Brickyard Healthcare - Elkhart Care Center

Based on record review and interview, the facility failed to ensure physician's orders regarding blood pressure medications were followed for 1 of 3 residents reviewed for quality of care. (Resident B)Finding includes:A record review for Resident B was completed on 1/12/2026 at 9:30 A.M. Diagnoses included, but were not limited to: congestive heart failure, chronic kidney disease stage 3, diabetes mellitus type 2 and acute metabolic acidosis.An admission Minimum Data Set (MDS) assessment, dated 11/6/2025, indicated Resident B was cognitively intact.A Physician's order, dated 11/5/2025, indicated the resident was to receive metoprolol 25 milligrams twice daily for hypertension. The order indicated the medication was to be held for a systolic blood pressure reading of less than 110 mm/Hg (millimeters of Mercury) or a pulse less than 60 beats per minute.A Medication Administration Record (MAR), for the month of November 2025 indicated the metoprolol medication had been administered on 11/22/2025 even though the resident's blood pressure was 102/42 mm/Hg.A MAR for the month of December 2025 indicated metoprolol had been administered on 12/20/2025 even though the resident's blood pressure was 102/80 mm/Hg. The medication was also administered on 12/21/2025 even though the resident's blood pressure was 104/73 mm/Hg.During an interview, on 1/16/2026 at 11:26 A.M., the Assistant Director of Nursing indicated nursing staff should have followed the physician's orders.A policy, titled, Provisions of Physician Ordered Services, was provided on 1/16/2026 at 11:41 A.M. The policy indicated, .The purpose of this policy is to provide a reliable process for the proper and constituent provision of physician ordered services according to professional standards of quality .This citation relates to Intake 27044933,1-37

Based on record review and interview, the facility failed to notify a personal representative at the request of the resident of new orders and a change of condition for 1 of 3 residents reviewed for notification of changes. (Resident B)Finding includes:A record review for Resident B was completed on 1/12/2026 at 9:30 A.M. Diagnoses included, but were not limited to: congestive heart failure, chronic kidney disease stage 3, diabetes mellitus type 2 and acute metabolic acidosis.An admission Minimum Data Set (MDS) assessment, dated 11/6/2025, indicated Resident B was cognitively intact. The 11/7/2025 3:28 P.M. Resident preferences evaluation indicated it was very important for the Resident to have their family or a close friend involved in their care.A Social Services note, dated 11/11/2025 at 4:39 P.M. indicated the resident had stated she wanted her granddaughter to be her emergency contact. Although the admission MDS assessment indicated the resident was cognitively intact, nursing progress notes on the following dates and times indicated the resident was exhibiting confusion and her confusion was chronic: 11/13/2025 at 4:09 P.M., 11/15/2025 at 4:11 P.M., 11/18/2025 at 3:37 P.M., 11/22/2025 at 7:18 P.M., 11/23/2025 at 12:41 A.M., 11/30/2025 AT 11:40 P.M. , 12/6/2025 at 7:37 P.M., 12/7/2025 at 6:17 P.M. and 12/21/2025 at 5:00 A.M.A General Nursing Progress Note, on 11/6/2025 at 8:56 A.M., indicated new orders had been obtained from the facility nurse practitioner for labs, melatonin 5 milligrams daily at bedtime and acetaminophen 325 milligrams two tablets daily at bedtime. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 11/13/2025 at 9:05 A.M., indicated new orders had been received for acetaminophen 325mg two tablets every six hours as needed for pain, metformin 1000 milligrams twice daily, lispro insulin four units before meals, prednisone 10 milligrams daily for COPD (chronic obstructive pulmonary disease) and Robitussin DM 10 milliliters every six hours for cough. Resident B's personal representative had not been notified of the new orders.A Physician's Note, on 11/25/2025 at 1:26 A.M., indicated Resident B had been seen for an acute visit for dehydration related to an increased laboratory result of a bun urea nitrogen (BUN). The physician ordered two liters of normal saline.An Alert Nursing Progress Note, on 11/25/2025 at 8:46 A.M., indicated new orders had been received for normal saline intravenously for two liters at 157 milliliters per hour related to high Bun results. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 11/26/2025 at 6:03 P.M., indicated urinalysis results had been received and new order for Macrobid 100 milligrams twice daily for five days related to a urinary tract infection. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 12/4/2025 at 8:26 A.M., indicated Keflex 500 milligrams every six hours for seven days related to cellulitis of the right leg. Resident B's personal representative had not been notified of the new orders.An Alert Nursing Progress Note, on 12/4/2025 at 6:59 P.M., indicated normal saline per hypodermoclysis 50 milliliters per hour for two liters due to a high BUN laboratory result. Resident B's personal representative had not been notified of the new orders.A General Nursing Progress Note, on 12/15/2025 at 4:39 P.M., indicated a new order for furosemide 40 milligrams daily due to excessive fluid seeping from bilateral lower extremities. Resident B's personal representative had not been notified of the new orders.A General Nursing Progress Note, on 12/16/2025 at 4:54 P.M., indicated new orders had been received for an increase in Lantus insulin to 15 units twice daily. Resident B's personal representative had not been notified of the new orders.A General Nursing Progress Note, on 12/17/2025 at 3:10 P.M., indicated Resident B had complained of chest pain. A new ordered had been obtained for nitroglycerin 0.4 milligrams every two hours as needed for chest pain. An initial dose had been given. Resident B's personal representative had not been notified of the change in condition or the new orders.A General Nursing Progress Note, on 12/17/2025 at 3:37 P.M., indicated a new order for a two-view chest x-ray. Resident B's personal representative had not been notified of the new orders.During an interview, on 1/12/2026 at 2:31 P.M., Resident B's emergency contact indicated she had not been informed of her grandmother's changes of condition nor updated on new orders received by the facility. She indicated her grandmother had periods of confusion and would not understand the orders that had been ordered for her conditions.During an interview, on 1/14/2026 at 9:46 A.M., the Assistant Director of Nursing indicated the family of Resident B should have been updated on any change of condition.A policy was provided, on 1/16/2026 at 11:44 A.M., by the Executive Director. The policy titled, Notification of Change, indicated, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there I a change requiring notification.Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.3. Circumstances that require a need to alter treatment. That may include: a. New treatment.Additional considerations: 1. Competent individuals a. The facility must still contact the resident's physician and notify resident representative, if known. B, A family member that wishes to be informed would designate a member to receive calls. C. When a resident is medically competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.This citation relates to Intake 27044933.1-4(l)(4)(A)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse, for 1 of 3 residents reviewed for abuse and neglect. (Resident B).Finding includes:On 10/1/25 at 12:16 P.M., Resident B's clinical record was reviewed. Diagnoses included but were not limited to multiple sclerosis, mild cognitive impairment, depression, epilepsy, anxiety, and mood disorder. Review of the resident's most recent Minimum Data Set (MDS), dated [DATE] for a Quarterly Assessment, indicated the resident was mildly cognitively impaired, had demonstrated verbal behaviors directed at others and had other behaviors not directed at others for 1 to 3 days of the assessment 7 day look back period. In addition, the assessment indicated Resident B utilized a motorized wheelchair independently for locomotion and was dependent on others for transferring, toileting, and bathing.A Nursing Progress Note, dated 7/4/25 at 9:00 A.M., indicated CNA 5 had answered Resident B's call light and was then was observed and heard coming out of the resident's room screaming. CNA 5 indicated that Resident B had ran over their foot with her motorized wheelchair, which caused the CNA pain. The Nursing Progress Note indicated Resident B immediately came out of the room in the motorized wheelchair, at a high rate of speed , coming right behind CNA 5. The resident indicated CNA 5 had hit her in her throat and pushed her into her chair. The Nursing Progress Note went on to indicate that a verbal altercation had ensued between CNA 5 and Resident B and multiple staff members had intervened to de-escalate the verbal altercation. Resident B and CNA 5 were immediately separated, and CNA 5 was asked to clock out and leave the facility premises. Resident B was taken back to her room for a full body assessment. Resident B's physical assessment was negative for injuries with no signs of swelling, bruising, or scratches found on her neck or chest though she complained of neck pain. The resident's physician, Administrator, Director of Nursing, and responsible parties were notified about the interaction at the time of the incidentAn Incident Report, completed by the local police department dated 7/4/25 at 1:09 P.M., indicated Case #2025-0704-015 incident dated involved, Battery Person Having Care Against Person with Disability. The report indicated the case was cleared with no prosecution.Review of the Indiana State Department of Health Incident Number 591 report, dated 7/4/25, was submitted by the facility on 7/4/25. The incident report indicated on 7/4/25 at 9:01 A.M., Resident B came out of her room on her power chair and ran over CNA 5's foot with her chair. CNA 5 then raised her voice at Resident B and Resident B alleged that CNA 5 hit her in the front of her neck while attempting to provide care. The resident was assessed immediately with no findings though she complained of discomfort to the front of her neck. All parties were notified. CNA 5 was removed from the facility and suspended pending an investigation, and then terminated for failure to provide customer service to Resident B.On 10/2/25 at 10:00 A.M., the Administrator provided the policy titled Abuse, Neglect and Exploitation, dated 2022, indicating it was the current facility policy. The Policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse means the willful infliction of injury.It includes verbal abuse.This citation relates to Intake 26183923.1-27(b)

Based on record review and interview, the facility failed ensure 2 of 6 residents reviewed for medications were free from unnecessary medications related to having an appropriate diagnosis for the use of an antipsychotic medication and a PRN (as needed) antianxiety medication used for greater than 14 days without adequate documentation. (Resident 125 and 72).1. The closed record for Resident C was completed on 8/10/2025 at 2:45 P.M. Diagnoses included but were not limited to: fracture to the left femur, diabetes, end stage renal disease, depression and anxiety.
Resident C's medication orders included Olanzapine (an antipsychotic medication) Oral Tablet 5 MG, 1 tablet by mouth at bedtime for Depression.
During an interview, on 8/11/2025 at 12:10 P.M., the Director of Nursing indicated depression was not an appropriate diagnoses for the medication. There was no other diagnosis or medical symptom to support the use of Olanzapine for Resident C.
2. A record review was completed for Resident 72 on 8/7/2025 at 10:49 A.M. Diagnoses included ,but were not limited to: anxiety disorder and dementia.
A Physician's Order, initiated on 12/18/2025 and discontinued on 1/18/2025 indicated Resident 72 had been prescribed lorazepam 0.5 mg (milligrams) one tablet by mouth as needed for anxiety and agitation.
Resident 72's electronic medical record lacked documentation from the physician for the use of an antianxiety medication for greater than 14 days.
During an interview, on 8/11/2025 at 2:36 P.M., the DON indicated Resident 72 should not have been on the lorazepam for greater than 14 days.
On 8/8/2025 at 1:09 P.M., the ED provided the policy titled Use of Psychotropic Medications, no date and indicated it was the policy currently being used by the facility. The policy indicated, 2. Psychotropic medications are to be used only when a practitioner determines that the medication is appropriate to treat a resident's specific, diagnosed and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. 16a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration
This citation relates to Complaint 1547766
3.1-26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a clean, sanitary and comfortable environment was maintained on 2 of 4 units. (400 hall and 500 hall).Findings include: 1. During an interview and observation, on 8/4/2025 at 10:18 A.M., Resident 56 complained of gnats and flies in her room. The resident indicated it had been going on for the past 2-3 weeks. The wall by the resident's bed had dark colored liquid speck marks and the privacy curtains were stained with dark colored specks. 2. During an observation, on 8/4/2025 at 10:41 A.M., several live flies were observed in room [ROOM NUMBER]. 3. During an interview, on 8/4/2025 at 11:07 A.M., Resident 95 indicated she still had flies in her room. She stated, We have them (flies) bad. 4. During an observation, on 8/4/2025 at 11:52 A.M., the wall behind Resident 87's bed was gouged and had black scuff marks. 5. During an observation of the memory care unit on 8/5/2025 at 8:38 A.M., there were several fruit flies seen throughout the unit. Resident 77 indicated, they (flies) were in his room and everyone else's. 6. During an observation, on 8/5/2025 at 10:10 A.M. in room [ROOM NUMBER], a foam fall mat on the floor next to Resident 3's bed had dark circular stained areas, the window blind was broken in numerous places and the trim around the window was cracked in two places.7. During an observation, on 8/5/2025 at 11:24 A.M., several flies were noted on Resident 17's bed linens. During a tour of the facility with the Administrator, on 8/12/2025 at 3:01 P.M., the following was observed:-flies were observed flying in the hallway leading to the 400 hall.-the floor in room [ROOM NUMBER]smelled of urine and floor was sticky -the 500 hall shower room had dead bugs in the sink and gnats flying around the sink, there was equipment stored in the tub and the tub had a dried brown substance in the bottom, there was also a bucket from a bed side commode that had a dark brown substance dried to the bottom surface. -the 400 hall lounge area had an accumulation of food crumbs on the rug, cob webs behind a love seat, a dried dark substance, bed linens and an empty snack bag on the floor. During an interview, on 8/12/2025 at 3:29 P.M., the Administrator indicated the dirty items, walls and broken items should be fixed and cleaned. He indicated the shower room was not being used as a shower room at this time. He indicated there should be a lock on the door to keep any resident out of the shower room. He indicated the facility followed the state guidelines on cleaning. On 8/12/2025 at 3:45 P.M., the Administrator provided the policy titled, Preventative Maintenance Program, undated, and indicated the policy was the one currently used by the facility. The policy indicated . A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public . 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required . 3. If preventative maintenance is required, the Maintenance director shall decide what tasks need to be completed and how often to complete them This citation relates to complaints IN00462615 and IN00461580. 3.1-19(f)

Based on observation and interview, the facility failed to dispose of expired foods in a timely manner within the main kitchen's walk-in cooler. This deficient practice had the potential to affect 112 of 114 residents who consumed food from the kitchen.Finding includes:During an initial tour of the kitchen, on 8/4/2025 at 9:44 A.M., the following was observed in the walk-in cooler:-A container of corn dated 7/29/2025 with a use by of 7/31/2025-A container of chicken dated 7/3/2025-7 individualized cartons of yogurt in a cardboard box with use by date of 8/1/2025 -A serving bin with ice had 2 outdated yogurts -6 one-half gallon jugs of lime juice with a use by date of 7/14/2025 During an observation and interview on 8/4/2025 at 9:54 A.M. with the Regional Certified Dietary Manager of the walk- in cooler, she indicated the foods should have been disposed within the expiration dates. A policy was provided, on 8/4/2025 at 11:27 A.M., by the Regional Certified Dietary Manager. The policy, titled, Date Marking for Food Safety, indicated, .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety of food .1. Refrigerated, ready-to-eat, time/temperature control for safety food [i.e. perishable food] shall be held at a temperature of 41 [degrees Fahrenheit] or less for a maximum of 7 days. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .5. The discard day or date may not exceed the manufacturer's use-by-date, or four days, which ever is earliest. The date of opening or preparation counts as day 1. [For example, food prepared on Tuesday shall be discarded on or by Friday]. 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed 3.1-21(i)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were available and administered as ordered (Resident B) and failed to ensure a residents reviewed for medications was assessed for potential adverse side effects. (Resident 13) This deficient practice affected 2 of 7 residents reviewed for medications. (Resident B and 13) Findings include:
1.The closed record for resident B was reviewed on 8/8/2025 at 7:52 A.M. Diagnoses included: diabetes, kidney transplant, epilepsy, atrial fibrillation, gastro esophageal reflux disease and depression. The resident was re-admitted to the facility on [DATE] and was discharged on 6/24/2025.
Resident B's May and June medications included the following: Apixaban 5 mg (milligram) 1 tablet twice a day; Glipizide 10 mg 1 tablet every day; Pantoprazole 40 mg 1 tablet twice a day and Pregabalin 50 mg 1 tablet once a day.
A Nurse's Progress Note, dated 5/10/2025 at 9:07 P.M. indicated the Apixaban medication was unavailable and was not administered.
A Nurse's Progress Note, dated 5/10/2025 at 9:08 P.M., indicated the Pantoprazole medications was unavailable and was not administered.
A Nurse's Progress Note, dated 5/10/2025 at 10:02 P.M., indicated the Pregabalin medication was unavailable and was not administered.
A Nurse's Progress Note, dated 5/11/2025 at 5:35 A.M , indicated awaiting from pharmacy of the Pregabalin medication and was not administered.
A Nurse's Progress Note, dated 5/11/2025 at 1:27 P.M., indicated awaiting from pharmacy of the Pregabalin medication.
A Nurse's Progress Note, dated 5/11/2025 at 9:01 P.M., indicated the Pregabalin medication was unavailable and was not administered.
A Nurse's Progress Note, dated 5/11/2025 at 9:13 P.M., indicated awaiting from pharmacy of the Pregabalin medication.
A Nurse's Progress Note, dated 5/11/2025 at 10:02 P.M., indicated the Pregabalin medication was on order and the nurse was notified.
A Nurse's Progress Note, dated 5/16/2025 at 10:20 A.M., indicated the Glipizide medication was not in the cart and was not administered.
On 8/11/2025 at 10:24 A.M., the Director of Nursing provided the list of emergency medications that would have been available in the emergency drug storage. The following medications were listed: Eliquis (Apixaban) 5mg tablets; Pantoprazole 40 mg tablets; Pregabalin 50 mg tablets and Glipizide 5 mg tablets.
During an interview, on 8/12/2025 at 2:45 PM., the Director of Nursing indicated the medications should have been pulled from the emergency drug supply and administered as ordered.
During an interview, on 8/12/2025 at 3:30 P.M., the Director of Nursing indicated she could not provide a policy regarding utilizing the facility's emergency drug supply.
2. A record review was completed for Resident 13 on 8/7/2025 at 2:27 P.M. Diagnoses included, but were not limited to: dementia with agitation, delirium due to known physiological condition and generalized anxiety disorder.
A Physician's Order, initiated on 12/12/2024 and discontinued on 12/23/2024 indicated Seroquel (an antipsychotic medication) 100 mg (milligrams), 1.5 tablets by mouth at bedtime was to be administered.
A Physician's Order, initiated on 5/13/2025 and discontinued on 6/10/2025 indicated quetiapine fumarate (an antipsychotic medication) 100 mg, one tablet by mouth at bedtime was to be administered.
A Physician's Order, initiated on 6/10/2025 and discontinued on 7/6/2025 indicated Seroquel 75 mg give one tablet by mouth at bedtime was to be administered.
A Physician's Order, initiated on 7/7/2025 indicated quetiapine fumarate 100 mg give one tablet by mouth at bedtime was to be administered.
There was only one Abnormal Involuntary Movement Scale (AIMS) assessment, dated 6/23/2025, completed for Resident 13 in the past 12 months.
During an interview, on 8/11/2025 at 8:50 A.M., the DON indicated Resident 13 should have had more than one AIMS assessment in the last 12 months and there was no other documentation Resident 13 had been assessed for adverse side effects related to the use of antipsychotic medications.
On 8/8/2025 at 1:09 P.M., the ED provided the policy titled, Use of Psychotropic Medications no date and indicated it was the policy currently being used by the facility. The policy indicated, .13. Residents who receive and antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, or PRN
This citation relates to Complaint 1547766
3.1-25(a)
3.1-25(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure interventions were implemented to prevent contractures for 1 of 3 residents reviewed for range of motion. (Resident 95)Finding includes:During an observation and interview on 8/5/2025 at 11:04 A.M., Resident 95 indicated she had an orthosis for her left hand, but did not know were the orthosis was located in her room. The resident was not wearing any orthosis on her left hand. During observations, on 8/6/2025 at 9:22 A.M., 8/6/2025 at 11:53 A.M., 8/7/2025 at 9:55 A.M., 8/7/2025 at 2:04 P.M., 8/8/2025 at 1:20 P.M. and 8/12/2025 at 9:45 A.M., Resident 95 was lying in bed with her left hand in a fisted position. She did not have an orthosis in place. A record review for Resident 95 was on 8/6/2025 at 11:16 A.M. Diagnoses included, but were not limited to: hemiplegia, lymphedema, diabetes mellitus type 2 and neuromuscular dysfunction of the bladder. A Quarterly Minimum Data Set (MDS) assessment, dated 7/20/2025, indicated Resident 95 was cognitively intact, was dependent for bed mobility and transfers, had range of motion impairment on one side of the body and had received occupational therapy from February 18, 2025 through March 17, 2025. A Physician's Order, dated 3/12/2025, indicated, .Place hand orthosis on in the morning and remove at bedtime An Occupational Therapy Discharge summary, dated [DATE] at 4:11 P.M., included a long term goal of: .Patient will tolerate opponens (opponent muscle])inflate hand orthosis [NAME] (inflatable splint) on discharge from occupational therapy, The notes indicated Resident 95 had been tolerating the [NAME] placements throughout the day with device removed at nighttime. A Nursing Progress Note, on 7/18/2025 at 2:23 P.M., indicated Resident 95 had upper and lower extremity impairment due to hemiplegia and staff assisted her with dressing, grooming, bathing, skin care, toileting/hygiene, transfers, bed mobility, and nutrition/fluid needs. There was no Care Plan addressing the resident's hemiplegia or the use of the orthosis. During an interview, on 8/12/2025 9:48 A.M., CNA 3 indicated Resident 95 had had an orthosis the prior year, but had not worn the orthosis recently. During an interview, on 8/12/2025 at 9:52 A.M., RN 4 indicated Resident 95 wore the orthosis when she was out of bed and in her wheelchair. However, during morning and afternoon observations, Resident 95 was always in her bed. A policy for orthosis use and range of motion was requested on 8/12/2025 at 12:42 P.M. The DON indicated, on 8/12/2025 at 2:44 P.M., a policy was not available for orthosis use or range of motion. 3.1-42(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medication orders were followed correctly regarding administering blood pressure medications and insulin and blood glucose assessments for 5 of 7 residents whose medications were reviewed. (Residents 87, 122, 2, 53 and 13) 1. The record for Resident 87 was completed on 8/4/2025 at 11:48 A.M. Diagnoses included, but were not limited to
end stage renal disease, orthostatic hypotension, hypertension and aortic valve stenosis.
Resident 87's Physician's Order, dated 7/21/2025, indicated to administer Midodrine (medication to treat low blood pressure) 10 milligrams (mg), 1 tablet three times a day for hypotension. The order indicated the following parameter: Do not give if SBP (systolic blood pressure) is greater than 100.
The Medication Administration Record (MAR) from July 22- 29, 2025, indicated the following:
-on 7/23 at 8:00 A.M., the blood pressure (B/P) was documented as 126/45 mmHg and the medication had been administered.
-on 7/23 at 2:00 P.M., the B/P was documented as 126/45 mmHg and the medication had been administered.
-on 7/24 at 2:00 P.M., the B/P was documented as 104/61 mmHg and the medication had been administered.
-on 7/26 at 8:00 A.M., the B/P was documented as 121/73 mmHg and the medication had been administered
-on 7/26 at 10:00 P.M., the B/P was documented as 107/75 mmHg and the medication had been administered.
-on 7/27 at 10:00 P.M., the B/P was documented as 133/59 mmHg and the medication had been administered.
-on 7/28 at 10:00 P.M., the B/P was documented as 134/63 mmHg and the medication had been administered.
A Physician's Order, dated 7/29/2025, indicated Midodrine 5 mg, 1 tablet three times a day for hypotension. The order included the following parameter: Do not give if SBP is greater than 110.
The Medication Administration Record (MAR) for July 30 - 31, 2025, indicated the following:
-on 7/30 at 2:00 P.M., the B/P was documented as 126/47 mmHg and the medication had been administered.
-on 7/30 at 10:00 P.M., the B/P was documented as 102/64 mmHg and the medication had been administered.
The MAR for August 2025 indicated the following:
-on 8/1 at 10:00 P.M., the B/P was documented as 111/58 mmHg and the medication had been administered.
-on 8/2 at 2:00 P.M., the B/P was documented as 108/58 mmHg and the medication had been administered.
-on 8/4 at 8:00 A.M., the B/P was documented as 117/55 mmHg and the medication had been administered.
-on 8/4 at 2:00 P.M., the B/P was documented as 104/43mmHg and the medication had been administered.
-on 8/4 at 10:00 P.M., the B/P was documented as 114/50 mmHg and the medication had been administered.
-on 8/5 at 2:00 P.M., the B/P was documented as 124/50 mmHg and the medication had been administered.
-on 8/6 at 8:00 A.M., the B/P was documented as 120/51 mmHg and the medication had been administered.
During an interview, on 8/8/2025 at 11:54 A.M., the Director of Nursing indicated the medication should have been held on the days the blood pressure was out of the parameters.
2 A record review for Resident 122 was completed on 08/11/2025 at 9:29 A.M . Diagnoses included, but were not limited to: Chronic Obstructive Pulmonary Disease, Type 2 Diabetes , Chronic Kidney Disease stage 3, muscle weakness, history of Pulmonary embolism, Congestive Heart Failure, heart valve disease, and atrial fibrillation.
A Physician's order, dated 6/11/2025, indicated Midodrine 2.5 milligrams, 1 tablet by mouth three times a day for low BP (blood pressure) for 2 weeks was to be administered. In addition, the following parameter was ordered: Hold for a systolic BP < (sic) 110*
A review of the June Medication Administration Record (MAR) indicated the following:
6/11/25 PM Blood Pressure 104/52 mmHg , Midodrine 2.5 mg administered.
6/12/25 AM Blood Pressure 121/56 mmHg , Midodrine 2.5 mg administered
6/12/25 Noon Blood Pressure 108/60 mmHg , Midodrine 2.5 mg administered
6/13/25 Noon Blood Pressure 102/64 mmHg , Midodrine 2.5 mg administered
6/14/25 AM Blood Pressure 96/53 mmHg , Midodrine 2.5 mg administered
6/14/2025 Noon Blood Pressure 90/51mmHg , Midodrine 2.5 mg administered,
6/14/2026 PM Blood Pressure 89/56 mmHg , Midodrine 2.5 administered
6/15/25 AM Blood Pressure 90/50 mmHg , Midodrine 2.5 administered
6/15/25 Noon Blood Pressure 90/51 mmHg , Midodrine 2.5 administered
6/15/25, PM Blood Pressure 93/58 mmHg , Midodrine 2.5 administered
6/16/25 AM Blood Pressure 109/75 mmHg, Midodrine 2.5 administered
6/16/25 Noon Blood Pressure 98/54 mmHg , Midodrine 2.5 administered
6/16/25 PM Blood Pressure 97/58 mmHg , Midodrine 2.5 administered
6/17/25 AM Blood Pressure 98/60 mmHg , Midodrine 2.5 mg administered
6/17/25 Noon Blood Pressure 96/66 mmHg , Midodrine 2.5 administered
6/18/25 AM Blood Pressure 95/66 mmHg , Midodrine 2.5 mg administered.
Resident122 was then discharged to an acute hospital for gastrointestinal bleeding.
During an interview, on 08/12/2025 at 9:55 AM, the DON reviewed the June MAR and July MAR for the inconsistency of the midodrine administration due to the incorrect use of the < symbol. The DON agreed that the < sign was wrong and should have been >. The DON indicated the facility did not have a policy regarding the use of symbols in charting.
3. A record review for Resident 2 was completed on 8/7/2025 at 10:33 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, borderline intellectual functioning and schizophrenia.
A Quarterly Minimum Data Set (MDS) assessment, dated 5/29/2025, indicated Resident 2 had moderate cognitive impairment and received insulin injections.
A current Care Plan, initiated on 3/21/2025, indicated Resident 2 had diabetes mellitus and was at risk for complications. Interventions included, but were not limited to: to give diabetes medications as ordered by the physician and monitor/document/report PRN (as needed) any signs/symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (a deep, labored and sometimes gasping type of breathing associated with metabolic acidosis), acetone breath (smells fruity), stupor or coma
A Physician's Order, dated 5/14/2025, indicated the resident was to receive Lispro Injection Solution (short acting insulin) 100 units per milliliters (unit/ml) inject 10 units subcutaneously before meals for hyperglycemia.
A Physician's Order, dated 7/13/2025, indicated the resident was to receive Glargine Subcutaneous Solution (long acting insulin) 100 unit/ml inject 20 units one time a day for diabetes mellitus type 2.
A blood glucose assessment, obtained, on 7/14/2025 at 5:20 P.M. had a result of 563 mg/dL (milligrams per deciliter) and was reported to the on-call Physician's Assistant.
A Physician's Assistant Triage Note, dated 7/14/2025 at 5:42 P.M., indicated the facility was to give 16 units of Lispro Injection Solution, ensure the Resident 2 ate dinner, push oral fluids and recheck the resident's blood sugar in 1 hour and if the blood sugar was greater than 450 mg/dL , they were to call for additional instructions.
However, review of the clinical record for Resident 2 indicated there was no documentation that the newly ordered amount of Lispro Injection Solution had been given, on 7/14/2025 or that the blood sugar had been rechecked an hour after the insulin was given.
During an interview, on 8/12/2025 at 11:35 A.M., the Director of Nursing (DON) indicated there was no documentation the orders given by the Physician Assistant, on 7/14/2025 in regards to a one time dose of Lispro insulin, pushing fluids or rechecking the resident's blood sugar after an hour had been followed. The DON indicated, on 8/12/2025 at 11:53 A.M., that the nurse on duty on 7/14/2025 indicated she had not documented the orders as having been completed.
A policy for following physician orders was requested on 8/12/2025 at 12:42 P.M. The DON indicated, on 8/12/2025 at 2:44 P.M., a policy was not available for following physician orders.
4. A record review was completed for Resident 53 on 8/6/2025 at 11:16 A.M. Diagnoses included, but were not limited to: hypertension and hypotension.
An admission Minimum Data Set (MDS), dated [DATE] indicated Resident 53's cognition was severely impaired.
A Physician's Order, dated 6/6/2025 indicated to give Propranolol hydrochloride 10mg (milligrams) one tablet by mouth three times a day for hypertension. Additional instructions included were to Hold Propranolol hydrochloride if systolic blood pressure was less than 110 mmHg (millimeters of mercury) or if heart rate was less than 60 bpm (beats per minute).
A Physician's Order, dated 5/15/2025 indicated to give Midodrine hydrochloride 5mg tablet by mouth three times a day for hypotension. Additional instructions were to: Hold Midodrine hydrochloride if systolic blood pressure was greater than 120 mmHg.
A review of Resident 53's Medication Administration Record (MAR) indicated Propranolol hydrochloride 10mg one tablet by mouth was administered to the resident on the following dates with the corresponding blood pressures readings:
-On 6/11/2025 Resident 53's blood pressure result was 109/73 mmHg.
-On 6/21/2025 Resident 53's blood pressure result was 98/52 mmHg.
-On 7/5/2025 Resident 53's blood pressure result was 98/74 mmHg.
-On 7/10/2025 Resident 53's heart rate was 56 bpm.
-On 7/20/2025 Resident 53's blood pressure result was 102/68 mmHg.
-On 7/30/2025 Resident 53's blood pressure results were 109/72 mmHg and 101/68 mmHg.
A review of Resident 53's MAR indicated Midodrine hydrochloride 5mg tablet by mouth was administered to the resident on the following dates with the corresponding blood pressures:
-On 5/17/2025 Resident 53's blood pressure result was 128/74 mmHg.
-On 5/19/2025 Resident 53's blood pressure results were 126/76 mmHg and 122/70 mmHg.
-On 5/23/2025 Resident 53's blood pressure results were 132/82 mmHg and 136/78 mmHg.
-On 5/27/2025 Resident 53's blood pressure results were 150/82 mmHg and 132/82 mmHg.
-On 5/28/2025 Resident 53's blood pressure results were 142/72 mmHg and 126/74 mmHg.
-On 5/30/2025 Resident 53's blood pressure result was 128/72 mmHg.
-On 5/31/2025 Resident 53's blood pressure result was 130/78 mmHg.
-On 6/1/2025 Resident 53's blood pressure results were 146/88 mmHg and 134/82 mmHg.
-On 6/2/2025 Resident 53's blood pressure results were 146/74 mmHg and 130/70 mmHg.
-On 6/6/2025 Resident 53's blood pressure results were 128/64 mmHg and 124/82 mmHg.
-On 6/9/2025 Resident 53's blood pressure result was 124/78 mmHg.
-On 6/10/2025 Resident 53's blood pressure results were 132/68 mmHg and 124/62 mmHg.
-On 6/12/2025 Resident 53's blood pressure result was 128/72 mmHg.
-On 6/14/2025 Resident 53's blood pressure results were 138/60 mmHg and 122/60 mmHg.
-On 6/15/2025 Resident 53's blood pressure results was 142/82 mmHg.
-On 6/18/2025 Resident 53's blood pressure result was 124/62 mmHg.
-On 6/19/2025 Resident 53's blood pressure result was 124/70 mmHg.
-On 6/20/2205 Resident 53's blood pressure results were 128/66 mmHg and 130/74 mmHg.
-On 6/22/2025 Resident 53's blood pressure result was 131/66 mmHg.
-On 6/23/2025 Resident 53's blood pressure results were 124/80 mmHg and 132/84 mmHg.
-On 6/24/2025 Resident 53's blood pressure results were 153/88 mmHg and 142/72 mmHg.
-On 6/25/2025 Resident 53's blood pressure results were 138/74 mmHg and 148/88 mmHg.-On 6/26/2025 Resident 53's blood pressure results were 130/62 mmHg and 160/93 mmHg.
-on 6/28/2025 Resident 53's blood pressure results were 130/76 mmHg and 136/80 mmHg.
-On 6/29/2025 Resident 53's blood pressure results were 130/76 mmHg and 128/60 mmHg.
-On 6/30/2025 Resident 53's blood pressure result was 126/78 mmHg.
-On 7/1/2025 Resident 53's blood pressure result was 128/72 mmHg.-On 7/2/2025 Resident 53's blood pressure result was 128/72 mmHg.
-On 7/4/2025 Resident 53's blood pressure results were 130/76 mmHg and 144/62 mmHg.
-On 7/8/2025 Resident 53's blood pressure result was 128/82 mmHg.
-On 7/10/2025 Resident 53's blood pressure result was 140/76 mmHg.
-On 7/12/2025 Resident 53's blood pressure results were 132/74 mmHg, 124/66 mmHg and 128/68 mmHg.
-On 7/13/2025 Resident 53's blood pressure results were 138/96 mmHg and 134/92 mmHg.
-On 7/16/2025 Resident 53's blood pressure result was 128/72 mmHg.
-On 7/18/2025 Resident 53's blood pressure results were 122/74 mmHg and 128/64 mmHg.
-On 7/23/2025 Resident 53's blood pressure results were 154/90 mmHg and 122/65 mmHg.
-On 7/26/2025 Resident 53's blood pressure result was 126/68 mmHg.
-On 7/27/2025 Resident 53's blood pressure results were 122/86 mmHg, 124/72 mmHg and 125/75 mmHg.
-On 8/1/2025 Resident 53's blood pressure results were 130/94 mmHg, 124/88 mmHg and 130/82 mmHg.
-On 8/5/2025 Resident 53's blood pressure result was 152/90 mmHg.
-On 8/7/2025 Resident 53's blood pressure result was 129/83 mmHg.
5. A record review was completed for Resident 13 on 8/7/2025 at 2:27 P.M. Diagnoses included, but were not limited to: hypotension.
A Physician's Order, dated 7/14/2025 indicated Midodrine hydrochloride 5mg give one tablet by mouth three times a day for hypotension. Additional instructions included to hold Midodrine hydrochloride 5mg tablet when the systolic blood pressure was greater than 125 mmHg.
A review of Resident 13's MAR indicated Midodrine hydrochloride was administered to the resident on the following dates with the corresponding blood pressures:
-On 7/16/2025 Resident 13's blood pressure result was 128/72 mmHg.
-On 7/17/2025 Resident 13's blood pressure result was 126/78 mmHg.
-On 7/18/2025 Resident 13's blood pressure results were 130/68 mmHg and 128/76 mmHg.
-On 7/21/2025 Resident 13's blood pressure result was 127/76 mmHg.
-On 7/22/2025 Resident 13's blood pressure results were 150/96 mmHg and 134/82 mmHg.
-On 7/23/2025 Resident 13's blood pressure results were 142/76 mmHg and 132/74 mmHg.
-On 7/24/2025 Resident 13's blood pressure result was 128/68 mmHg.
-On 7/26/2025 Resident 13's blood pressure result was 126/72 mmHg.
-On 7/27/2027 Resident 13's blood pressure results was 128/92 mmHg.
-On 7/28/2025 Resident 13's blood pressure result was 128/72 mmHg.
-On 7/30/2025 Resident 13's blood pressure result was 128/74 mmHg.
-On 7/31/2025 Resident 13's blood pressure results were 134/82 mmHg and 130/70 mmHg.
-On 8/1/2025 Resident 13's blood pressure results were 150/98 mmHg, 136/82 mmHg and 133/78 mmHg.
-On 8/5/2025 Resident 13's blood pressure results were 126/70 mmHg and 140/88 mmHg.
-On 8/9/2025 Resident 13's blood pressure results were 126/70 mmHg, 130/72 mmHg and 132/68 mmHg.
-On 8/10/2025 Resident 13's blood pressure result was 140/86 mmHg.
During an interview, on 8/11/2025 at 8:50 A.M. the DON indicated Residents 53 and 13 should not have been receiving the Midodrine or the Propranolol if their vital signs were outside the ordered parameters.
On 8/11/2025 at 12:02 P.M., the DON provided the policy titled, Medication Administration, no date and indicated it was the policy currently being used by the facility. The policy indicated, 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters
This citation relates to Complaints 1547766 and 1547767
3.1-37

Based on record review and interview, the facility failed to ensure a care plan related to pressure ulcers was initiated timely for 1 of 3 residents reviewed for pressure ulcers. (Resident 7) In addition, the facility failed to ensure a comprehensive plan of care initiated for post traumatic stress disorder had personalized interventions for 1 of 1 residents reviewed .for post traumatic stress disorder (Resident 46) 1.A record review for Resident 7 was completed, on 8/6/2025 at 11:11 A.M. Diagnoses included, but not limited to, cardiac arrest, ischemia of lower extremity resulting in left leg gangrene and amputation, right leg extensive debridement and resulting foot drop, cardiomyopathy, sarcoidosis of the heart, type 2 diabetes, atrial fibrillation and sleep apnea.
A weekly skin check, dated 4/23/25, indicated the resident had developed a new, unstageable deep tissue injury, on the right lateral forefoot near the 5th digit. The wound measured 0.4 centimeters wide by 1.6 centimeters deep.
On 4/25/2025, the facility physician examined the resident's right foot wound and recommended to continue Betadine treatment.
On 4/29/2025, an order was received for ProT Gold twice daily.
On 5/7/2025, weekly skin check records indicated the wound measured 0.4 cm wide by 0.7 deep.
On 5/19/2025, nursing progress notes indicated the resident had returned from a doctor appointment with new orders to cleanse the right lateral foot wound, stop the Betadine and apply Medihoney and cover with gauze daily.
On 5/28/2025, weekly skin check forms indicated the right foot wound measured 1 cm wide by 1.2 cm deep.
An order was received, on 5/30/2025, to refer the resident to a wound center.
On 6/4/2025, nursing progress notes indicated the referral had been faxed to a local wound clinic, and the facility was waiting on the wound clinic to call back with a scheduled appointment for the resident.
On 6/4/2025 an order for fortified foods for nutritional support was entered in the medical record.
On 6/11/2025, per the weekly skin check record, the right foot wound measured 0.8 cm wide by 0.9 cm deep.
On 6/12/2025, a care plan was created for the right foot wound which included the following interventions: following facility protocols for treatment of injury, monitor and document location, size and treatment of skin injury and providing a pressure relieving/reducing mattress to protect skin while in bed.
During an iinterview, on 08/11/2025 8:52 AM, the Director of Nursing indicated a care plan for the right foot wound should have been created when the wound was identified in April.
2. A record review was completed for Resident 46 on 8/8/2025 at 8:55 A.M. Diagnoses included, but were not limited to: post-traumatic stress disorder and behavioral disturbance.
A Care Plan, initiated on 5/10/2017 indicated Resident 46 had a diagnosis of personal history of adult physical and sexual abuse, personal history of physical and sexual abuse in childhood, and post traumatic stress disorder that may contribute to behaviors. Interventions included and were limited to: encourage participation from resident who depends on others to make own decisions, if I'm upset, please re-direct the conversation or task as able, offer me step-by-step instructions and give me visual and verbal cues throughout care.
Resident 46's care plan lacked person centered interventions.
During an interview, on 8/8/2025 at 9:37 A.M., LPN 5 indicated loud noises and overstimulation were triggers for Resident 46's post traumatic stress disorder. She indicated doing one on one time, offering the resident drinks or snacks and taking the resident to a new area were interventions that worked for the resident. She indicated Resident 46's care plan was not person centered and the interventions that helped the resident should have been added to her care plan.
On 8/11/2025 at 12:02 P.M., the DON provided the policy titled Comprehensive Care Plans, no date and indicated it was the policy currently being used by the facility. The policy indicated, Policy: 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 and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care areas triggered by the MDS will be considered in the developing the plan of care. 3. The comprehensive care plan with describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 3G. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated . Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the triggers on the resident.
3.1-35
3.1-35(b)(1)
3.1-35(c)(1)

Based on interview and record review, the facility failed to implement their policy related to reporting an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident B)
Finding includes:
During an interview on 1/22/25 at 12:45 P.M., Resident B indicated one night the previous week,
Employee 3 entered her room to assist with changing her brief. Resident B indicated Employee 3 commented the odor was strong and sprayed her buttocks with room deodorizer and then pushed the spray can into her rectum. Resident B indicated on 1/20/25, at an unknown time, she was in the lobby of the facility and reported the incident to Employee 6. Resident B indicated on 1/22/24 during morning physical therapy, she reported the allegation to Employee 2.
During an interview on 1/22/25 at 1:15 P.M., the Administrator indicated he was made aware of an allegation of abuse for the first time from Employee 2 on 1/22/25 at 12:30 P.M. The Administrator indicated he immediately suspended Employee 3, pending an investigation, reported the allegation to the State Agency, and initiated an investigation. The Administrator indicated the allegation of abuse should have been reported to him by Employee 6 immediately and that Employee 6 had been trained regarding the requirement to report all allegations of abuse to the Administrator and Director of Nursing immediately.
During an interview on 1/23/25 at 1:25 P.M., Employee 6 indicated sometime in the evening of 1/20/25, Resident B was in the lobby of the facility and reported to her that sometime in the night on 1/16/25, Employee 3 entered her room to change her brief and and sprayed her with room spray and made remarks about the way she smelled and that the employee practically sodomized her with the can of room spray. Employee 6 indicated she should have reported the allegation immediately to the Administrator but did not.
On 1/23/25 at 10:20 A.M., the Administrator provided a policy titled, Abuse, Neglect and Exploitation, dated 2024, and indicated it was the current facility policy. The policy indicated, .The facility will .implement written policies and procedures .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .
This citation relates to Complaint IN00451700.
3.1-28(c)

Based on observation, record review and interview, the facility failed to ensure food was
served at palatable temperatures in 1 of 1 kitchens observed (Main Kitchen). This deficient practice potentially affected 110 of 120 residents who consumed food from the main kitchen.
Finding includes:
During a meal observation with [NAME] 1 in the Main Kitchen, on 10/1/24 at 12:00 P.M., the food temperatures of hot foods on the steam table were a follows: pureed corn 105 F (Fahrenheit), cream corn 123 F, pureed beef 118 F, beef gravy 128 F, pepper steak 123 F, whole corn 141 and sweet potato 140
During observation of room trays on the 500 hall, conducted on 10/1/24 at 12:37 P.M., meals were transported to the unit, from the kitchen on metal covered, noninsulated carts. The last tray to be served, at 12:37 P.M., had the following food temperatures at the point of service: pepper steak 80 F, sweet potatoes 85 F and whole corn 85*F.
During an interview on 10/1/24 at 12:05 P.M., [NAME] 1 indicated hot food temps should be held at or above 140 F while on the steam table.
During an interview on 10/1/24 at 12:24 P.M. the Dietary Manager indicated hot foods were to be temperature checked at the steam table and should be held at at least 135 F.
During an interview on 10/1/24 at 12:49 P.M., Resident E indicated the hot food was always cold when served.
During an interview, on 10/1/24 at 12:52 P.M. in the dining room, Resident G and Resident H both indicated the food was often served cold and needed to be warmer.
On 10/1/24 at 12:00 P.M., during food service distribution, in a hot food temps check with [NAME] 1, [NAME] 1 check the food temps and agreed that the following foods tempt out at:
Pureed corn: 105 F, Cream corn 123, whole corn 141, pureed beef 118, beef gravy 128, pepper steak 123, sweet potato 140
During an interview on 10/1/24 at 12:58 P.M., the Administrator indicated hot foods should be served at appropriate temperatures and not below.
On 10/1/24 at 2:32 P.M., the Director of Nursing provided the policy titled, Maintaining a Sanitary Tray Line, dated 12/17 and indicated it was the current facility policy. The policy indicated the priority of food service was to ensure foods were handled safely and held at proper temperatures and to periodically monitor food temperatures throughout the meal service to ensure hot foods were maintained at or above 135 F.
This citation relates to Complaint IN00443191.
3.1-21(a)(2)

Based on observation, record review, and interview, the facility failed to provide a peripherally inserted central catheter care for 1 of 5 residents reviewed for infection control (Resident 266)
Finding includes:
On 7/29/2024 at 9:32 A.M., Resident 266 was observed to have vancomycin and piperacillin hanging from an intravenous pole. He had a peripherally inserted central catheter (PICC) to his left antecubital space (the crook of the elbow), the transparent dressing, dated 7/24/2024, was folded in half with the insertion point site of the PICC line exposed.
On 7/29/2024 at 2:37 P.M., the PICC line transparent dressing remained folded in half with the insertion point site of the PICC line exposed.
During an observation, on 8/1/2024 at 9:45 A.M., the transparent dressing was observed to not be adhered along the lateral edges of the dressing. Resident 266 indicated he had received a shower the previous evening, and the dressing became wet.
A record review was completed on 8/1/2024 at 10:14 A.M. Diagnoses included, but were not limited to, osteomyelitis, methicillin-susceptible staphylococcus aureus, and diabetes mellitus type 1.
A Physician's Order, dated 7/26/2024, indicated to complete a PICC line dressing change weekly and as needed every night shift.
During an interview, on 8/1/2024 at 3:06 P.M., LPN 2 indicated the PICC line dressing are changed weekly and as needed if the dressing was peeling or soiled. She indicated she had seen the dressing on 7/29/2024, and the dressing was changed during night shift the next day.
A policy was provided as current on 8/2/2024 at 11:43 A.M. by the Director of Nursing. The policy, titled, PICC/Midline/CVAD [central venous access device] Dressing Change, indicated, .It is the policy of this facility to change peripherally inserted central catheter [PICC], midline or central venous access devices [CVAD] dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of change
3.1-47(a)(2)

Based on observation, interview and record review, the facility failed to verify controlled substance counts for 1 of 1 medication cart observed. (SW Unit)
Finding includes:
During a medication storage observation of the SW Unit medication cart, on 8/2/24 at 9:43 A.M. with RN 11, the controlled medication log book had missing signatures for the count sheets on July 1, 5, 6, 11, 13, 14, 17, 18 and 27, 202.4
During an interview on 8/2/24 at 11:14 P.M., the Director of Nursing indicated all narcotic count sheets were to be signed by the oncoming and offgoing nurse/QMA for verification of residents' medications.
A current policy was provided on 8/2/24 at 1:10 P.M. by the Director of Nursing. The policy, titled, Controlled Substance Administration and Accountability, indicated .for areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift
3.1-25(e)(2)

Based on record review and interview, the facility failed to ensure a surety bond sufficiently covered the total monies in the Resident Fund account. This had the potential to affect the 56 residents who had resident fund accounts managed by the facility.
Finding includes:
During an interview and record review of Resident Fund accounts, with the Business Office Manager (BOM) and the Executive Director, on 8/2/2024 at 8:25 A.M., the total amount in the Resident Fund accounts was $286,128.00. The BOM indicated the amount was higher than usual due to a closed account with funds from a home sale for which she was waiting on verification before sending the funds back to Medicaid.
Review of the facility's Surety Bond insurance rider to cover Resident Fund monies, dated April 1, 2020, indicated the covered amount had been increased to $250,000.
During an interview with the Executive Director (ED) on 8/5/2024 at 9:40 A.M. he indicated he did not know why the Corporation had not raised the Resident Fund Surety Bond amount higher. He confirmed the total amount noted on 8/2/2024 was unusually high for that account.
The current facility policy titled Surety Bond Requirements provided by the ED on 8/5/2024 at 9:00 A.M., included the following: .The surety bond, or alternative to a surety bond, must be equal to or greater than the total amount of residents' funds, as of the most recent quarter .
3.1-6(j)

2. The record for Resident 36 was completed on 7/31/2024 at 9:54 A.M. Diagnoses included, but were not limited to: diabetes, hypertension, anxiety, depression, epilepsy, and Schizophrenia.
Physician's orders, dated 8/1/2024- 8/31/2024, lacked documentation of physician's orders for code status preferences.
During an interview, on 7/31/2024 at 12:10 P.M., LPN 13 indicated the resident should have had an order for his code status.
On 28/1/2024 at 12:25 P.M., the Director of Nursing provided the policy titled,Communication of Code Status, dated 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to adhere to residents' rights to formulate advanced directives .When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: a. Full Code. b. Do Not Resuscitate. c. Do Not Intubate. d. Do Not Hospitalize. 3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record. 4. The designated sections of the medical record are: Active order, copy of code status uploaded into electronic file.8. The resident's code status will be reviewed as least quarterly and documented in the medical record
3.1-4(f)(7)
Based on record review and interview, the facility failed to provide accurate orders for resuscitative wishes for 2 of 3 resident reviewed for advanced directives. (Residents 94 & 36)
Findings include:
1. A record review for Resident 94 was completed on 7/31/2024 at 11:19 A.M. Diagnoses included, but were not limited to: cerebral infarction, chronic obstructive pulmonary disease (COPD), congestive heart failure, atrial fibrillation, epilepsy, and diabetes mellitus type 2.
An admission Minimum Data Set (MDS) assessment, dated 6/7/24, indicated Resident 94 had severe cognitive impairment.
A Physician Orders for Scope of Treatment (POST) form, dated 6/1/2024, and signed by the nurse practitioner on 6/27/2024, indicated to not attempt resuscitation.
A Physician's Order, dated 6/10/2024, indicated Resident 94 was a full code, indicating cardiopulmonary resuscitation to was to be completed.
A Care Plan, dated 6/13/2024, indicated Resident 94 had an advanced directive of a full code. The goal, dated 6/13/2024, indicated that Resident 94's wishes would be honored. The interventions include cardiopulmonary resuscitation would be honored, and to review code status quarterly.
During an interview, on 7/31/2024 at 12:19 P.M., LPN 3 indicated Resident 94 had an order to be a full code. The POST form indicated his wishes to be a do not resuscitate. LPN 3 indicated the physician's order, care plan and the POST form conflicted related to the wishes of Resident 94.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A record review for Resident 14 was completed, on 8/2/24 at 9:35 A.M. Diagnoses included included, but were not limited to major depressive disorder, heart disease, edema, type 2 diabetes, hypertension, muscle weakness, chronic pain syndrome and absence of left and right leg below knee.
An admission MDS (Minimum Data Set) assessment, dated 7/12/24, indicated Resident 14 has intact cognition.
A baseline care plan, completed on 7/15/24, indicated Resident 14 had a history of falls prior to admission and as ordered psychotropic medication.
During an interview on 8/2/24 at 1:34 P.M., the Director of Nursing (DON) indicated a baseline care plan should have been completed within 48 hours of admission, it was late and should have been completed timely.
4. A record review for Resident 99 was completed on 7/30/24 at 2:10 P.M. Diagnoses included, but were not limited to, diabetes, dementia, pressure ulcer, muscle weakness and diabetes.
A Significant Change MDS assessment, dated 5/17/24, indicated Resident 99 has moderate cognitive impairment.
A baseline care plan, completed on 4/29/24, indicated Resident 99 was admitted with a pressure ulcer.
During an interview on 8/1/24 at 2:52 P.M., the DON indicated a baseline care plan should have been completed for her wounds within 48 hours of admission.
On 8/2/24 at 1:16 P.M., the Executive Director provided the policy titled, Baseline Care Plan, dated 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .1. The baseline care plan will:
a. Be developed within 48 hours of a resident's admission.
b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:
i. Initial goals based on admission orders.
ii. Physician orders.
iii. Dietary orders.
iv. Therapy services.
v. Social Services.
vi. PASARR recommendation, if applicable
3.1-30(a)
Based on record review and interview, the facility failed to ensure baseline care plans were initiated for a resident receiving dialysis, a resident with falls and edema, and a resident with a wound, and failed to ensure baseline care plans were completed timely for a resident with an enteral feeding tube, for 4 of 27 residents reviewed for baseline care plans. (Residents 36, 107, 14 and 99)
Findings include:
1. The record for Resident 36 was completed on 8/01/2024 at 8:48 A.M. Diagnoses included, but were not limited to, end stage renal disease, neurogenic bladder, viral hepatitis, and diabetes.
An admission Minimum Data Set (MDS) assessment, dated 6/13/2024, indicated Resident 36 was receiving dialysis.
A Baseline Care Plan form, dated 6/7/2024, indicated the resident required dialysis. The form lacked any goals, interventions, and any special needs to to address the resident's current needs to properly care for the resident.
During an interview, on 8/2/2024 at 2:58 P.M., the Director of Nursing indicated the resident had a baseline care plan, but it did not have all the information in it from the chart.
2. During an observation of Resident 107, on 7/29/2024 at 10:00 A.M., a bottle of Glucerna 1.5 was infused at 60 milliliters per hour via a tube feeding.
A record review for Resident 107 was completed on 7/31/2024 at 1:57 P.M. Diagnoses included, but were not limited to, cerebral infarction, dysphagia, and diabetes mellitus type 2. He was admitted on [DATE].
An admission Minimum Data Set (MDS) assessment, dated 7/9/2024, indicated Resident 107 received tube feeding, and had moderate cognitive impairment.
Physician's Orders, dated 7/3/2024, indicated for Glucerna 1.5 to infuse via a gastrostomy tube at 60 milliliters per hour (ml/hr).
A Care Plan, dated 7/18/2024, indicated Resident 107 received nutrition/hydration via a gastrostomy tube. All goals and interventions were dated 7/18/2024.
During an interview, on 8/1/2024 at 3:13 P.M., LPN 2 indicated the baseline care plan was dated 7/9/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure comprehensive person-centered plans of care were created related to behaviors, a urinary tract infection, constipation, impaired vision and edema for 5 of 23 residents reviewed for comprehensive care plans. (Residents 28, 10, 14, 66 & 215)
Findings include:
1. The record for Resident 28 was reviewed on 7/31/2024, at 9:15 A.M. Diagnoses included but were not limited to: hemiplegia and hemiparesis, cerebral infarction, unspecified dementia, atrial fibrillation, cardiomegaly, hypertension, and anxiety disorder.
Resident 28's current medications included Zyprexa (antipsychotic) 10 milligrams (mg) 1 tablet by mouth at bedtime for dementia with agitation.
A Care Plan, dated 7/28/2024, indicated the resident had target behaviors of paranoia and agitation. Interventions included, but were not limited to, assess for pain, monitor for side effects of antipsychotics and report to the physician, monthly pharmacy review of the medication regimen, offer to call the resident's wife, offer to sit and talk about the resident's wife, provide medications as ordered and evaluate for effectiveness, psychotropic risk/benefit and reduction plan as recommended by the physician and pharmacist, and reassure the resident of his safety.
Resident 28's record lacked person-centered Care Plan interventions for behaviors.
During an interview, on 7/31/2024 at 1:43 P.M., CNA 4 indicated all behaviors exhibited by the residents were charted in the electronic medical record system. The CNA indicated any interventions attempted by the CNA's were charted in electronic medical record system and were not individualized to the specific resident, the interventions were the same for every resident.
During an interview, on 8/1/2024, at 2:41 P.M., the Memory Care Director indicated the interventions were individualized for the anxiety portion but not the antipsychotic portion of the care plan. She indicated that all parts of the care plan should be patient-centered.
4. During an interview, on 7/30/2024 at 9:07 A.M., Resident 66 indicated he had a urinary tract infection.
A record review was completed on 8/1/2024 at 8:48 A.M. Diagnoses included, but were not limited to, hypertension, end stage renal disease, neurogenic bladder, Viral hepatitis, and diabetes.
Resident 66's current Physician Orders, dated 7/29/2024, included Cephalexin (antibiotic) 500 mg (milligram) - Give 1 capsule orally every 12 hours for UTI (urinary tract infection) for 5 days.
The record lacked a care plan for the urinary tract infection.
During an interview, on 8/2/2024 at 2:48 P.M., the Director of Nursing indicated there should have been a UTI Care Plan on the chart.
5. During an interview, on 7/29/2024 at 3:03 P.M., Resident 215 indicated he had not had a bowel movement (BM) in 14 days.
The record for Resident 215 was completed on 7/30/2024 at 11:00 A.M. Diagnoses included, but were not limited to: Neurogenic bladder, anxiety, and depression.
A Quarterly Minimum Data Set (MDS) assessment, dated 4/29/24, indicated the resident received opioid medications and received scheduled pain medications.
The documentation for bowel continence, dated July 2024, indicated Resident 215 had no bowel movement documented from July 16 on the night shift to July 22 on the night shift.
The clinical record lacked a person centered care plan for constipation.
During an interview, on 8/5/2024 at 10 :11 A.M., the Director of Nursing indicated there should have been a care plan for constipation.
On 8/2/2024 at 1:11 P.M., the Director of Nursing provided the policy titled,Comprehensive Care Plans, dated 2023, and indicated the policy was the one currently used by the facility The policy indicated . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident right's, 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 . 1. The care planning process will include and assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed .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 practicable physical, mental, and psychosocial well being . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress
3.1-35(a)
2. The record for Resident 10 was reviewed on 7/30/2024 at 2:20 P.M. Diagnoses included, but were not limited to, Alzheimer's disease, schizoaffective disorder, bipolar disorder, mild cognitive impairment and anxiety.
During an interview with Resident 10, on 7/29/2024 at 9:30 A.M., she indicated she could not see very well and her eye glasses were not working. The resident was not wearing her glasses, but a hard covered eyeglass case was noted by the television. The resident indicated she did not think she had seen an eye doctor recently.
The Quarterly Minimum Data Set (MDS) assessment, completed 6/19/2024, indicated her vision was adequate without corrective lenses.
There was no current care plan for Resident 10 related to impaired vision and the need for eye glasses and/or any other intervention to address the resident's impaired vision.
The most recent LTC (Long Term Care) facility evaluation, completed on 7/14/2024 indicated the resident's vision was adequate and she did not utilize corrective lenses.
During an interview, on 7/31/2024 at 1:45 P.M. QMA 13 indicated she had not observed Resident 10 wearing eyeglasses.
During an observation and interview, on 7/31/24 at 1:45 P.M., Resident 10's eyeglass case, located on the dresser in front of her television, was opened and a pair of prescription eyeglasses that looked like bifocals was observed. The resident indicated she was not wearing the glasses because they were not working for her.
During an interview with the MDS coordinator, on 7/31/2024 at 2:00 P.M. she indicated the Social Service Director had completed the section of the MDS pertaining to vision and had inaccurately marked no corrective lenses. The MDS coordinator confirmed Resident 10 did have eyeglasses and the resident had been seen by the in-house eye doctor in March of 2024 and was prescribed bifocal eye glasses. The resident was not due to be seen again for 12 - 15 months from that time.
3. During an observation and interview on 7/29/2024 at 11:34 A.M., alert and oriented Resident 14 indicated he was admitted to the facility with edema to his bilateral below the knee amputation stumps. His prosthetic leg appliances were observed leaning against the wall in his room. He indicated his legs were too swollen to wear the prosthetic legs. The resident's lower thighs, knees and stump areas were observed to be swollen and looked similar in circumference to his upper thighs. A bandage was noted on the bottom of the left stump.
The record for Resident 14 was reviewed on 7/31/2024 at 11:31 A.M. He was admitted to the facility on [DATE] with diagnoses including but not limited to, major depressive disorder, recurrent severe, pressure ulcer stage 3 right lateral hip, chronic pain syndrome, lack of coordination, muscle weakness, type 2 diabetes, insomnia, obsessive-compulsive disorder, history of acquired absence of the left leg and right leg below knee.
The physician's orders for medication included an order, dated 7/29/2024 to administer Lasix (a diuretic medication) 40 mg tablet at bedtime for Inflammation for 3 days. A subsequent order, dated 8/1/2024, indicated the resident had received Lasix 40 mg one tablet at bedtime for Edema.
The admission MDS assessment, completed on 7/12/2024, indicated the resident was alert and oriented, utilized a wheelchair independently for mobility and required moderate assistance for lower body dressing.
The current care plans for Resident 14 did not include a care plan to monitor the resident's edema to his bilateral lower extremity edema. A care plan to address the resident's coronary artery disease diagnosis included an intervention to monitor the resident for edema and other potential complications of the disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide resident-centered activities for 1 of 3 residents reviewed for activities. (Resident 93)
Finding includes:
During an observation on 7/29/2024 at 3:08 P.M., Resident 93 was lying in bed. There was no radio or television on in the room.
On 7/30/3034 at 11:22 A.M., Resident 93 was observed in bed, with a loud hum of the oxygen concentrator and no radio or television playing.
A record review was completed on 7/31/2024 at 8:57 A.M. Diagnoses included, but were not limited to: unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy.
A Quarterly Minimum Data Set (MDS) assessment, dated 6/23/2024, indicated cognitive function could not be assessed due to unresponsiveness. An admission MDS, dated [DATE], indicated activity interview responses had no answers due to non-responsiveness.
During observations on 7/31/2024 at 9:12 A.M. and 2:56 P.M., no music or television was observed to be on in the resident's room.
An Activity Participation Review, dated 3/27/2024 at 10:11 A.M., indicated Resident 93 liked to listen to easy listening music, liked to watch cartoons, talk shows, and Hallmark type of movies.
A Care Plan, dated 3/27/2024, indicated Resident 93 was unresponsive, and her mother would visit weekly. An intervention, dated 4/9/2024, indicated per Resident 93 mother's request, a television or music should be on in the room.
A Progress Note, dated 5/28/2024 at 1:52 P.M., indicated Resident 93's activities preferences from the family as the following:
- It is somewhat important to Resident to listen to music they like. Preferred music genre: Easy listening.
- It is somewhat important for Resident to do their favorite activities. Favorite activities include: Watch television
A Physician's Order, dated 7/6/2024, indicated Resident 93 may participate in activities per her individual plan of care.
The Activity Tasks for the month of July 2024 indicated television was the activity provided for Resident 93 twice daily.
On 8/1/24 at 9:54 A.M., the Activity Director (AD) observed Resident 93's room, and indicated, Oh, there's no television in here. They must have taken it out when she was at the hospital. The AD indicated Resident 93 liked easy listening music and had not received any one-on-one visits since she came back from her hospitalization in July.
A policy was provided by the Director of Nursing, on 8/1/2024 at 12:18 P.M. The policy titled, Activities, indicated, . It is the policy of this facility to provide ongoing program to support in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community
3.1-33(b)(6)(C)
3.1-33(b(8)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure edema was monitored for 1 of 1 residents reviewed for edema. (Resident 14) and failed to ensure antibiotic medication was administered timely for 1 of 2 residents reviewed for antibiotic use. (Resident 99)
Findings include:
1. During an observation and interview on 7/29/2024 at 11:34 A.M., alert and oriented Resident 14 indicated he was admitted to the facility with edema to his bilateral below the knee amputation stumps. His prosthetic leg appliances were noted leaning against the wall in his room. He indicated his legs were too swollen to wear the prosthetic legs. The resident's lower thighs, knees and stump areas were noted to be swollen and looked similar in circumference to his upper thighs. A bandage was noted on the bottom of the left stump.
The record for Resident 14 was reviewed on 7/31/2024 at 11:31 A.M. He was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder, recurrent severe, pressure ulcer stage 3 right lateral hip, chronic pain syndrome, lack of coordination, muscle weakness, type 2 diabetes, insomnia, obsessive-compulsive disorder, history of acquired absence of the left leg and right leg below knee.
The admission Minimum Data Set (MDS) assessment, completed on 7/12/2024, indicated the resident was alert and oriented, utilized a wheelchair independently for mobility and required moderate assistance for lower body dressing.
The current care plans for Resident 14 did not include a care plan to monitor the resident's edema to his bilateral lower extremity edema. A care plan to address the resident's coronary artery disease diagnosis included an intervention to monitor the resident for edema and other potential complications of the disease.
The Nursing Clinical admission Assessment, completed on 7/6/2024, indicated the resident had no edema.
The most recent weekly Skin and Wound assessment and the most recent weekly skin assessments, dated 8/1/2024, indicated the resident's edema was not assessed.
During an interview, on 8/1/2024 at 2:11 P.M., the Rehab (Rehabilitation) Director indicated Resident 14 had been admitted to the facility with significant bilateral edema to his legs and stumps. The edema was present in the resident's thighs and down to his stumps. He indicated the resident was not tolerating the stump shrinker in therapy and due to his edema, he thought the resident had been prescribed a diuretic medication about a week and a half ago.
The physician's orders for medication included an order, dated 7/29/2024, to administer Lasix (a diuretic medication) 40 mg tablet at bedtime for edema for 3 days. A subsequent physician's order, dated 8/1/2024, indicated the resident had received Lasix 40 mg one tablet at bedtime for Inflammation of his stumps.
During an interview with the Medical Record Nurse, on 8/1/2024 at 1:30 P.M. she indicated she was providing nursing coverage for the nursing unit on which Resident 14 resided. If edema was assessed, it would be documented in nursing progress notes, weekly skin assessments and weekly skin and wound assessments, and possibly on shower record sheets. She indicated the shower record sheets were not a part of the clinical record and if edema was noted on the shower record, the nurse should assess the edema and note it on the weekly skin assessments.
During an interview, on 8/5/2024 at 9:00 A.M., the Director of Nursing (DON) indicated the physician and the Nurse Practitioner had assessed the resident's edema. The facility did not have a policy and procedure specific to monitoring for edema.
2. The record for Resident 99 was reviewed on 7/31/2024 at 2:01 P.M. Diagnoses included but were not limited to, diabetes mellitus with hyperglycemia, delusional disorder, unspecified psychosis, dementia, encephalopathy, chronic pain syndrome, insomnia, old myocardial infarction, unsteadiness and lack of coordination.
During an observation and interview with Resident 99, on 7/29/2024 at 10:08 A.M., Resident 99 indicated she was receiving an antibiotic for her infected toe and it was very painful. The resident's right foot was noted to a scabbed area on the top of the toes.
During an observation of wound care on 8/1/2024 at 8:40 A.M. with the Wound Nurse, Resident 99's third toe was noted to have an open area and her toe was red and swollen.
A Nursing Progress Note, dated 7/20/2024, indicated the resident had a blister noted to the right foot middle/3rd toes, the physician had observed the blister and did not want a treatment.
A Nursing Progress Wound Note, dated 7/25/2024, indicated the right foot toe wound was covered with eschar (dead tissue that sheds or falls off from the skin), the periwound was edematous and red, and she recommended an antibiotic.
The physician was notified and an order received on 7/25/2024 for Doxycycline Hyclate (an antibiotic) 100 mg one capsule two times a day for cellulitis of the right third toe. The order was entered and discontinued in the electronic computer system on 7/25/2024. The order was then put in again on 7/26/2024 and discontinued. The current order was then entered in the electronic medical system for the antibiotic on 7/26/2024 at 8:00 P.M. Review of the Medication Administration Record for Resident 99 indicated the scheduled evening dose of Doxycycline for 7/26/2024 was not administered and the resident did not receive the first dose of antibiotic until 7/27/2024 in the morning.
During an interview with the Director of Nursing, on 8/5/2024 at 9:00 A.M., she indicated the facility did not have a policy specific to timeliness of following antibiotic orders. A copy of medications included in the facility's Emergency Drug Kit was requested on 8/4/2024 and 8/5/2024 and not provided prior to the survey exit.
3.1-37

Based on observation, record review, and interview, the facility failed to provide a range of motion program to prevent further contractures for 1 of 2 residents reviewed for range of motion. (Resident 93)
Finding includes:
During an observation on 7/29/2024 at 3:11 P.M., Resident 93 was observed to have her hands in a fist-like position and her knees bent.
On 7/31/2024 at 9:19 A.M., a straight legged, cushioned boot was observed sitting on a table at the end of the resident's bed.
A record review was completed on 7/31/2024 at 8:57 A.M. Diagnoses included, but were not limited to, unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy.
Past Physician's Orders included the following:
- 3/28/2024-6/24/2024 Resting hand splint to right hand in the morning, and remove at night for skin integrity.
- 3/27/2024-6/24/2024 Foot brace to left lower extremity drop foot.
- 3/27/2024-6/24/2024 Passive range of motion to residents upper and lower extremities every shift and can be completed per Qualified Medication Assistant of Certified Nursing Assistant.
A Physician's Order, dated 7/6/2024, indicated physical therapy, occupational therapy, and speech therapy, if indicated.
A Care Plan, dated 3/26/2024, indicated Resident 93 had a physical functioning deficit related to impaired mobility, impaired cognition, incontinence, and required assistance with her activities of daily living. Resident 93 was in a persistent vegetative state. The goal, dated 3/26/2024 and revised on 7/28/2024, indicated Resident 93 would maintain the current level of physical functioning through the next review date of 9/23/2024. Interventions included, monitor and report changes in range of motion ability, and to provide passive range of motion as ordered.
During an interview, on 8/1/2024 at 9:24 A.M., LPN 2 indicated Resident 93 had a passive range of motion program prior to her hospitalization on 6/23/2024 with a return date of 7/6/2024. LPN 2 indicated Resident 93 should be receiving a passive range of motion program, and that her hands and knees were tight. LPN 2 could not provide documentation that a passive range of motion program was being completed. She indicated Resident 93's splints were discontinued due to causing anxiety.
A policy was provided by the Director of Nursing, on 8/1/2024 at 12:18 P.M. The policy titled, Prevention of Decline in Range of Motion, indicated, .Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational consultant shall establish and utilize a systemic approach for prevention of decline in range of motion, including assessment, appropriate care planning, and preventative care
3-1-42(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an appropriate diagnosis for a resident who received an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 28)
Finding includes:
The record for Resident 28 was reviewed on 7/31/2024 at 9:15 A.M. Diagnoses included, but were not limited to, hemiplegia and hemiparesis, cerebral infarction, unspecified dementia, atrial fibrillation, cardiomegaly, hypertension, and anxiety disorder.
Current medications for Resident 28 included Zyprexa (Olanzapine - an antipsychotic) 10 mg (milligram) 1 tablet by mouth at bedtime for dementia with agitation.
A Psychiatric Note, dated 7/24/2024 at 8:09 P.M., lacked an approved diagnosis and documented a plan by the psychiatric provider to continue Zyprexa despite being clinically contraindicated, as benefits outweighed risks.
A professional resource, https://medlineplus.gov/druginfo/meds, indicated the following:
Olanzapine is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) in adults and teenagers [AGE] years of age and older. Olanzapine is in a class of medications called atypical antipsychotics . IMPORTANT WARNING: Studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) who take antipsychotics (medications for mental illness) such as olanzapine have an increased chance of death during treatment. Older adults with dementia may also have a greater chance of having a stroke or mini-stroke during treatment. Olanzapine is not approved by the Food and Drug Administration (FDA) for the treatment of behavior disorders in older adults with dementia. Talk to the doctor who prescribed this medication if you, a family member, or someone you care for has dementia and is taking olanzapine. For more information visit the FDA website: http://www.fda.gov/Drugs.
During an interview on 8/2/2024, at 1:32 P.M., the DON indicated that the resident did not have an appropriate diagnosis for taking the antipsychotic.
On 8/5/2024, at 12:34 P.M., the Director of Nursing provided a policy titled, Unnecessary Drugs - Without Adequate Indication for Use, dated February 2023, and indicated the policy was the one currently used by the facility. The policy indicated .documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed .
3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure food was handled appropriately,
foods were sealed appropriately, and failed to date foods when opened. This had the potential to affect 114 residents of 115 residents who received meals from the kitchen.
Findings include:
1. An initial walk through of the kitchen with the Dietary Manager was completed on 7/29/2024 at 9:35 A.M. The following were observed: in the dry storage area was an opened/undated box of lasagna noodles not sealed, a gallon of vanilla with an opened date of 4/15/2023. In the walk-in cooler was an undated container of gravy and 3 health shakes with an expiration date of 7/23/2024, and an opened and undated box of Cream of Wheat cereal.
2. During a meal observation, on 7/29/2024 at 12:35 P.M., CNA 17 was observed to have her thumb extending over the plates' rim onto the food surface of the plate when serving 2 different residents.
During an interview, on 7/29/2024 at 12:50 P.M., CNA 17 indicated her thumb should be underneath the plate.
3. During an observation, on 7/29/2024, CNA 18 was observed to hold the meal tray on her shoulder with one hand underneath the tray. While she was moving and walking, her hair was observed touching the top of the tray.
During an interview, on 7/29/2024 at 12:58 P.M., CNA 18 indicated she should not put the tray on her shoulders.
On 8/2/2024 at 12:18 P.M., the Director of Nursing provided the policy titled, Date Marking for Food Safety, dated 2024, and indicated the policy was the one currently used by the facility. The policy indicated .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consists of the day/date of opening, and the day/date the item must be consumed or discarded .6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly
A policy was requested on meal tray delivery, but one was not provided prior to the survey exit.
3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure staff change gloves and complete hand hygiene when providing perineal care for 1 of 1 resident reviewed for personal care. (Resident 47)
Finding includes:
During a random observation, on 7/29/2024 at 3:20 P.M., Resident 47 was observed lying on wet bed linens. Resident 47 indicated, they don't clean me up like they should.
During a random observation, on 7/31/2024 at 1:23 P.M., Resident 47's call light was on. CNA 15 was observed answering the light. After the aide exited the residents' room, she indicated the room had a strong urine smell. CNA 15 indicated she smelled the urine and was not sure when he was checked or changed last.
On 7/31/2024 at 1:38 P.M., CNA was observed to provide perineal care to Resident 46. CNA 16 applied gloves and obtained a wash basin and washcloth and a towel. He removed the brief, and with the same area of the washcloth wiped both sides of the residents groin, then washed the penis. He then rinsed the areas with another washcloth. With the same gloves still on, CNA 16 then put the wet brief in the trash bag and moved the covers on the bed. CNA 16 then washed the buttocks and dried the area. He placed the dirty linens along with a rolled up bed sheet that was wet with a large yellow stain on the night stand. CNA 16 obtained a new clean sheet and placed it on the bed. With the same gloves on, the aide then placed a clean brief on the resident. CNA 16 then put the resident's pants on him. He then touched the clean towel and then emptied the basin. The CNA removed the dirty bed linens from the night stand and then placed them in a bag. CNA 16, still with the same gloves on, touched the bedside table placed everything in another bag and left the room without washing his hands.
During an interview, on 7/31/2024 at 1:46 P.M., the CNA indicated he should have changed his gloves and washed his hands.
On 8/1/2024 at 12:25 P.M., the Director of Nursing provided the policy titled,Hand Hygiene, dated 2002, and indicated the policy was the one currently used by the facility. The policy indicated . All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hygiene prior to donning gloves, and immediately after removing gloves
3.1-18(b)

Based on observation, record review, and interview, the facility failed to provide adequate tracheostomy care for 1 of 1 resident reviewed for tracheostomy/ventilation. (Resident 93)
Finding includes:
During an observation on 7/29/2024 at 9:39 A.M., Resident 93's oxygen collar was observed to be to the left of her tracheostomy stoma site.
On 7/29/2024 at 10:44 A.M., Resident 93's oxygen collar was observed to be at left of the tracheostomy stoma site. At 10:49 A.M., Qualified Medication Assistant (QMA) 19 was requested to obtain an oxygen saturation. The saturation level read 85-86 percent. QMA 19 indicated it was due to the way Resident 93 slept, and many interventions had been attempted. A rolled towel was observed on the right side of the neck. At 10:51 A.M., Resident 93's oxygen saturations were observed to be at 89 percent. Resident 93 was repositioned in bed, and at 10:53 A.M., her oxygen saturations were 92 percent.
A record review was completed on 7/31/2024 at 8:57 A.M. Diagnoses included, but were not limited to, unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy.
A Quarterly Minimum Data Set (MDS) assessment, dated 6/23/2024, indicated cognitive function could not be assessed due to unresponsiveness. The assessment indicated Resident 93 received treatments of oxygen therapy, suctioning, and tracheostomy care.
Current Physician's Orders for tracheostomy care included the following:
- 6/24/2024 Disposable Ambu bag (a positive pressure ventilation for a person with insufficient or ineffective breathing, a complete back-up tracheostomy set, and a suction machine set up at bedside.
- 7/7/2024 Continuous humidified oxygen via tracheostomy collar at 5 liter per minute to the stoma, and to call the physician if oxygen saturations were below 90 percent.
- 7/7/2024 Suction as needed for tracheostomy care.
The physician's orders did not include changing the suction canister and tubing weekly and as needed, changing the tracheostomy ties weekly and as needed, routine tracheostomy care and suctioning every shift and as needed, and the tracheostomy tube needed should it be expelled.
A review of the Medication and Treatment Administration Record for July 2024 indicated no entries for tracheostomy care.
A Care Plan, dated 3/26/2024, indicated Resident 93 had a tracheostomy secondary to cerebral vascular accident (CVA), encephalopathy/anoxic brain injury, chronic hypoxic respiratory failure, and a history of traumatic brain injury. The goal, dated 3/36/3034 and updated 7/28/2024, indicated Resident 93 would have adequate gas exchange as evidenced by no adventitious breath sounds, and absence of respiratory distress. The interventions included to administer humidified oxygen as ordered, check oxygen saturations as needed, observe tracheostomy site daily for signs and symptoms of infection, provide tracheostomy care daily as ordered and as needed, suction tracheostomy as ordered and as needed, and to place the tracheostomy tube size above the bedside for emergency use.
During an interview, on 8/1/2024 at 9:12 A.M., LPN 2 indicated tracheostomy care included cleaning it daily and as needed, suctioning as needed, changing the gauze around the tracheostomy daily and as needed, and changing the oxygen collar weekly or as needed. She indicated the tracheostomy did not have an inner cannula to change. All oxygen humidification tubing was changed by an outside vendor. LPN 2 indicated Resident 93 should have had orders for all the care needed for the tracheostomy.
A policy was provided by the Director of Nursing, on 8/1/2024 at 12:18 P.M. The policy titled, Tracheostomy Care, indicated, .The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences
3.1-4(a)(6)

Based on interview and record review, the facility failed to ensure resident funds were available on the same day of the request and for the desired amount for 4 of 4 residents reviewed for facility-managed personal funds. (Residents 18, 5, 31 and 8)
Findings include:
During an interview on 7/29/24 at 10:15 A.M., Resident 18 indicated he was able to obtain money from his facility account between the hours of 9 A.M. and 4 P.M. weekdays, and not at all on Saturday and Sunday.
During an interview on 7/29/24 at 10:54 A.M., Resident 5 indicated he was only able to get five dollars from his facility account on the weekends.
During an interview on 7/30/24 at 9:42 A.M., Resident 31 indicated she could only get money from her facility account until 4 P.M. weekdays, and not at all on Saturday and Sunday.
During an interview on 7/30/24 at 1:15 P.M., Resident 8 indicated she was unable to get money from her facility account after 4 P.M.
During an interview on 7/31/24 at 2:27 P.M., LPN 13 indicated the residents had a five dollar limit that they could take out of their facility accounts.
During an interview on 7/31/24 at 2:13 P.M., the Business Office Manager (BOM) indicated the residents should not have a five dollar withdrawal limit for their facility accounts.
During an interview on 8/2/24 at 2:14 P.M., the Executive Director (ED) indicated he was unaware that staff was telling the residents they had a 5 dollar limit to withdraw from their facility accounts.
On 8/1/24 at 2:32 P.M., the Director of Nursing provided a policy titled, Availability of Resident Funds-After Business Office Hours no date, and indicated the policy was the one currently used by the facility. The policy indicated .During non-business office hours (e.g., nights, weekends, and holidays), the Business Office Manager, or designee, provides the Nurse Supervisor on duty at the time the business office closes a residents' fund petty cash box
3.1-6(a)

Based on observation and interview, the facility failed to ensure medications were available from the pharamacy for 2 of 4 residents reviewed for pain. (Resident 26 & B)
Findings include:
1. A record review was completed on 7/25/2023 at 11:30 A.M. Resident 26's diagnoses included, but were not limited to: Multiple Sclerosis, epilepsy, depression, hypertension and diabetes.
Current physician orders included: Vumerity delayed release capsule 231 mg (milligrams) 2 capsules 2 times a day related to MS (Multiple Sclerosis), and Ascorbic acid (vitamin C) 1000 mg daily.
The June MAR (Medication Administration Record) indicated on June 1st the Vumerity order was documented as (3) hold/see nurses notes. The Nurses Note, dated 6/1/2023 at 9:17 P.M., indicated the Vumerity medication not given pending pharmacy delivery.
The June MAR indicated on June 2nd and 3rd the Vumerity medication was documented as (7) other/see nurses notes.
A Nurse's Note, dated 6/2/2023 at 10:53 A.M., indicated the Vumerity medication needs reordered.
A Nurses' Note, dated 6/2/2023 at 7:37 P.M., indicated Vumerity medication was not available, waiting for pharmacy to deliver.
A Nurse's Note, dated 6/3/2023 at 4:48 A.M., indicated the Vumerity medication was not available, waiting for pharmacy to deliver.
A Nurse's Note, dated 6/3/2023 at 11:36 A.M., indicated the Vumerity medication was not available,waiting on the arrival from pharmacy.
The June MAR indicated on June 9th the Ascorbic Acid medication was documented as a (7) other see nurses notes.
A Nurse's Note, dated June 9th at 7:27 A.M., indicated the medication was not given due to awaiting pharmacy to deliver, nurse aware.
2. A Record review was completed on 7/25/2023 at 2:33 P.M. Resident B's diagnoses included, but were not limited to: rheumatoid arthritis, fractured left hip anemia and depression.
Current physician orders for July, included the following: Rinvoq 15 mg (milligrams) 1 tablet every day for Rheumatoid Arthritis.
The June MAR indicated on 6/30/2023 the Rinvoq medication was documented as a (7) other/see nurses notes).
A Nurses' Note, dated 6/30/2023 at 8:54 A.M., indicted medication unavailable , awaiting pharmacy to deliver.
The July MAR indicated on 7/1, 7/2, 7/3, 7/4, 7/5, and 7/6/2023 the Rinvoq was documented as (7) other/see nurses notes.
The Nurse's Notes dated for July 1st and 2nd lacked the documentation of why the medication was not administered.
The Nurses Note, dated July 3 at 12:49 P.M., indicated the Rinvoq medication was not available.
The Nurses Notes, dated July 4 and 5, lacked the documentation of why the medication was not administered.
The Nurses' Note, dated July 6 at 6:49 A.M., indicated the Rinvoq medication was not available.
The Nurse's Notes, dated July 7, lacked the documentation of why the medication was not administered.
The July MAR indicated on 7/1, 7/2, 7/3, 7/4, 7/5 and 7/6/2023, the Rinvoq was not administered
A current care plan, dated 6/30/2023, indicated Resident B was at risk for pain and discomfort secondary to diagnoses of status post fractured hip, Rheumatoid arthritis, and left hip surgical wound. Interventions included, but were not limited to: administer medications as ordered.
During an interview, on 7/27/2023 at 10:27 A.M., LPN 8 indicated all the medications do not come with the resident when admitted . They have to have the order in the computer/pharmacy before they will send it. The EDK (Emergency Drug Kit) does not have all the medications and indicated the physician should have been notified of the missed med's.
On 7/27/2023 at 1:15 P.M., the Regional Director of Clinical Operations provided the policy titled, Unavailable Medications, undated, and indicated the policy was the one currently used by the facility. The policy indicated .The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn and emergency drugs . The facility shall follow established procedures for ensuring residents have a sufficient supply of medications
This Federal tag relates to Complaint IN00412325.
3.1-25(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were kept in a locked cart when unattended, failed to ensure medication storage areas were free from loose medications; failed to date medications when opened during medication storage reviews for 4 of 4 medication carts observed and 2 of 3 medication rooms observed. (500, 300, 400 and 200 medication carts, 200 and 300 medication rooms)
Findings include:
1. During a random observation, on 7/24/2023 at 5:35 A.M., the 500 Hall medication cart was observed to be unlocked with no staff in site of the cart.
During an interview, on 7/24/2023 at 5:38 A.M., LPN 11 indicated the cart should have been locked.
2. During a medication storage observation, on 7/26/2023 at 9:35 A.M., on the 300 Hall medication cart with LPN 19 the following was observed: a loose pill was noted in a drawer.
During an interview, on 7/26/2023 at 9:38 A.M., LPN 19 indicated there should be no loose pills in the medication cart.
3. During a medication room observation on the 300 Hall, on 7/26/2023 at 9:37 A.M., the medication refrigerator freezer section was full of ice build up.
During an interview, on 7/26/2023 at 9:39 A.M., LPN 19 indicated the freezer should have been defrosted.
4. During a medication storage observation on the 400 Hall, on 7/26/2023 at 9:50 A.M., with QMA 9, the following was observed: the middle hall cart had 1 loose pill in the drawer.
During an interview, on 7/26/2023 at 9:51 A.M., QMA 9 indicated there should be no loose pills in the medication cart.
5. During a medication storage observation, on 7/26/2023 at 10:17 A.M., with LPN 10, on the 200 Hall medication cart the following was observed: 2 loose pills and 3 opened and undated [NAME] lax bottles.
During an interview on 7/26/2023 at 10:19 A.M., LPN 10 indicated there should be no loose pills in the medication cart and the opened containers should have had open dates on them.
6. During a medication storage observation on the 200 Hall medication room with LPN 10 on 7/26/2023 at 10:24 A.M., the following was observed: an expired (4/8/2023) glucose control solution and an expired (7/13/2023) bottle of Liquid Protein.
During an interview, on 7/26/2023 at 10:25 A.M., LPN 10 indicated the expired control solution, and the liquid protein should have been thrown away.
On 7/27/2023, at 1:15 P.M., the Regional Director of Clinical Operations provided the policy titled,Medication Storage, undated, and indicated the policy was the one currently used by the facility. The policy indicated .All drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms)
On 7/27/2023, at 1:15 P.M., the Regional Director of Clinical Operations provided the policy titled,Storage of Medications, dated 11/2018, and indicated the policy was the one currently use by the facility. The policy indicated .B. Medication rooms, carts,, and medication supplies are locked when not attended by persons with authorized access . H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal . Temperature: F. The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day . Expiration Dating (Beyond- use dating) . c. Certain medications, including some multi-dose preparations, may require different dating once opened per regulations/guidelines. d. when the original seal of a manufacture's container or vial is initially broken, it is recommended that a nurse write the date opened on the medication container or vial . F. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining
3.1-25(j)
3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure the ceiling, oven, counters, and floor were clean and in good condition in the main kitchen; failed to ensure refrigerated foods were held at safe temperatures in the walk-in cooler; failed to dispose of expired foods; failed to ensure a refrigerator was clean; and failed to label and date foods brought in by residents, in 2 of 4 pantries (400 & 500 Halls) and the main kitchen. This deficient practice had the potential to affect 95 of 95 residents who received meals out of the kitchen.
Findings include:
1. During an observation of the main kitchen, on 7/20/2023 at 9:45 A.M., with the certified dietary manager (CDM) the following was observed:
A hole in the ceiling directly next to the air conditioning/heating vent that had an open bag of insulation hanging down and insulation was on the floor. Two buckets and four towels were under the vent and water was present on the floor.
The outside of the oven had grease and food debris.
The inside of the oven had a buildup of grease.
The stainless-steel counters had food debris.
Two containers of potato salad that expired on 7/11/2023.
A container of pasta salad with mold made on 6/20/2023 and expired on 6/23/2023.
1 case of rotten lemons with visible mold dated 3/17/2023.
33 individual Jell-O cups with an expiration date of 7/15/2023.
The stand alone refrigerator had 6 pitchers of undated apple juice,7 pitchers of undated lemonade, 1 undated plate of salad, and 1 undated plate with a sandwich.
During an interview, on 7/20/2023 at 10:07 A.M., the CDM indicated that pitchers of juice and lemonade did not contain an expiration date, but the pitchers should have an expiration date.
A single serve milk carton was opened, and the temperature of the milk was 48 degrees.
The temperature on the inside of the cooler registered 50 degrees, and the temperature on the outside of the walk-in cooler registered 48 degrees. The temperature log on the outside of the door indicated the temperatures of the walk-in cooler were:
On 7/17/2023 a morning temperature of 44 degrees with no evening temperature documented.
On 7/18/2023 a morning temperature of 46 degrees and an evening temperature of 50 degrees.
On 7/19/2023 a morning temperature of 46 degrees with no evening temperature documented.
During an interview,conducted at that time, the CDM indicated there was a service order for the leaking vent and the hole was for access to the vents and indicated the hole should be covered, that the oven and counters were dirty and should be clean, the expired food should have been thrown away on or before their expiration date, she indicated the pitchers of juice and lemonade should have an expiration date. The CDM indicated the temperatures of the refrigerator were not within safe storage temperature range and should be within safe storage temperature ranges. The CDM indicated she was notified on 7/20/2023 at 6:00 A.M. that the walk-in cooler was not working, and a service call was placed to have the walk-in cooler repaired.
2. During an observation of the Main Dining Hall, on 7/20/2023 at 11:56 A.M., cottage cheese was observed being served to a resident. The outside temperature of the walk-in cooler was 52 degrees, and the inside temperature registered 50 degrees.
During an interview, on 7/20/2023 at 12:01 P.M., the CDM indicated they were serving the cups of cottage cheese that were sitting in ice at this time. When inquired about where the cottage cheese was taken from, Dietary Aide 3 indicated the cottage cheese was served from the walk-in cooler. The CDM indicated the cottage cheese was only stored in the walk-in cooler and cottage cheese should not have been served.
3. During an observation of the 400 Hall Pantry, on 7/20/2023 at 12:44 P.M., the following was observed:
The rubber seal around the refrigerator door was broken.
There was a sandwich with the date of 7/16/2023.
A bottle of water with no name, and an opened and undated bottle of ensure.
The inside of the fridge was dirty and had a red substance on the bottom.
During an interview, on 7/20/2023 at 12:49 P.M., Licensed Practical Nurse (LPN) 7 indicated they needed a new refrigerator, the food items should have the resident's name and dates on them, and expired items should have been discarded on the date of expiration.
4. During an observation of the 500 Hall Pantry, on 7/20/2023 at 12:52 P.M., the following was observed:
The microwave was dirty with an area that looked as if there were burnt areas.
A broken thermometer in the refrigerator.
During an interview, on 7/20/2023 at 12:56 P.M., LPN 7 indicated the microwave should be clean, and the refrigerator should have had a working thermometer.
On 7/24/2023 at 12:20 P.M., the CDM provided a current policy titled, Use and Storage of Food Brought in by Family or Visitors, and indicated the policy was the one currently used by the facility. The policy indicated .Food items that are already prepared by the family or visitor brought in must be labeled with content and dated .The prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by facility staff
On 7/24/2023 at 1:39 P.M., the CDM provided an undated current policy titled, Date Marking for Food Safety, and indicated the policy was the one currently used by the facility. The policy indicated .Refrigerated, ready-to eat, time/temperature control for safety food (i.e., perishable food) shall be held at a temperature of 41 F [Fahrenheit] or less for a maximum of 7 day. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded
On 7/24/2023 at 1:39 P.M., the CDM provided an undated current policy titled, Sanitation Inspection, and indicated the policy was the one currently used by the facility. The policy indicated .All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects .The sanitation inspections will be conducted in the following manner: Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. Weekly: The dietary manager or designee shall inspect all food service areas 3 times per week to ensure the areas are clean and comply with sanitation and food service regulations.
3.1-21(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment was maintained, related to a broken towel rack, plastic wrapped around the cord of a power strip, stained ceiling tiles, broken heater, dead bugs in the light covers, and black mold on vents. (room [ROOM NUMBER], 217, 303, and 200, 400 and 500 Hall)
Findings include:
During an environmental tour, on 7/27/2023 at 2:30 P.M., with the Maintenance Director, Maintenance Assistant and Account Manager, the following was observed:
room [ROOM NUMBER] had a broken towel rack.
room [ROOM NUMBER] had a power strip plugged into the electric outlet but the cord to the power strip was still wrapped in plastic. The resident was using the power strip to power their television.
There were ceiling tiles on the 200 hallway with large dark stains.
room [ROOM NUMBER] had a broken baseboard heater.
The 500 Hall had dead bugs that could be seen in five light covers.
The 400 Hall had black mold that was observed on two of the air vents above the nurse's station.
During an interview, on 7/27/2023 at 2:54 P.M., the Maintenance Director indicated that there should not be stains on the ceiling tiles. He indicated he was not aware of the broken towel rack and did not have a work order for the broken towel rack. He indicated he was not aware of the plastic on the power strip and the plastic should not be there. The Maintenance Director indicated the power strip was new and not one of the facilities, and that family had likely brought it in. He indicated the power strip had not been tested before being used. In room [ROOM NUMBER], the maintenance director didn't have a work order and didn't know the baseboard heater was broken, and it should not be broken and needed fixed. When asked who is responsible for the dead bugs in the light fixtures, the Maintenance Director indicated the maintenance department was responsible, and that the dead bugs should be remove. When asked how work was prioritized, the Maintenance Director indicated work orders were put in and prioritized based on the work order. The Maintenance Director indicated that daily rounds of the facility included the common areas and main hallways. He indicated that the rooms are broken up into blocks and each room is checked by maintenance personnel quarterly.
On 7/27/2023 at 3:03 P.M., a policy for the use of outside electrical devices was requested.
On 7/27/2023 at 3:04 P.M., a policy for environmental services was requested, but one was not provided.
During an interview, on 7/27/2023 at 3:05 P.M., the Account Manager indicated that the two vents were dirty and should have been cleaned. He indicated floor technicians were responsible for cleaning the vents weekly.
On 7/27/23 at 3:06 P.M., a policy for sanitation of the facility was requested, but one was not provided.
On 7/27/23 at 3:07 P.M., a floor tech cleaning schedule was provided by the Account Manager, and indicated the vents are to be cleaned every Friday.
On 7/27/2023 at 3:22 P.M., the Maintenance Assistant provided an undated policy titled, Electrical Safety, and indicated it was the policy currently used by the facility. The policy indicated .Power strips used in a patient care vicinity must be tested by the maintenance department prior to use. Tests shall include the equipment to be powered by the strip
On 7/27/2023 at 3:22 P.M., the Maintenance Assistant provided a checklist titled, Preventative Maintenance, and indicated it was currently being used by the facility. The checklist included checking baseboard heater, inspect hardware, and inspect electrical outlets.
3.1-19(f)

Based on record review and interview, the facility failed to notify a plysician timely of missed doses of unavailable medication for 2 of 5 residents whose medications were reviewed. ( Resident 26 & B)
Findings include:
1. A record review was completed on 7/25/2023 at 11:30 A.M. Resident 26's diagnoses included, but were not limited to: Multiple Sclerosis, epilepsy, depression, hypertension and diabetes.
Current physician orders included: Vumerity delayed release capsule 231 mg (milligrams) 2 capsules 2 times a day related to MS (Multiple Sclerosis), and Ascorbic acid (vitamin C) 1000 mg daily.
The June MAR (Medication Administration Record) indicated on June 1st the Vumerity order was documented as (3) hold/see nurses notes. The Nurses Note, dated 6/1/2023 at 9:17 P.M., indicated the Vumerity medication not given pending pharmacy delivery.
The June MAR indicated on June 2nd and 3rd the Vumerity medication was documented as (7) other/see nurses notes.
A Nurse's Note, dated 6/2/2023 at 10:53 A.M., indicated the Vumerity medication needs reordered.
A Nurses' Note, dated 6/2/2023 at 7:37 P.M., indicated Vumerity medication was not available, waiting for pharmacy to deliver.
A Nurse's Note, dated 6/3/2023 at 4:48 A.M., indicated the Vumerity medication was not not available, waiting for pharmacy to deliver.
A Nurse's Note, dated 6/3/2023 at 11:36 A.M., indicated the Vumerity medication was not not available, waiting on the arrival from pharmacy.
The June MAR indicated on June 9th the Ascorbic Acid medication was documented as a (7) other see nurses notes.
A Nurse's Note, dated June 9th at 7:27 A.M., indicated the medication was not given due to awaiting pharmacy to deliver, nurse aware.
A general note, dated 6/5/2023 at 12:19 P.M., indicated the Physician's Assistant and the MD were notified of the Vumerity Capsule being missed x 5 doses.
2. A Record review was completed on 7/25/2023 at 2:33 P.M. Resident B's diagnoses included, but were not limited to: rheumatoid arthritis, fractured left hip anemia and depression.
Current physician orders for July, included the following: Rinvoq 15 mg (milligrams) 1 tablet every day for Rheumatoid Arthritis.
The June MAR indicated on 6/30/2023 the Rinvoq medication was documented as a (7) other/see nurses notes).
A Nurses' Note, dated 6/30/2023 at 8:54 A.M., indicted medication unavailable , awaiting pharmacy to deliver.
The July MAR indicated on 7/1, 7/2, 7/3, 7/4, 7/5, and 7/6/2023 the Rinvoq was documented as (7) other/see nurses notes.
The Nurse's Notes dated for July 1st and 2nd lacked the documentation of why the medication was not administered.
The Nurses Note, dated July 3 at 12:49 P.M., indicated the Rinvoq medication was not available.
The Nurses Notes, dated July 4 and 5, lacked the documentation of why the medication was not administered.
The Nurses' Note, dated July 6 at 6:49 A.M., indicated the Rinvoq medication was not available.
The Nurse's Notes, dated July 7, lacked the documentation of why the medication was not administered.
The July MAR indicated on 7/1, 7/2, 7/3, 7/4, 7/5 and 7/6/2023, the Rinvoq was not administered
During an interview, on 7/27/2023 at 11:08 A.M., LPN 8 indicated the physician should have been notified of the missed medications.
On 7/27/2023 at 4:25 P.M., the Regional Director of Clinical Operations provided the policy titled, Unavailable Medications, undated and indicated the policy was the one currently used by the facility. The policy indicated .Notify physician of inability to obtain medication upon notification or awareness that medication is not available
3.1-5(a)

Based on interview and record review, the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were accurately completed for 3 of 3 residents whose Advanced Directives were reviewed. (Resident 71, 72, & 4)
Findings include:
1. A record review was completed on 7/21/2023 at 2:21 P.M. Resident 71's Physician Orders for Scope of Treatment (POST) form lacked the following documented information: the printed treating physicians name; the date; the office telephone number and the physician's licenses number.
2. A record review was completed on 7/24/2023 at 6:31 A.M. Resident 74's Physician Orders for Scope of Treatment (POST) form lacked the following documented information: the date; the office telephone number and the physician's licenses number.
3. A record review was completed on 7/21/2023 at 1:45 P.M. Resident 84's Physician Orders for Scope of Treatment (POST) form lacked the following documented information: the printed treating physicians name; the date; the office telephone number and the physician's licenses number.
During an interview, on 7/27/2023 at 11:12 A.M., the Regional Director of Clinical Operations indicated the post forms were not completed and should have been.
On 7/27/2023 at 11:13 A.M., a policy was requested regarding advance directives/POST forms, but one was not provided.
3.1-4(I)(7)

Based on observation and interview, the facility failed to ensure standards of care of visually observing a resident take their medications was followed for 1 of 1 residents randomly observed. (Resident 75)
Finding includes:
On 7/20/2023 at 11:14 A.M., a souffle cup with 4 pills was randomly observed on the resident's bedside table.
During an interview, on 7/20/2023 at 11:14 A.M., Resident 75 indicated they brought them in and I have until later to take them.
During an interview, on 7/20/2023 at 11:28 A.M., LPN 20 indicated the pills should not have been left at the bedside, and stated after leaving the residents room that she had watched the resident take her medications that morning and did not know where the medications on the bedside table came from.
On 7/27/2023 at 1:15 P.M., the Regional Director of Clinical Operations provided the policy titled, Medication Administration-Preparation and General Guidelines, dated 10/2017, and indicated the policy was the one currently used by the facility. The policy indicated .18. The resident is always observed after administration to ensure that the dose was completely injested
3.1-11

Based on observation, record review, and interview, the facility failed to provide sanitation of the continuous positive airway pressure (C-Pap) equipment for 1 of 3 residents reviewed for supportive respiratory usage. (Resident 15)
Finding includes:
During an observation on 7/20/2023 at 10:19 A.M., Resident 15's continuous positive airway pressure (C-Pap) mask was lying over the top of the machine on the bedside table.
A record review for Resident 15 was completed on 7/25/2023 at 10:36 A.M. Diagnoses included, but were not limited to: morbid obesity and renal dialysis.
A Physician's Order, dated 6/22/2023, indicated a C-Pap at bedtime and as needed.
During an interview on 7/26/2023 at 1:03 P.M., Resident 15 indicated the C-Pap tubing, mask, and canister had not been cleaned at the facility.
On 7/26/2023 at 1:04 P.M., LPN 7 indicated there was not an order for washing the mask, tubing, or canister. The only order related to the C-Pap was to wear the C-Pap at night and as needed.
On 7/27/2023 at 1:07 P.M., a policy titled, CPAP/BiPAP Cleaning was provided by the Regional Director of Clinical Operations. The policy indicated, .It is the policy of this facility to clean CPAP/BiPAP equipment in accordance with current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection .Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use .Weekly cleaning activities: Wash headgear/straps in warm, soapy water and air dry. Wash tubing with warm, soapy water and air dry
3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure showers were provided timely for 1 of 3 residents reviewed for activity of daily living (ADL) care. (Resident 47)
Finding includes:
During an interview on 7/20/2023 at 11:15 A.M., Resident 47 indicated he was not receiving his showers routinely, and staff would state they were out of hot water or there was not enough staff to complete the shower.
A record review was completed on 7/24/2023 at 11:53 A.M. Diagnoses included, but were not limited to: left below the knee amputation, muscle weakness, and chronic obstructive pulmonary disease.
A 5-Day Minimum Data Set (MDS) Assessment, dated 6/17/2023, indicated Resident 47 was dependent with the assistance of one staff member for bathing.
On a Significant Change MDS Assessment, dated 5/9/2023, Resident 15 indicated it was very important to him to chose between a tub bath, shower, bed bath or sponge bath.
The Tasks section of the electronic medical record indicated Resident 47's showers were scheduled for Tuesdays and Fridays.
A Care Plan, dated 3/23/2022, and revised on 5/31/2023, indicated resident 47 had a physical functioning deficit. An intervention included assistance with staff member for bathing.
On 7/26/2023 at 9:59 A.M., a shower binder that had shower documentation sheets from June 2023 to July 2023 was reviewed. Resident 47 had the following shower documentation sheets dated: 6/20/2023, 7/11/2023, 7/14/2023, and 7/18/20023.
A review of showers documented in the electronic medical record indicated no showers were provided in June 2023, and showers were provided on 7/6/2023 and 7/12/2023.
During an interview on 7/26/2023 at 9:26 A.M., LPN 7 indicated showers are documented on a shower sheet and within the electronic medical record. She indicated residents should get a shower twice a week unless the resident requested for additional shower days.
On 7/26/2023 at 10:29 A.M., LPN 6 reviewed the shower binder. She was able to find one additional shower sheet, and indicated no more shower sheets were available.
During an interview on 7/26/2023 at 11:28 A.M., Resident 47 indicated he did not receive a shower yesterday. Resident 47's hair was observed to be greasy in the front and sides of his head.
On 7/27/2023 at 1:07 P.M., the Regional Director of Clinical Operations provided the policy titled, resident Showers. The policy indicated, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per standards of practice .Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety
3.1-38(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide a care plan for the use of a continuous positive airway pressure (C-Pap) device for 1 of 28 residents reviewed for care plans. (Resident 15)
Finding includes:
During an observation on 7/20/2023 at 10:19 A.M., Resident 15's continuous positive airway pressure (C-Pap) mask was lying over the top of the machine on the bedside table.
A record review was completed on 7/25/2023 at 10:36 A.M. Diagnoses included,but were not limited to: morbid obesity and renal dialysis.
A Physician's Order, dated 6/22/2023, indicated a C-Pap at bedtime and as needed.
A care plan was not located in the medical record for use of the C-Pap.
During an interview on 7/26/2023 at 1:09 P.M., the MDS Coordinator indicated an order was placed for the C-Pap at admission on [DATE]. She indicated Resident 15 should have a care plan for the use of the C-Pap.
On 7/27/2023 at 1:07 P.M., a policy titled, Comprehensive Care Plans was provided by the Regional Director of Clinical Operations. The policy indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that 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
3.1-35(b)(1)

Based on record review and interview, the facility failed to provide transfer form information for 1 of 3 residents reviewed for hospitalization. (Resident 72)
Finding include:
During an interview, on 7/20/2023 at 3:03 P.M., Resident 72 indicated he had gone to the hospital 2 weeks ago.
A clinical record review was completed on 7/24/2023 at 2:12 P.M., Resident 72's diagnoses included, but were not limited to chronic kidney disease stage 3, obstructive and Reflux Uropathy, diabetes and depression.
A Nurse's Note, dated 7/12/2023 at 8:45 P.M., indicated: QMA on staff contacted this writer to assess resident left Nephro tube, upon assessment this writer found left tube to be leaking urine from insertion site resident entire shirt soiled with urine. No urine noted in left leg bag and blood noted in tubing. On call NP (Nurse Practitioner) called - new orders to send resident to emergency room.
A general note, dated 7/13/2023 at 2:32 A.M., indicated the resident returned from the hospital.
During an interview, on 7/26/2023 at 10:00 A.M., the Regional Director of Clinical Operations indicated they could not provide any transfer form documentation for the resident and there should have been one.
On 7/26/2023 at 10:55 A.M., the Regional Director of Clinical Operations provided the policy titled, Transfer and Discharge (including AMA), undated, and indicated the policy was the one currently used by the facility. The policy indicated .For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner who was responsible for the care of the resident; Resident representative information, including contact information; Advance directive information; Resident status, including baseline and current mental , behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; Medications (including when last received) ; and Most recent relevant labs, other diagnostic tests, and recent immunizations . Emergency Transfers/Discharges .The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record
3.1-12(25)(A)

Based on interview and record review, the facility failed to ensure pertinent transfer and resident clinical information was completed for 1 of 3 residents reviewed for transfers. (Resident 72)
Finding includes:
During an interview, on 7/20/2023 at 3:03 P.M., Resident 72 indicated he had gone to the hospital 2 weeks ago.
A clinical record review was completed on 7/24/2023 at 2:12 P.M., Resident 72's diagnoses included, but were not limited to chronic kidney disease stage 3, obstructive and Reflux Uropathy, diabetes and depression.
A Nurse's Note, dated 7/12/2023 at 8:45 P.M., indicated: QMA on staff contacted this writer to assess resident left Nephro tube, upon assessment this writer found left tube to be leaking urine from insertion site resident entire shirt soiled with urine. No urine noted in left leg bag and blood noted in tubing. On call NP (Nurse Practitioner) called - new orders to send resident to emergency room.
A general note, dated 7/13/2023 at 2:32 A.M., indicated the resident returned from the hospital. Left nephrostomy tube was changed without incident and is draining clear, yellow urine.
During an interview, on 7/26/2023 at 10:00 A.M., the Regional Director of Clinical Operations indicated they could not provide any transfer form documentation for the resident and there should have been one
On 7/26/2023 at 10:55 A.M., the Regional Director of Clinical Operations provided the policy titled, Transfer and Discharge (including AMA), undated, and indicated the policy was the one currently used by the facility. The policy indicated .For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner who was responsible for the care of the resident; Resident representative information, including contact information; Advance directive information; Resident status, including baseline and current mental , behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; Medications (including when last received) ; and Most recent relevant labs, other diagnostic tests, and recent immunizations . Emergency Transfers/Discharges .The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record
3.1-12(a)(9)