 get the Director Of Nursing and another nurse come help her. CNA 2 did not have another staff member assisting her with the resident's care. During an interview with RN 1 on 1/24/24 at 12:58 p.m., indicated the resident had on socks and hospital gown when she fell . The resident did not have on a brief. The resident had urinated on the floor when she fell . RN 1 indicated it was a struggle to clean the resident and put on the brief because they were trying not to move the resident. RN 1 indicated LPN 4 assisted her. During an interview with LPN 4 on 1/24/24 at 7:58 p.m., indicated she assisted with Resident B on 12/22/23 when she fell out of bed. LPN 4 indicated CNA 2 came to the nursing station and said she had rolled the resident over to clean her up and get her dressed and the resident grabbed the privacy curtain and rolled out of bed. The resident had a laceration above her right eye, the right side of her face was red and there was blood on the floor. LPN 4 held a washcloth on the resident's laceration to prevent blood from going into her eyes and held the resident's hand while RN 1 was vital signs. Resident B did not have on a brief and had urinated on the floor after she fell out of the bed. LPN 4 and RN 1 put a brief on the resident before the ambulance arrived. During an interview with Resident B Family member 2 on 1/25/24 at 11:57 a.m., indicated the resident should have never fallen out of bed on 12/22/23, the resident was suppose to have two staff when providing care. Family member 2 indicated she talked with the Administrator and the Director Of Nursing and they told her the resident was suppose to have to have 2 staff when providing care and they would ensure that she would have 2 staff from now on. Family member 2 indicated this was an unfortunate situation that should have never happened to begin with. Review of the record of Resident B on 1/24/24 at 1:17 p.m., indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease, diabetes, bipolar, dementia, pain, hypertension and depression. The Annual Minimum Data Set (MDS) assessment for Resident B, dated 11/30/23, indicated the resident was severely cognitive impaired for daily decision making. The resident was dependent with toileting needs and was always incontinent of bowel and bladder. The resident ability to roll from lying on back to left and right side, and returning to lying on back on the bed, the resident was dependent. The resident had a fall with a major injury. The State Optional MDS assessment for Resident B, dated 11/30/23, the resident required extensive assistance of two people for bed mobility and toileting need. The fall plan of care for Resident B, dated 11/30/23, indicated the resident at risk for falls related to dementia, arthritis, cancer, diabetes mellitus, history of falls, impaired mobility, non ambulatory, use of anti anxiety medication. The interventions included, but were not limited to, 2 staff to assist with bathing, turning and repositioning. The fall risk assessment for Resident B, dated 11/30/23, indicated the resident was disoriented x 3, chair bound, required assistance with elimination, and takes 3-4 medications that can contribute to falls, and 1-2 predisposing diseases that could contribute to falls. The progress note for Resident B, dated 12/22/23 at 6:40 a.m., Interdisciplinary Team (IDT) progress note indicated resident noted with fall during staff assistance. Nurse called to room, found resident on right side, laceration noted to right outer eyebrow, forehead , applied cold towel and pressure, notified the physician and orders to send to emergency room for evaluation and called Emergency medical Services, notified the daughter and care plan updated with bed moved to wall if daughter agreeable. The hospital note for Resident B, dated 12/22/3, indicated per report the resident fell out of bed while being cleaned this morning. The CAT SCAN (CT) of the head showed Parenchymal hemorrhage in the right frontal lobe, right parietal lobe and left parietal lobe (largest in the left parietal region) (bleeding in the brain). The resident was not a candidate for surgery and a hospice consult was obtained. The resident had a 2.5 centimeter (cm) laceration on the right eyebrow and 5 sutures was applied. During an observation on 1/26/24 12:27 p.m., CNA 2 and CNA 3 provided the Resident B with incontinent care, rolling the resident from side to side with total assist, the resident did not participate in the bed mobility. B.) During an observation on 1/22/24 at 1:41 p.m., Resident D was sitting in her recliner, the resident's call light was on the floor between the bed and the wall. The roommates call light was activated. CNA 2 came into the room and retrieved the resident's call light and indicated she would get a clip on the call light so she could clip it to her bed. The resident was observed to have one touch pad call light and not two as care planned. During an interview with Resident D's family on 1/23/24 at 1:14 p.m., indicated the resident fell in October 2023 and fractured her pelvis. During an observation on 1/25/24 at 11:11 a.m., Resident D was sitting in her recliner , the resident did not have a call light available it was located between the wall and bed on the floor. RN 1 came in and clipped the pad call light to the resident's bed. The resident was observed to have one touch pad call light and not two as care planned. Review of the record of Resident D on 1/29/24 at 12:00 p.m., indicated the resident's diagnoses included, but were not limited to, thrombocythemia, vascular dementia, major depressive disorder, history of transient ischemic attack, cerebral infarction, hyperlipidemia, urinary tract infection, Alzheimer's disease and pelvic fracture. The progress note for Resident D, dated 10/11/23 at 11:24 a.m., indicated the resident had a fall and was complaining of right groin pain. An order was received for an x-ray. Received x-ray and resident had a pelvic fracture. Called Orthopedics for an appointment. The Significant Change Minimum Data (MDS) assessment for Resident D, dated 10/28/23, indicated the resident was severely impaired for daily decision making. The resident required substantial/maximal assistance with toileting, putting on and taking off footwear. The resident had a fall with a major injury. The plan of care for Resident D, dated 1/2/23, indicated the resident was at risk for falls related to dementia, history of falls, history of transient ischemic attack and pelvic fracture. The interventions included, but were not limited to, 2 touch pad call lights on bed/chair and call light in reach, encourage resident to use it. and respond promptly to call light. During an interview with the Director Of Nursing (DON) on 1/25/24 at 3:30 p.m., indicated it was the responsibility of all nursing staff to ensure Resident D's fall interventions were in place and her call light was within reach. The fall management policy provided by the Administrator on 1/26/24 at 10:50 a.m., indicated the purpose was to protect residents and promote safety. The call light policy provided by the Administrator on 1/26/24 at 10:50 a.m., indicated the resident's call light was to be within reach. This Federal tag relates to Complaint IN00425076. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview, observation, and record review, the facility failed to complete self-administration assessment for a resident that self-administers nasal spray for 1 of 1 resident reviewed for self-administration. (Resident 37) Findings include: The clinical record for Resident 37 was reviewed on 1/24/2023 at 11:30 a.m. The medical diagnosis included paranoid schizophrenia. A physician order for Resident 37, dated 12/7/2021, indicated for him to utilize a nasal spray that may be kept at the bedside and self-administered. An observation on 1/22/2024 at 11:05 a.m. indicated Resident 37 sitting in his recliner with a bottle of nasal spray on the table next to him. An observation and interview with Resident 37 on 1/22/2024 at 1:30 p.m. indicated that he utilized nasal spray for the last few years for congestion. The staff will order more when he runs low, but he is able to take care of giving himself the nasal spray. An interview with the DON on 1/25/2024 at 1:00 p.m., indicated that they did not have a self-administration assessment for Resident 37. A policy entitled, Medication Administration-Prerpation and General Guidelines, was provided by the Administrator on 1/25/2024 at 2:50 p.m. The policy indicated, .For those resident who self-administer, the interdisciplinary team verified the resident's ability to self-administer medication by means of a skill assessment conducted on a [quarterly] basis or when there is a significant change in condition . [sic] 3.1-11(a)

Based on observation, interview and record review the facility failed to provide fresh water daily for 2 of 5 residents reviewed for hydration (Resident D and Resident 45). Findings include: 1.) During an observation on 1/22/24 at 1:45 p.m., Resident D was sitting in her recliner, there was no water pitcher in the room. Resident D indicated she has a faucet in the bathroom that she could get water out of. During an observation on 1/23/24 at 10:49 a.m., Resident D was sitting in her recliner with no water pitcher in her room. During an observation and interview on 1/23/24 at 1:12 p.m., Resident D and her family was visiting in the resident's room, the resident did not have any water available. Resident D's family searched the resident's room for her water pitcher and was unable to locate it. Resident D's family indicated they were unsure why the resident did not have water available. During an observation on 1/24/24 at 11:22 a.m., Resident D was sitting in her recliner with no water pitcher in her room. During an observation and interview on 1/24/24 at 1:06 p.m., Resident D was sitting in her recliner with no water pitcher in her room. The resident searched her room for her water pitcher and was unable to find one. The resident indicated staff must have forgotten to give her water. During an observation on 1/25/24 at 11:11 a.m., Resident D was sitting in her recliner with no water pitcher in her room. Review of the record of Resident D on 1/29/24 at 12:00 p.m., indicated the resident's diagnoses included, but were not limited to, thrombocythemia, vascular dementia, major depressive disorder, history of transient ischemic attack, cerebral infarction, hyperlipidemia, urinary tract infection, Alzheimer's disease and pelvic fracture. The plan of care for Resident D, dated 2/7/23, indicated the resident had the potential for fluid deficit related to dementia. The interventions included, but were not limited to, encourage fluid intake, Offer fluids between meals and water pitcher at bedside. The dehydration assessment for Resident D, dated 11/2/23, indicated the resident was independent with fluid intake. 2.) During an observation on 1/23/24 at 11:14 a.m., Resident 45 was sitting in a recliner in the telephone room with a bedside table beside her with no fluids available. Interview with RN 1 indicated the resident never stayed in her room, she preferred to sit in the telephone During an observation on 1/23/24 at 1:32 p.m., Resident 45 was sitting in a recliner in the telephone room with a bedside table beside her with no fluids available. During an observation on 1/24/24 at 11 a.m., Resident 45 was sitting in a recliner in the telephone room with a bedside table beside her with no fluids available. During an observation on 1/25/24 at 11:01 a.m., Resident 45 was sitting in a recliner in the telephone room with a bedside table beside her with no fluids available. Review of the record of Resident 45 on 1/29/24 at 11:40 a.m., indicated the resident's diagnoses included, but were not limited to, dementia, anxiety, hyperlipemia and diverticulosis. The dehydration risk assessment for 45, dated 1/2/24, indicated the resident required limited assist with fluid intake, incontinent of urine, had 1-3 predisposing factors and took 1-3 medications of consideration for dehydration. The plan of care for Resident 45, dated 3/13/23, indicated the resident had potential for fluid deficit related to dementia and use of diuretic medication. The interventions included, but were not limited to, encourage fluid intake and keep fluids within reach. During an interview with the Director Of Nursing (DON) on 1/25/24 at 3:45 p.m., indicated it was the responsibility of all nursing staff to ensure Resident D and Resident 45 was provided fluids. The protocol was fluids were passed every shift. The hydration policy provided by the Administrator on 1/26/24 at 10:50 a.m., indicated the facility would offer each resident sufficient fluid, including water and other liquids, consistent with the resident needs and preferences to maintain proper hydration and health. 3.1-3(v)(1)

Based on interview and record review the facility failed to provide a resident with her choice and preference to when she went to bed for 1 of 2 residents reviewed for choices (Resident 56). Finding include: During an interview with Resident 56 on 1/22/24 at 12:52 p.m., indicated she did not feel like her right to choose was honored by the facility. The resident indicated the staff put her to bed at 7:00 p.m., and she preferred to go to bed at 9:00 p.m. or later,. The resident indicated she had talked to the facility about her preference about her bedtime, but they continue to assist her to bed at 7:00 p.m. Review of the Resident 56 on 1/25/24 at 2:00 p.m., indicated the resident's diagnoses included, but were not limited to, dementia, chronic kidney disease, depression, anxiety, osteoarthritis and history of falling. The activity interview and preferences for Resident 56, dated 12/12/23, indicated it was very important to choose her own bedtime. The resident preferred to go to bed after 9:00 p.m., 10:00 p.m., or later. The resident was a late night person. The plan of care for Resident 56, dated 12/13/23, indicated the resident required assistance with Activities of Daily Living (ADL) related to impaired mobility. The interventions include, but were not limited to, bedtime as preferred. During an interview with Minimum Data Coordinator 1 on 1/25/24 at 2:05 p.m., indicated it was communicated to the CNA's what resident's preferences were on plan of care. The resident rights policy provided by the Administrator on 1/26/24 at 10:50 a.m., indicated each resident had the right to choose his/her own activities, schedules including sleeping and waking times. 3.1-3(u)(1)

Based on interview and observation, the facility failed to submit a Discharge or Death Entry Minimum Data Set (MDS) assessment for Resident 48 and failed to accurately code specialized services for Resident 32 for 2 of 2 residents reviewed for MDS assessment accuracy. Findings include: 1. The clinical record for Resident 48 was reviewed on 1/25/2024 at 12:57 p.m. The last MDS assessment for Resident 48 was an admission MDS on 8/28/2023. A nursing progress note, dated 8/30/2023, indicated Resident 48 had passed away. No discharge/death MDS completed. 2. The clinical record for Resident 32 was reviewed on 1/23/2024 at 1:47 p.m. A MDS assessment, dated 11/2/2023, indicated Resident 32 was receiving specialized services of chemotherapy, oxygen therapy, suctioning, tracheostomy care, invasive and non-invasive ventilation, IV medications, dialysis, transfusion, hospice, and isolation. These services were not reflected in the medical record. An interview with the MDS nurse on 1/25/2024 at 2:00 p.m. indicated that the death/discharge assessment for Resident 48 was missed and the specialized services for Resident 32 were coded incorrectly. She would enter a modification for Resident 32's assessment and enter the death/discharge assessment for Resident 48. A policy entitled MDS 3.0 Completion, was provided by the Administrator on 1/25/2024 at 2:50 p.m. The policy indicated that MDS assessments should be standardized and accurate, and that Death Tracking should be completed within seven calendar days of the of the discharge (death) date.

Based on observation, interview and record review, the facility failed to develop a care plan for 1 of 2 residents reviewed for skin tears. (Resident 111) Findings include: On 1/23/24 at 2:05 p.m., Resident 111 was observed sitting in a chair by the nurse's station on the South Unit. The area was above her right wrist, oval in shape and scabbed with a black color. Resident 111's record was reviewed on 1/25/24 at 1:32 p.m. and indicated diagnoses that included, but were not limited to, weakness, heart disease, and high blood pressure. An Admission Minimum Data Set assessment, dated 1/9/24, indicated Resident 111 was severely impaired in cognitive skills for daily decision making, and had a skin tear. Progress notes, dated 1/3/24 at 11:30 a.m., indicated: resident in MDR (main dining room) playing noodle ball with peers, called to MDR and resident has 2 skin tears to her right forearm. 1cm (centimeter) x 1cm x 0.1cm and 0.5cm x 0.5cm x 0.1cm. Treatment applied to arm. On 1/29/24 at 1:36 p.m., the Administrator indicated they did not have a care plan for the skin tear. A policy for Comprehensive Care Plans was provided by the Administrator on 1/25/24 at 2: 50 p.m. The policy included, but was not limited to: 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 includes 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. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being .Resident specific interventions that reflect the resident's needs and preferences 3.1-35(a) 3.1-35(b)(1)

Based on interview and observations, the facility failed to promote a clean environment for Resident 35 by having dried fecal matter on his toilet and a dried brown substance on his bed linens for 1 of 2 residents reviewed for clean environment. Findings include: The clinical record for Resident 35 was reviewed on 1/25/2024 at 10:55 a.m. The medical diagnosis included Parkinson's disease and chronic respiratory failure. A Quarterly Minimum Data Set Assessment, dated for 12/28/2023, indicated that Resident 35 was cognitively intact. An observation and interview with Resident 35 on 1/22/2024 at 1:19 p.m. indicated that his bathroom had dried fecal matter on the toilet bowl and debris on the floor. He stated that they don't clean his bathroom often or always change his linens. An observations on 1/23/2024 at 1:08 p.m. of Resident 35's room indicated he continues to have dried fecal matter on his toilet bowl and dried brown substance on his linens. An interview with the Administrator on 1/25/2024 at 1:15 PM indicated that it is the housekeeping and nursing staff's responsibility to ensure rooms are kept cleaned. A policy entitled, Safe and Homelike Environment, was provided by the Administrator on 1/25/2024 at 2:50 p.m. The policy indicated, .the facility will provide a safe, clean, comfortable and homelike environment . 3.1-19(f)

Based on interview and record review the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being in that staff failed to immediately ensure the physician was aware of the residents decline of condition in relation to [MEDICATION NAME] (blood thinner) therapy, continually monitor the effects of [MEDICATION NAME] and failed to ensure 2 of 3 residents reviewed for [MEDICATION NAME] were promptly treated when they experienced bleeding from the nose, blood in the urine, dark tarry stools and vomiting dark brown liquid while receiving [MEDICATION NAME] therapy and required hospitalization in a sample of 15. (Resident #A and #B) This deficient practice resulted in an Immediate Jeopardy (IJ). An Immediate Jeopardy was identified on 2/11/11 at 1:20 p.m. The IJ began on 10/3/10 at 8:15 a.m., when through record review and interview it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being in that staff failed to immediately ensure the physician was aware of the residents decline of condition in relation to [MEDICATION NAME] (blood thinner) therapy, continually monitor the effects of [MEDICATION NAME] The Administrator, Heritage House group manager and Director of Nursing (DON) were notified of the IJ on 2/11/11 at 1:20 p.m. The IJ was removed on 2/14/11 at 5:05 p.m., but the facility remains out of compliance at a level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been inserviced and the continued need to interview and monitor staff's knowledge regarding the risks of [MEDICATION NAME] therapy. Findings include: 1.) A document provided by the Administrator on 2/9/10 at 3:35 p.m., titled "Anticoagulant Therapy" undated, indicated the following: Purpose, To ensure safe delivery of anti-coagulant therapy for residents in facility. Policy: It is the policy of this facility that residents receiving anti-coagulant (blood thinner) will receive laboratory blood tests that support the dosage as ordered and determined by the physician. Action: Prior to giving the anti-coagulant medication, the licensed nurse will ensure the medical chart contains evidence of the laboratory test results and that the physician has been advised of the result. a.) The physician will be paged for any questions concerning the provision of the anti-coagulant therapy medication, prior to administering it to the resident. b.) Side effects of the medication will be documented and physician will be advised: i.e. hematuria, bleeding from gums or other orifices (opening through which something may pass), excessive bruising; [MEDICAL CONDITION] intestinal bleeding symptoms.... 2.) The record of Resident #A was reviewed on 2/8/11 at 1:20 p.m. Resident #A's [DIAGNOSES REDACTED]. Resident #A's Minimum Data Set (MDS) assessment, dated, 10/18/10, indicated the following: "- ability to express ideas and wants, understood - ability to understand others, understands - able to report correct year, missed by 2-5 years - able to report correct month, missed by 6 days to 1 month - able to report correct day of the week, incorrect - able to recall 'sock', yes - able to recall 'blue', no - able to recall 'bed', no" Resident #A's physician order [REDACTED]." Resident #A's laboratory reports indicated PT ([MEDICATION NAME] time)/INR(international normalized ratio), (bleeding times) levels (normal PT 9.5-11.7/INR 2-3) as follows: - 8/19/10, PT 11.5/INR, 1.1 - 9/7/10, PT, 15.4/INR, 1.45 - 9/10/10, PT, 10.9/INR, 1.02 - 9/14/10, PT, 11.0/INR, 1.03 - 10/3/10 at 3:58 p.m. PT, over 125/INR, unable to calculate - 10/4/10 at 12:40 a.m., PT, over 125/INR, unable to calculate The documentation indicated Resident #A's [MEDICATION NAME] was increased from 2.5 mg to 5 mg on 9/7/10. Documentation of the PT/INR labs were checked on 9/7/10, 9/10/10 and 9/14/10 but no other PT/INR were obtained until 10/3/10 when Resident #A exhibited a nose bleed that lasted approximately 8 minutes. On 2/11/11 at 3:15 p.m. during an interview with the DON regarding the lapse of time for the PT/INR labs the DON stated "the PT/INR were monitored on 9/10/10 and 9/14/10 after the [MEDICATION NAME] was increased to 5 mg. on 9/7/10 and were all too low. Lippincott's, Pocket Manual of Nursing Practice, second edition, "monitoring of [MEDICATION NAME] therapy indicates: PT monitors oral anticoagulant therapy-INR should be greater than 2.0-2.5, or higher based on condition being treated." Patricia Dwyer Schull's, 2010 Nursing Spectrum Drug Handbook, "[MEDICATION NAME] warning, may cause major or fatal bleeding. Bleeding is more likely during starting period and with higher dosage (resulting in higher INR) monitoring . Monitor INR regularly in all patients. Those at high risk bleeding may benefit from more frequent INR monitoring, and careful dosage adjustment." Resident #A's nursing notes indicated the following: "- (Sunday), 10/3/10 at 8:15 a.m., Client had nose bleed (moderate amount) [MEDICATION NAME] approximately 8 minutes, pressure applied, physician faxed. Will monitor - 10/3/10 at 1:30 p.m., Client had nose bleed moderate amount called physician, left message (on call physician) waiting return call - 10/3/10 at 1:48 p.m., New order received and noted stat (immediately) PT/INR - 10/3/10 at 2:20 p.m., After going to (local hospital) laboratory to obtain supplies, attempted times 2 to obtain blood for laboratory unsuccessful - 10/3/10 at 2:30 p.m., Attempted blood draw right antecubital (arm in front of elbow), vein blew - 10/3/10 at 3:05 p.m., PT/INR drawn left leg times 1 stick, lab slip/blood taken to (local hospital) laboratory. Informed on coming nurse of order for stat results to be called to (physician on call) - 10/3/10 at 5:00 p.m., Received lab results from (local hospital) laboratory - 10/3/10 at 5:15 p.m., Lab results faxed to physician and left message for (on call physician) - 10/3/10 at 5:45 p.m., New order received to hold 8:00 p.m., [MEDICATION NAME], (local hospital ran wrong lab) new order to draw resident again at 12:00 a.m., 10/4/10 and again at 8:00 a.m., 10/4/10 - 10/4/10 at 12:35 a.m., Exhibited urine rose colored, bowel movement dark black. Obtained blood specimen after 2 times, sticks with butterfly draw for PT/INR, right lower extremity - 10/4/10 at 2:35 a.m., (name) from laboratory called with high critical, over 125 PT. This nurse notified on call (name) physician and received new order. Continue holding [MEDICATION NAME] until further notice from physician. Repeat PT/INR at 8:00 a.m., if resident starts bleeding again send to emergency room - 10/4/10 at 8:35 a.m., Blood specimen drawn for PT/INR, no blue top available. Sent specimen with no needle in place. Syringe 6 cc (cubic centimeters) noted. Transferred to (local hospital) laboratory per staff - 10/4/10 at 9:30 a.m., Staff reported lab through (sic) specimen into trash. Called lab and lab related specimen clotted, unable to test. Related would send someone to draw between 10:30 a.m. and 11:00 a.m. - 10/4/10 at 10:15 a.m., Client has nose bleed moderate amount [MEDICAL CONDITION] intact stool black/tarry, also has rose colored urine - 10/4/10 at 10:30 a.m., Report called to (local hospital) emergency room , ambulance call to transport to local emergency room per physician orders - 10/4/10 at 10:40 a.m., Ambulance here to transport to (local hospital) emergency room per physician orders - 10/4/10 at 2:30 p.m., Called (local hospital) emergency room to check on client. Spoke with (name), was informed that client is being admitted to (local hospital) intensive care unit (ICU)" Resident A's physician was not notified after the 10/4/10 nursing note at 12:35 a.m. when she exhibited rose colored urine and a dark black bowel movement. Resident #A's hospital's "History and Physical" dated 10/4/10, indicated "Chief complaint: Elevated PT with epistaxis (nose bleed) and hematuria (blood in urine). History of present illness: The patient is a [AGE] year old white female...who presented to the emergency room with a highly elevated pro time (PT). The entire history is provided by the daughter who was present as well as the emergency room record. Apparently for the last 2 days, she has had (pro times) that were unable to be calculated since they were extremely elevated. The staff at the Heritage House, where she is a resident, noted that she had some mild nose bleed as well as dark stool and blood in the urine was noted as well. When she was seen in the emergency room , it was noted that she had a pro time that was greater than 125 and the INR was unable to be calculated since it was so high. The daughter states that there was no recent fever or chills, nausea, vomiting, abdominal pain, chest pain, shortness of breath or other difficulty. She was in her normal state of health. Apparently she is somewhat debilitated, has a poor appetite at times, but otherwise does seem to ambulate with assistance and is able to feed herself." Interview with Resident #A's family member on 2/10/11 at 1:05 p.m., indicated Resident #A was bleeding from her nose and kidneys with PT/INRs critically high and she had to remain in the ICU and her PT/INRs had not been obtained for 20 days. Interview with staff LPN #3 on 2/10/11 at 9:20 a.m., indicated the lab from the hospital does regular lab draws on Tuesday and Friday but if we have an order for [REDACTED]. Interview with the Director of Nursing (DON) on 2/10/11 at 9:35 a.m., indicated the facility did not have any vials for blood draws in the building at this time because the vials expire and they have to be throw away. She indicated we either get them from the lab staff on the days they are at the facility to do their lab draws or we get them from the hospital at the time that they are needed. Interview with DON on 2/11/10 at 10:10 a.m., indicated the facility did not have a policy with guidelines on if the staff should call or fax the physician with a change in the condition of a resident but the nurses are only to fax the physician if it is not a pertinent problem. For an immediate response and in the evening or on the weekend the nurse should call the resident's physician or the physician on call. She also indicated if the nurse didn't agree the resident was receiving the treatment they needed to call the Medical Director but they did not have a policy for that and that had never happened. Interview with the Administrator on 2/11/10 at 11:00 a.m., indicated the nurses had not had an inservice on [MEDICATION NAME] therapy. Interview with the Administrator on 2/15/11 at 2:30 p.m., stated "we (DON) have no idea why the nursing notes say the hospital ran the wrong lab. The nurse that wrote that is no longer here. I called the hospital and they do not know anything about it." 3.) Resident #B's bedroom was observed on 2/11/11 at 9:23 A.M. An emesis basin was on a small kitchen table with dried black coffee ground emesis on the bottom and sides of the basin. An interview with CNA #2 on 2/11/11 at 9:30 A.M., indicated Resident #B had been sent to the local hospital that morning. CNA #2 indicated Resident #B had been sent to the local hospital quickly and the emesis basin had not been cleaned yet. Resident #B's record was reviewed on 2/11/11 at 10:00 A.M. [DIAGNOSES REDACTED]. Resident #B was admitted from home to a local hospital on [DATE], and then admitted to the facility from the local hospital on [DATE]. A review of Resident #B's systems on a dictated note at the local hospital dated 1/26/11, indicated Resident #B was positive for bedsore, increasing [MEDICAL CONDITION] congestion with gurgles, shortness of breath, increasing weakness with increasing difficulty walking, left hand [MEDICAL CONDITION], and bilateral lower extremity [MEDICAL CONDITION]. The local hospital note indicated Resident #B had progressive debilitation, and was barely able to ambulate back and forth to the restroom. Facility admission orders [REDACTED]. A [MEDICATION NAME] care plan for Resident #B indicated the following: Problem - Potential for hemorrhage related to anticoagulant therapy. Goal - Resident will be free of signs/symptoms of hemorrhage through next review. Approach - Monitor for signs of bleeding, black tarry stools, bruising, hematuria, headache, nose bleeds, etc... and report to the physician. A physicians order dated 2/2/11, indicated Resident #B to have a Pro-time (PT)/International ratio (INR) drawn 2/7/11. Lab results for resident #B on 2/8/11, indicated a PT result of 72.9, and INR result of 7.08. The normal range for PT is 9.5 to 11.7, and the normal range for INR is 2.0 to 3.0. Local hospital lab values indicated normal PT 9.5-11.7/INR 2-3. Lippincott's, Pocket Manual of Nursing Practice, second edition, "monitoring of [MEDICATION NAME] therapy indicates: PT monitors oral anticoagulant therapy-INR should be greater than 2.0-2.5, or higher based on condition being treated." A physicians order dated 2/8/11, indicated to hold Resident #B's [MEDICATION NAME] until after lab results on Friday 2/11/11. Re-check PT/INR on 2/11/11. Encourage the resident to eat green vegetables. Nurses notes for Resident #B indicated the following: 2/10/11 at 9:30 A.M. - Vital signs = B/P 148/97, pulse 54, respirations 18, and temperature 98.0. The resident is agitated this A.M., stating "nurse didn't give me my mediation". Explained to the resident a Qualified Medication Aide (QMA) had given the resident her medications, and the resident was witnessed taking them by other staff. 2/10/11 at 6:25 P.M. - The resident was given mediations and explained exactly what they were. Once I left the room she asked the Director of Nursing (DoN) for the same medications she had just received. The resident was given medication for nausea. A fax was sent to the physician on 2/10/11 at 7:19 P.M. . The fax indicated the following comments: The resident has been vomiting dark brown liquid. The resident states she hasn't eaten very much today. She has been drinking 7-up in small sips. Nurses notes for Resident #B indicated the following: 2/10/11 at 9:00 P.M. - Vital signs = B/P 188/82, temperature 98.0, pulse 62, and respirations 18. Vomiting most of the evening, dark brown liquid. The resident stated "someone put my meds in my water". No medications had been given at that time. Nurses notes for Resident #B indicated the following: 2/11/11 at 7:30 A.M. - Called to residents room by QMA. The resident is confused - speech irrational, skin cool, dry, and pale. Vomited moderate amount of dark coffee ground consistency emesis - hema-tested positive. Oxygen saturation 70's - placed on 3 liters oxygen at this time. Oxygen saturation increased to 88%. Vital signs = B/P 128/95, pulse 51, and respirations 20. Called M.D. on call with information and condition of resident. Note Dr's order. 2/11/11 at 7:40 A.M. - Called the sheriffs department for transport, and the local hospital emergency room (ER) with report. 2/11/11 at 7:45 A.M. - Sheriff department here to transport resident to local hospital ER. 2/11/11 at 8:30 A.M. - Received call from local hospital ER. Staff explained current [MEDICATION NAME] orders - holding, and PT/INR drawn this A.M. 2/11/11 at 9:30 A.M. - Received call from local hospital lab - PT/INR critical at 9.61 INR - Local hospital lab notified ER and M.D. An interview with RN #1 on 2/11/11 at 11:05 A.M., indicated she reported to work on 2/10/11 at 10:30 P.M., and received report. RN #1 received in report Resident #B was given [MEDICATION NAME] the evening of 2/10/11 for nausea, and as far as she knew it was effective. RN #1 indicated she was unaware that Resident #B had been vomiting the evening of 2/10/11. RN #1 indicated Resident #B rested most of the night. A CNA had called RN #1 to Resident #B's room between 4:30 A.M., and 5:00 A.M. RN #1 listened to Resident #B's breath sounds - clear, and bowel sounds - active times 4 quadrants with the left lower quadrant hyperactive. RN #1 had the CNA check Resident #B's bowel record and the CNA reported - no bowel movement in 3 days. RN #1 indicated she noted the basin with dried coffee ground emesis when she was helping get vital signs to send Resident #B to the local ER the morning of 2/11/11. RN #1 indicated she had not documented her charting for Resident #B on the night shift yet. On 2/11/11 at 12:30 P.M., the following nurses notes were documented, that were not documented when the record was reviewed on 2/11/11 at 10:00 A.M. 2/10/11 at 11:40 P.M. - The resident is in bed alert, skin warm and dry, respirations even and non-labored, oxygen infusing at 2 liters per nasal canula, and abdomen soft with bowel sounds noted times 4 quadrants. No distress exhibited at this time. Exhibits some confusion at times. Call light in reach. 2/11/11 at 2:30 A.M. - The resident is in bed resting with her eyes closed, respirations even and non-labored, oxygen infusing at 2 liters per nasal canula. Call light in reach. 2/11/11 at 5:00 A.M. - The resident is in bed, alert, very drowsy, exhibits increased confusion, lungs are clear to ascultation, abdomen soft with bowel sounds noted times 4 quadrants with left lower quadrant hyperactive, verbally responsive when asked questions. Call light in reach. Vital signs = Respirations 20, and oxygen saturation 90%. Offered water to drink. The resident responded "there is no water in there". Held cup up to resident lips, and she drank two sips. The head of the bed is raised for comfort. An interview with the DoN on 2/11/11 at 1:15 P.M., indicated no response was available in Resident #B's record in regard to the fax sent to the Physician on 2/10/11 at 7:19 P.M., concerning Resident #B vomiting. The DoN indicated the facility had no way to determine if the physician reviewed a fax unless the facility received a response. A nurses note dated 2/11/11 at 2:00 P.M., indicated the following: Received call from local hospital - resident admitted to Intensive Care Unit. An Immediate Jeopardy was identified on 2/11/11 at 1:20 p.m. The IJ began on 10/3/10 when a resident on [MEDICATION NAME] therapy who had not had a PT/INR to monitor her bleeding time for 20 days experienced a nose bleed [MEDICATION NAME] approximately 8 minutes and the physician was not promptly notified. When a laboratory test was ordered the facility did not have the equipment to obtain the lab draw. The Administrator, Heritage House group manager and Director of Nursing (DON) were notified of the IJ on 2/11/11 at 1:20 p.m. The IJ was removed on 2/14/11 at 5:05 p.m. when through record review and interviews, it was determined that the facility had implemented the plan of action to remove the IJ and that the steps taken removed the immediacy of the problem. The facilities new policy on when to fax or call the physician, where to find vials for laboratory tests and inservices on [MEDICATION NAME] therapy were reviewed. Nurses were interviewed on their knowledge of the new policies and [MEDICATION NAME] therapy. Even though the facilities corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity level of isolated no actual harm with potential for more than minimal harm. This federal tag relates to complaint IN 511. 3.1-37(a)

Based on interview and record review, the facility failed to ensure that medications were properly administered and residents properly monitored while taking their medication to ensure the correct resident takes the correct medication for 1 resident of current population of 66 residents. (Resident A) Findings include: Resident A's record was reviewed on 9-21-10 at 3:50 p.m. Her [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 7-1-10, indicated she has short term and long term memory problems and is moderately impaired in the ability to make reliable and reasonable decisions regarding tasks of daily living. The MDS indicated she required extensive assistance of 1 to 2 persons in ambulating, dressing, eating, personal hygiene and toileting. In interview with a family member on 9-21-10 at 2:55 p.m., he indicated Resident A recently had taken the morning medications of a fell ow resident that was seated at the same dining table. He indicated on that particular morning, the staff member provided the morning medications as usual to Resident A and observed her take the medications. However, he indicated, the fell ow resident wished to finish his breakfast and his medications were still sitting in the medicine cup beside his plate. He indicated he was unsure of exactly what happened next, but Resident A then took the other resident's medication, too. He indicated the resident was monitored closely and when her blood pressure dropped down, she was sent to the emergency room to be checked out. He identified the staff person as QMA #1. In review of the record, nursing notes indicated on 8-1-10 at 8:25 a.m., a Certified Nursing Assistant (CNA) informed Registered Nurse (RN) #1 that Resident A had taken another resident's morning medication after the other resident had gone to the restroom and left his medication on the dining table. Upon return to the table, the other resident asked where his medication was. The CNA indicated she had observed Resident A take the medications. Vital signs at this time were within normal range. The physician was notified of the situation and provided an order to check her vitals signs hourly for the next 12 hours and to send her to the emergency room if her heart rate dropped below 50. The nursing notes indicated close monitoring of the resident and vital signs with vital signs within normal range, until assessed at 1:15 p.m. At 1:15 p.m., nursing notes indicated her blood pressure was low at 70/48 and the physician was again notified. Notes indicated at 1:35 p.m., the physician indicated he wished for the resident to be evaluated at the local emergency room . A hospital transfer summary, dated 8-2-10, indicated Resident A had inadvertently taken the medications of another resident. The medications listed that the resident took [MEDICATION NAME] mg (blood pressure medication,) [MEDICATION NAME] 1 mg (anti-anxiety medication,) [MEDICATION NAME] 5 mg (blood pressure medication,) [MEDICATION NAME] XL 50 mg (blood pressure medication,) and one multi-vitamin. The summary indicated upon admission, the resident's blood pressure was low at 70/40. The summary indicated the resident remained in the hospital for observation, intravenous (IV) fluid hydration and close monitoring. The summary indicated Resident A did well and was returned to the facility the following day in stable condition. This federal tag relates to complaint number IN 027. 3.1-48(c)(1) 3.1-48(c)(2)