Cobblestone Crossings Health Campus

Based on record review and interview, the facility failed to prevent physical and mental abuse of a resident by a staff member during resident transfer for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:An Indiana report form, dated 10/10/25 at 6:01 p.m., indicated CNA (Certified Nursing Aide) 2 had reported CNA 4 had rushed Resident B during care. CNA 4 was suspended, and an investigation was initiated. Residents with a BIMS (Brief Interview for Mental Status) of 8 or above were interviewed and skin checks completed on residents with a BIMS below 8 were completed. In-service trainings were started with staff. Resident B was to be monitored for psychosocial well-being.A clinical record review for Resident B was completed on 10/22/25 at 11:30 a.m. Diagnoses included Alzheimer's disease, depression, and total urinary and bowel incontinence.An admission Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident had severe cognitive impairment. She had difficulty communicating some words or finishing thoughts but was able, if prompted or given time, and could usually understand although missed some part/intent of a message but comprehends most conversation. She had no behaviors, no delusions or hallucinations, and no rejection of care. The resident used a wheelchair for mobility and was dependent on staff for all activities of daily living. She was totally incontinent of bowel and bladder and had a fall in the last month before admission.A health care plan, dated 9/19/25, indicated resident was at risk for skin breakdown related to mobility, weakness, Alzheimer's disease, and received hospice services. The goal was for resident's skin to remain intact. Interventions included to avoid shearing skin during positioning, turning, and transferring.A health care plan, dated 9/19/25, indicated Resident B required staff assistance to complete self-care and mobility functional tasks completely and safely. The goal was the resident would have functional needs met safely by staff. Interventions included to allow resident sufficient time to complete all or parts of tasks and to not rush the resident.A health care plan, dated 9/30/25, indicated resident's profile care guide included maximum assistance of two staff members for transfers.An Investigation Summary, dated 10/12/25 at 6:00 p.m., provided by the Administrator on 10/22/25 at 12:01 p.m., indicated a staff member had reported a concern about an interaction with CNA 4 during care with Resident B. The staff member felt CNA 4 had rushed the resident during care.A nursing progress note, dated 10/10/25 at 4:40 p.m., (recorded as a late entry on 10/12/25 at 6:47 a.m.) indicated physical and psychological assessments were completed. The resident was smiling, responsive and without distress. No physical injuries were noted and no bruising was noted at this time. Will continue to observe and update as needed.A care conference note, dated 10/12/25 at 9:30 a.m., with resident's husband, indicated the following: Discussed occurrence regarding incident with team member and provided information to resident husband. Resident husband stated that resident does become combative at times, and DHS [Director of Health Services] stated that should not affect care that is given, and it is the resident's right to be treated fairly. Resident's husband stated that he was grateful for the follow-up with this situation. DSS [Director of Social Services] to continue to check on resident daily x3 days and assess for psycho-social well-being. Will continue to hold care conferences as needed and quarterly.During a telephone interview, on 10/22/25 at 12:12 p.m., CNA 4 indicated she only knew of one incident when the resident was in bed and when she reached for her brief to change her, she kicked her in the face and knocked her glasses off. She responded by picking up her glasses and leaving the room after making sure the resident was covered and safe. She returned a bit later and she was cooperative with care, and she was able to provide it. The staff told her that she had not explained what she was going to do with the resident prior to performing care and that was why she reacts in that manner. She had no problem with her prior to this. She reported that the resident kicked her in the face. She did not have any injury to her face except a small scratch where her glasses had scratched her. She was suspended about a week after this occurrence. She had no other incidents that she recalls following that. The DON (Director of Nursing) indicated that she had to jump through hoops not to report her license. The DON indicated that it was because of CNA 4's tone and attitude and that was why she was being suspended. She would not have had an attitude with Resident B due to her dementia, and she was very aware of how to care for a resident with dementia. If they start to become upset, she will leave and come back (if safe to do so). She was not told what incident they were referring too. She was fired without explanation except her tone, attitude. She has felt like the DON had it out for her since the DON started with the facility. During an interview on 12/22/25 at 1:58 p.m., the Corporate Nurse Consultant indicated she had received a phone call from the DON regarding an incident that had been reported to her where CNA 4 had rushed a resident during care. They did not think her approach was appropriate when transferring a resident. During investigation many resident's were interviewed. She indicated the residents had no concerns with the CNA or any staff members.During a telephone interview on 10/22/25 at 4:19 p.m., CNA 7 indicated when she entered Resident B's room on 10/9/25 around 8:00 p.m., the room chair (not her wheelchair) was scooted closer to the bed. CNA 4 had her left hand on the back of the chair and her right arm linked under the resident arm, pulling and yanking her up. She stopped yanking on Resident B's arm when she saw CNA 7 in the doorway. The resident was resisting getting out of the chair and trying to move away. The resident was laughing angrily with her teeth gritted and showing. CNA 4 was heard saying, come on get up, we gotta get up, in a loud voice, repetitively. CNA 7 indicated she asked CNA 4 to leave the room. CNA 4 started talking about what was going on and CNA 7 repeated her request that she leave the room. She would not leave the room. CNA 7 got on her knees next to the chair to speak with Resident B to calm her down as she was very upset. At that time, LPN 8 entered the room and asked CNA 4 to leave the room. CNA 4 left the room at that time. CNA 7 indicated she was able to calm Resident B down within about five minutes and was able to transfer her to bed without issues. During a telephone interview on 10/22/25 at 4:37 p.m., LPN 8 indicated she was outside the room when CNA 4 had been pulling and jerking Resident B's arm. Resident B had been asleep in the recliner and CNA 4 had entered the room and pulled the room chair close to the bed without speaking to the resident. The resident woke up with CNA 4 pulling her arm to transfer her to bed. Resident B got very upset. LPN 8 indicated to CNA 4 to stop what she was doing and leave the room. She indicated to CNA 4 she would find other help to transfer Resident B to bed. When she arrived back to the room, she observed CNA 7 on the floor next to Resident B's chair and CNA 4 standing on the other side of the chair. Apparently CNA 4 had returned to the room when she had gone to find CNA 7, and CNA 4 had observed her again tugging on Resident B's arm. She asked CNA 4 at that time to again leave the room.During an interview on 10/23/25 at 10:20 a.m., the Administrator indicated they had not felt the incident constituted abuse. CNA 4 would not return to the facility to speak with her about the incident, so they decided to part ways. When she spoke with CNA 4 on the telephone she was not willing to acknowledge the requests to leave the room, and truly could not understand any errors in her behavior. The Administrator did feel CNA 4 would be safe to work with a dependent resident given more training and she did not feel she needed reported to the Board of Nursing for investigation.During a phone interview on 10/23/25 at 1:04 p.m., Resident B's husband indicated the incident happened on a Friday and he was not informed until he received a phone call on Sunday at noon. The DON called and said there had been an incident on Friday. It was a little situation that escalated to a point they felt they needed to suspend the staff member. That was all he had been told. She indicated they had looked Resident B over and they had not observed any bruising or redness. He was told they were going to investigate the incident and would inform him of the details when completed. She told him that under no circumstances would they allow a resident to be treated like that and it should not have happened. The employees know it was not allowed at this facility. He felt she was trying to figure out if he was going to make a thing out of it. He remains in the dark about the specifics of what occurred. It had been a couple weeks now and he still had no specific information.During a telephone interview on 10/23/25 at 1:37 p.m., the DON indicated she had spoken to Resident B's spouse on the phone in the middle of the investigation and had told him the details of the occurrence. She indicated during her investigation she had spoken to residents and other staff members. She did not feel CNA 4 had intent to harm the resident. She did not feel it was an abuse situation due to the lack of intent. She felt CNA 4 was focused on getting her task completed of getting the resident to bed, so even though she was asked to leave by other employees, she returned to complete her task. She could not speak to what CNA 4 was thinking by returning after being asked to leave.An in-service document used for staff education, titled, Preventing, Recognizing, and Reporting Abuse & Neglect, provided by the Administrator on 10/22/25 at 12:01 p.m., included the following: Physical Abuse Definition includes hitting, slapping, pinching, spitting, holding or handling roughly, etc. It also includes controlling behavior through corporal punishment.Examples.Staff to resident abuse with or without injury; Staff member pulls a resident in order to make them move more quickly.This citation relates to Intake 2641594.3.1-27(a)(1)

Based on record review and interview, the facility failed to report an incident of potential resident abuse by a staff member in a timely manner to the Administrator for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:An Indiana report form, dated 10/10/25 at 6:01 p.m., indicated CNA (Certified Nursing Aide) 2 had reported CNA 4 had rushed Resident B during care. CNA 4 was suspended, and an investigation was initiated. Residents with a BIMS (Brief Interview for Mental Status) of 8 or above were interviewed and skin checks completed on residents with a BIMS below 8 were completed. In-service trainings were started with staff. Resident B was to be monitored for psychosocial well-being.A clinical record review for Resident B was completed on 10/22/25 at 11:30 a.m. Diagnoses included Alzheimer's disease, depression, and total urinary and bowel incontinence.An admission Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident had severe cognitive impairment. She had difficulty communicating some words or finishing thoughts but was able, if prompted or given time, and could usually understand although missed some part/intent of a message but comprehends most conversation. She had no behaviors, no delusions or hallucinations, and no rejection of care. The resident used a wheelchair for mobility and was dependent on staff for all activities of daily living. She was totally incontinent of bowel and bladder and had a fall in the last month before admission.A health care plan, dated 9/19/25, indicated resident was at risk for skin breakdown related to mobility, weakness, Alzheimer's disease, and received hospice services. The goal was for resident's skin to remain intact. Interventions included to avoid shearing skin during positioning, turning, and transferring.A health care plan, dated 9/19/25, indicated Resident B required staff assistance to complete self-care and mobility functional tasks completely and safely. The goal was the resident would have functional needs met safely by staff. Interventions included to allow resident sufficient time to complete all or parts of tasks and to not rush the resident.A health care plan, dated 9/30/25, indicated resident's profile care guide included maximum assistance of two staff members for transfers.An Investigation Summary, dated 10/12/25 at 6:00 p.m., provided by the Administrator on 10/22/25 at 12:01 p.m., indicated a staff member had reported a concern about an interaction with CNA 4 during care with Resident B. The staff member felt CNA 4 had rushed the resident during care.A nursing progress note, dated 10/10/25 at 4:40 p.m., (recorded as a late entry on 10/12/25 at 6:47 a.m.) indicated physical and psychological assessments were completed. The resident was smiling, responsive and without distress. No physical injuries were noted and no bruising was noted at this time. Will continue to observe and update as needed.During an interview on 12/22/25 at 1:58 p.m., the Corporate Nurse Consultant indicated she had received a phone call from the DON on 10/10/25 at 4:40 p.m., indicating on 10/9/25 at around 8:30 p.m., LPN 8 had observed an incident with Resident B and CNA 4, where CNA 4 had was pulling on Resident B's arm in an effort to transfer her from her chair to her bed. An investigation was started at that time. LPN 8 had indicated to her that she had performed a head-to-toe assessment of Resident B, but had failed to document the incident or the assessment in the clinical record. She had not taken vital signs or completed a pain assessment following the incident. The facility follows their policy regarding any needed assessments. A current facility policy, undated, titled, Abuse and Neglect Procedural Guidelines, provided by the Administrator on 10/22/25 at 12:01 p.m., included the following: .Identification.ii. Any person with knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal.iv. Immediately notify the Executive Director.This citation relates to Intake 2641594.3.1-28(c)

Based on record review and interview, the facility failed to ensure medication was administered after a critical lab result and labs were re-checked as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications (Resident 34). Findings include:Resident 34's record was reviewed on 8/22/25 at 10:26 a.m. Diagnoses on the resident's profile included, but were not limited to, hypokalemia (low potassium) and unspecified atrial fibrillation (irregular and rapid heart rate). A quarterly Minimum Data Set (MDS) assessment, dated 7/14/25, indicated the resident had a severe cognitive impairment. A lab report, dated 7/9/25, indicated the resident had a low potassium level of 3.4 millimoles (mmol)/liter (L). The normal range was 3.5 to 5.1 mmol/L. A lab report, dated 8/5/25, indicated the resident had a critically low potassium level of 2.6 mmol/L. The lab reported the critically low potassium to the facility at 5:42 p.m. An abnormal, critical lab event, dated 8/5/25, indicated the resident's potassium level was 2.6 mmol/L, which was a critically low level. The physician and resident representative were notified. A Medication Administration Record (MAR), dated August 2025, included the following physician's orders: -A physician's order, dated 6/27/25 and discontinued on 8/5/25, indicated potassium chloride extended release particles/crystals 20 milliequivalents (mEq) by mouth twice daily. -A physician's order, dated 8/5/25, indicated potassium chloride extended release particles/crystals 20 mEq, administer 40 mEq, one time only at 5:30 p.m. The MAR indicated the medication was not administered because it was unavailable. The MAR lacked documentation the physician was notified of the missed medication administration. -A physician's order, dated 8/5/25, indicated potassium chloride extended release particles/crystals 20 mEq, administer 40 mEq, one time only at 11:30 p.m. The MAR indicated the medication was not administered because it was unavailable. The MAR lacked documentation the physician was notified of the missed medication administration. -A physician's order, dated 8/6/25, indicated potassium chloride tablet extended release 20 mEq, give 40 mEq daily. A nursing progress note, dated 8/5/25, indicated the lab called to report a critical potassium level. The physician was notified, and new orders were received. An interdisciplinary team (IDT) progress note, dated 8/6/25, indicated a critical potassium lab was reported to the physician, and new orders were received. The note lacked documentation the physician was notified the medication was not administered as ordered. A pharmacy recommendation observation, dated 8/12/25, indicated the resident's potassium level was 2.6 mmol/L on 8/4/25. The resident's diuretic medication was reduced. The pharmacist recommended the lab be re-checked. The recommendation lacked documentation the extra doses of potassium were not administered as ordered by the physician. The physician accepted the recommendation and agreed to re-check the lab. A lab report, dated 8/23/25, indicated the resident had a critically low potassium of 2.7 mmol/L. The resident's record lacked documentation the resident's potassium level was re-checked prior to 8/23/25. A progress note, dated 8/23/25 at 10:41 a.m., indicated the lab notified the facility the resident had a critically low potassium level. The physician was notified and ordered a one-time dose of potassium 40 mEq by mouth. The note lacked documentation the physician was notified the previous extra doses of potassium were not administered. A progress note, dated 8/23/25 at 5:36 p.m., indicated the resident was given 40 mEq of potassium due to lab results. During an interview, on 8/22/25 at 1:40 p.m., the Regional Nurse Consultant indicated although the resident already had potassium ordered, medications came pre-packaged per med pass, and there were no extra doses of potassium available. Potassium was available in the emergency drug kit (EDK), but she thought the nurse had trouble accessing it. The potassium should have been pulled from the EDK and administered to the resident, on 8/5/25. If the potassium was not administered, the physician should have been notified. The physician did not order the lab to be re-checked at that time. During an interview, on 8/22/25 at 3:13 p.m., the Regional Nurse Consultant indicated she reviewed what was available in the EDK, and the potassium in the EDK was a different formulation than what was ordered. The nurse should have notified the physician what potassium was available in the EDK. There was also a back-up pharmacy they could have ordered potassium from to be delivered to the facility. During an interview, on 8/25/25 at 10:12 a.m., the Regional Nurse Consultant indicated the lab was drawn to re-check the resident's potassium level on 8/14/25, after the physician agreed to the pharmacy recommendation on 8/12/25. There was a problem with the specimen and the lab was not completed. She was not sure if the lab had been re-drawn. During an interview, on 8/25/25 at 11:52 a.m., the Regional Nurse Consultant indicated the lab was re-drawn on 8/23/25 to re-check the resident's potassium level. The lab should have been re-drawn before 8/23/25, but it had been missed. The lab faxed notifications if there were issues with labs, and the fax may have been missed. On 8/22/25 at 3:13 p.m., the Regional Nurse Consultant provided an undated list of medications available in the EDK. The list indicated potassium chloride 20 mEq/15 milliliters (ml) and potassium chloride extended release 10 mEq capsules were available in the EDK. On 8/22/25 at 3:13 p.m., the Regional Nurse Consultant provided a document titled, Medication Orders, last revised in January 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe.Procedures.D. The prescriber is contacted by facility personnel for direction when delivery of a medication will be delayed or the medication is not or will not be available. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (catheter-a thin, flexible tube inserted into the bladder to drain urine, which is held in place by a small, inflatable balloon and connected to a drainage bag) was maintained in a sanitary condition, for 1 of 2 residents reviewed for urinary catheters (Resident 33). Findings include:During an initial observation, on 8/21/25 at 12:05 p.m., Resident 33 was in the therapy room sitting in her wheelchair (WC). The resident's catheter bag (receptacle to collect urine) was in contact with the floor. During a random observation, on 8/21/25 at 1:59 p.m., the resident was sitting in her WC in the lounge area. Her catheter bag was in contact with the floor. During a random observation, on 8/25/25 at 1:32 p.m., the resident was asleep in her bed. The catheter bag was hanging from the side of the bed. The bag was in contact with the base of her overbed table (a mobile, adjustable-height table designed to be rolled over a bed, chair, or couch to provide a convenient surface for eating, working, or holding personal items while a person is in a recumbent or seated position). Resident 33's record was reviewed on 8/26/25 at 9:00 a.m. The profile indicated the resident diagnoses included, but were not limited to, flaccid neuropathic bladder (when the bladder cannot effectively squeeze to empty itself, leading to urinary retention and potential overflow, caused by nerve damage). An admission Minimum Data Set (MDS) assessment, dated 7/17/25, indicated the resident had moderate cognitive deficit and had an indwelling urinary catheter. A care plan, dated 8/20/25, indicated the resident had an active diagnosis of urinary tract infection (UTI-an infection in any part of your urinary system, most caused by bacteria that enter the body and multiply in the bladder). Interventions included, but were not limited to, use proper infection control precautions as indicated and per policy. The record lacked documentation of a specific care plan related to the resident's catheter. A McGeer's criteria (standardized definitions and guidelines for diagnosing infections in long-term care [LTC] residents, used for surveillance to identify actual infections and estimate their prevalence, not for guiding immediate treatment decisions) infection tracking report, dated 8/19/25, indicated the resident had a healthcare acquired (developed in the facility) UTI. During an interview, on 8/26/25 at 9:16 a.m., the Regional Nurse Consultant indicated the expectation was that catheter bags, or the tubing should never be allowed to contact the floor or any other object. ON 8/26/25 at 11:36 a.m., the Regional Nurse Consultant provide a document, dated 12/16/24, titled, Preserving Dignity with Indwelling Catheter, and indicated it was the policy currently used by the facility. The policy indicated, .1. General guidelines.e) Urinary drainage bags and catheter tubing should be kept from touching the floor surface. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure foods were disposed of after the use by date, cold foods were maintained at a safe temperature on the salad bar, beard restraints were effectively worn, and employee drinks were not kept in food prep areas during 4 of 4 kitchen observations. This deficient practice had the potential to affect 40 of 40 residents who received food from the kitchen. Findings include:During an initial kitchen tour with the Food Services Director, on 8/21/25 at 10:20 a.m., a container of French toast mix was labeled with a use by date of 8/19/25. At the same time, the Food Service Director indicated the date on the container was the last date the food was able to be used, and she disposed of the French toast mix. During a continuous lunch observation, on 8/21/25 from 11:30 a.m. to 12:06 p.m., a salad bar was observed with cottage cheese and hard boiled eggs. Three residents were served food from the salad bar. At 12:06 p.m., the Food Services Director indicated the temperature of the cottage cheese was 53 degrees Fahrenheit (F), and the temperature of the hard boiled eggs was 55 degrees F. The Food Services Director indicated foods on the salad bar should have been held at 40 degrees F or below, and she removed the food from salad bar. During a kitchen observation, on 8/26/25 at 9:15 a.m., [NAME] 9 was placing food onto a plate. [NAME] 9 was wearing a beard cover, but it was pulled down below his mouth, exposing his mustache. During a kitchen observation, on 8/26/25 at 10:42 a.m., Dietary Corporate Support 10 was filling small cups with condiments. In the same area an unopened energy drink was observed. At the same time, the Food Service Director indicated employee drinks should not have been in food prep areas, and she threw the drink away. During an interview, on 8/26/25 at 10:53 a.m., the Food Services Director indicated all facial hair was required to be contained in the beard cover. The employee's beard cover should not have been pulled down below his mustache. On 8/22/25 at 8:55 a.m., the Executive Director (ED) provided a document titled, Food Production Guidelines, last revised on 7/9/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purpose of this policy is to: To provide clear direction and understanding of safe and sanitary handling of food during food production.Policy: Safe and sanitary handling of food will be employed during food production. Procedure.5. Food is served as soon after preparation as possible and is held at the following.Hold food-COLD = 41 F or below. 6. Leftovers must be dated, labeled, covered, and immediately refrigerated or frozen for later use. Refrigerated leftover must be used within 72 hours. On 8/26/25 at 11:35 a.m., the Regional Nurse Consultant provided a document titled, [NAME] and Hairnet, last revised on 7/9/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purpose of this policy is to: Beards and mustache hair must be covered while in kitchen food product areas. Facial hair restraints are required in any food production area. Facial hair is not exempt from the hair restraining standard.Procedure: Some common approaches include: cover all beard or mustache hair that is more than 1/8 of an inch growth. On 8/26/25 at 11:58 a.m., the Regional Nurse Consultant provided an untitled, undated document and indicated it was the policy currently being used by the facility. The policy indicated, .410 IAC [Indiana Administrative Code] 7-24-136 Eating, drinking.Sec. 136. (a) Except as specified in subsection (b), an employee shall.eat and drink food.only in designated areas where the contamination of: (1) exposed food.cannot result. (b) A food employee may drink from a closed beverage container if the container is handled in a manner that prevents contamination of the following.(3) Exposed food. 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure lab tests were completed as ordered by the physician, for 1 of 5 residents reviewed for unnecessary medications (Resident 6). Findings include:Resident 6's record was reviewed on 8/25/25 at 9:04 a.m. The profile indicated the resident's diagnoses included, but were not limited to, alcoholic cirrhosis of the liver (severe, irreversible scarring of the liver caused by long-term, heavy alcohol use) and unspecified psychosis (when a person exhibits symptoms of psychosis, such as hallucinations or delusions, but the information is insufficient to diagnose a specific psychotic disorder). A quarterly Minimum Data Set (MDS) assessment indicated the resident had no cognitive deficit and indicated no documented behaviors. A care plan, dated 12/17/24, indicated the resident had a history of inappropriate behaviors. A care plan, dated 2/21/19, indicated the resident had a history of altered behaviors. A pharmacy recommendation, dated 12/24/24, recommended to draw a CMP (complete metabolic panel-a group of blood tests that measures 14 different substances in the blood to assess the body's chemical balance and overall health), CBC (complete blood count- a common blood test that measures the number of different cells in the blood), B-12 ( a medical test that measures the amount of vitamin B12 [an essential nutrient vital for making healthy red blood cells, keeping nerves and brain cells healthy] in the blood), TSH (thyroid stimulating hormone- measures the amount of TSH in the blood, which is produced by the pituitary gland to signal the thyroid gland to make thyroid hormones), and FT3 (measures the amount of free or active triiodothyronine [T3 hormone- a thyroid hormone that regulates your metabolism, energy use, and body temperature by controlling the speed at which your body uses calories] circulating in the bloodstream). The document indicated the physician accepted the recommendation to get the lab work completed. The record lacked documentation that the lab work had been completed as ordered. During an interview, on 8/25/25 at 11:52 a.m., the Regional Nurse Consultant indicated she was unable to locate any of the labs that had been ordered. She was unaware why the lab work had not been completed as ordered. She was unable to find any progress notes to explain why the labs had not been completed. When the physician agreed with the pharmacy recommendation for the labs, it was the physician's order to complete the lab work. On 8/25/25 at 11:55 a.m., the Regional Nurse Consultant provide a document, dated 9/12/17, titled, Physician-Provider Notification Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure. 1. Resident.ordered labs and/or other diagnostic tests should be completed in a timely manner. 3.1-48(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure assistance was provided for activities of living (ADLs) for residents unable to carry out ADLs on their own for 4 of 16 residents reviewed for ADLs (Residents 34, 3, 11, and 36). Findings include: 1. On 8/21/25 at 2:57 p.m., Resident 34 was observed with long, untrimmed fingernails, with dark debris underneath them, on both hands.
On 8/25/25 at 10:06 a.m., Resident 34 was observed with long, untrimmed fingernails, with dark debris underneath them, on both hands.
Resident 34's record was reviewed on 8/22/25 at 10:26 a.m. Diagnoses on the resident's profile included, but were not limited to, unspecified dementia with agitation and major depressive disorder.
A quarterly Minimum Data Set (MDS) assessment, dated 7/14/25, indicated the resident had a moderate cognitive impairment and required substantial/maximal assistance from staff for personal hygiene.
A profile care guide care plan, dated 3/22/25, indicated the resident was scheduled for a shower on Tuesdays and Fridays day shift.
Point of care bathing documentation, dated July 2025, indicated the resident received four showers during the month. The point of care record lacked documentation the resident refused care.
Point of care bathing documentation, dated August 2025, indicated the resident received one shower during the month. The point of care record lacked documentation the resident refused care.
Progress notes, dated July and August 2025, lacked documentation the resident refused bathing, showers, or nail care.
During an interview, on 8/25/25 at 10:38 a.m., Licensed Practical Nurse (LPN) 7 indicated fingernail care should have been completed with showers. Activities also provided manicures once a week. There were no paper shower sheets anymore, and bathing was documented in the electronic record. If the resident refused a shower, they should have had the resident sign something stating they refused, but that normally would have been the paper shower sheet. Since they no longer used paper, she was not sure what the resident should have signed with refusals. The aides should have documented any care refusals in the electronic record.
During an interview, on 8/25/25 at 1:20 p.m., the Regional Nurse Consultant indicated nail care should have been provided with showers and as needed, but there was no specific facility nail care policy. Showers should have been provided as scheduled, and shower refusals should have been documented for each scheduled shower. Resident 34 refused care at times, but she was unable to provide documentation the resident refused showers or nail care.
2. On 8/21/25 at 2:06 p.m., Resident 3 was observed with a full beard and mustache. At the same time, the resident indicated he had not received a shower since his admission because he had a port in his chest for dialysis, and the staff did not want to get it wet. The resident wanted to be clean shaven and asked to be shaved several times. The resident indicated the staff told him he needed to be on the list to be shaved.
On 8/25/25 at 10:07 a.m., the resident was observed with a full beard and mustache. At the same time, the resident indicated he had not been shaved since his admission to the facility despite asking staff for assistance numerous times. He did not want to have a beard.
Resident 3's record was reviewed on 8/26/25 at 10:02 a.m. Diagnoses on the resident's profile included, but were not limited to, end stage renal disease (condition in which the kidneys have permanently lost their ability to function properly) and dependence on renal dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so).
Census information indicated the resident was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) assessment, dated 7/31/25, indicated the resident had a moderate cognitive impairment and required substantial/maximal assistance from staff for showers and bathing.
Progress notes, dated July and August 2025, lacked documentation the resident refused showers or shaving.
A Life Enrichment Assessment, dated 8/4/25, indicated it was very important to the resident to choose the type of bath he received, and he preferred showers.
A profile care guide care plan, dated 8/5/25, indicated the resident was scheduled for a shower on Mondays and Thursdays, evening shift.
An ADL care plan, dated 8/5/25, indicated the resident required staff assistance to complete self-care and mobility functional tasks completely and safely. Interventions included, but were not limited to, offer facial shaving on shower days, as needed, or as requested, and notify the nurse of refusals.
Point of care bathing documentation, dated August 2025, indicated the resident received one shower during the month. The bathing record lacked documentation the resident refused showers.
During an interview, on 8/26/25 at 1:57 p.m., the Regional Nurse Consultant indicated residents' bathing preferences were determined during the life enrichment assessment. The shower schedule was updated according to this assessment.
During an interview, on 8/26/25 at 2:00 p.m., Certified Resident Care Assistant (CRCA) 11 indicated residents should have been shaved with showers and as needed. She was not told anything about Resident 3's beard and just thought he wanted a long beard. The resident was scheduled for showers.
3. On 8/21/25 12:09 p.m., during an initial observation and interview Resident 11 indicated there was not enough staff to provide for her care needs, and she had not received a shower since admission. She had requested a shower and none had been given.
On 8/22/25 9:46 a.m., during an interview the resident indicated she still had not received a shower. Noted her hair was oily and unkept. Resident indicated she wanted her hair washed.
On 8/22/25 at 10:00 a.m., the medical record of Resident 11 was reviewed. The record indicated the resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side and right dominant side, type 1 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life).
An admission Minimum Data Set (MDS) assessment, dated 8/13/25, indicated the resident required assistance with bathing and transfers and indicated the resident's cognition was moderately impaired.
A care plan, dated 8/20/25, indicated the resident required assistance with daily care needs. Interventions included but not limited to assist with ADL (activities of daily living) care as needed.
A care plan, dated 8/11/25, indicated Profile Care Guide, interventions included but not limited to shower Tuesday and Friday evenings.
The record lacked documentation of showers being administered since admission to the facility on 8/8/25. The nurse progress notes lacked documentation of resident refusals.
On 8/22/25 at 2:10 p.m., during an interview the Regional Nurse Consultant (RNC) indicated the residents should have a shower at a minimum of twice weekly unless the resident had an alternate preference.
On 8/25/25 at 10:13 a.m., during an interview the RNC indicated the resident had refused several offers of showers. She indicated the software system did not indicate the refusal by the resident. She indicated the care plan had not included shower preferences.
4. On 8/21/25 at 2:01p.m., during initial observation and interview noted Resident 36 with heavy beard growth. During interview the resident indicated he preferred to be shaved, and the staff usually shaved him or assisted him to shave. He could not remember the last time he had been shaved.
On 8/22/25 at 2:45 p.m., the medical record of Resident 36 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but were not limited to paroxysmal atrial fibrillation and Congestive Heart Failure (CHF).
A quarterly MDS, dated [DATE], indicated the resident required assistance with daily care needs and was cognitively intact.
A care plan, dated 3/6/25, indicated resident will have functional needs met safely by staff.
A care plan, dated 3/6/25, indicated showers will be administered on Monday and Thursday evenings.
A care plan, dated 3/6/25, indicated to offer facial shaving on shower days, prn (as needed), or as requested. Notify nursing of refusals.
A review of the medical record indicated the resident did not receive a shower from 5/26/25 to 8/7/25. From 8/7/25 to 8/25/25 the resident received two showers and the months of The record indicated other was provided 24 times.
On 8/25/25 at 10:13 a.m., during an interview the RNC indicated she did not know what other indicated on the care record.
On 8/26/25 at 9:27 a.m., during an interview Licensed Practical Nurse (LPN) 4 indicated she was not sure of the policy regarding shaving, but she assumed it was to be done on shower days or if they ask.
On 8/26/25 at 9:34 a.m., during routine observation noted the resident had not been shaved and had a heavy beard growth. He indicated he was planning to have the staff assist him to shave. The resident could not recall when he had been administered a shower.
On 8/26/25 at 11:35 a.m., the RNC provided a document titled, Guidelines for bathing preferences, dated 12/17/24, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The resident shall determine their preference for bathing upon admission. A. Day of week. B. Time of day – morning or evening. Type of bathing – tub bath, bed bath or shower.4. Bathing shall occur at least twice a week unless resident preference states otherwise.
3.1-38(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired medication was disposed of and failed to ensure medication was stored properly for 1 of 4 medication carts reviewed for medication storage. (Resident 16).Findings include:1. On [DATE] at 8:45 a.m., the back 200 hall medication cart contained an opened insulin pen with an open date of [DATE]. The insulin pen contained a label that indicated it was for Resident 16. During an interview, on [DATE] at 8:46 a.m., Certified Resident Medication Aide (CRMA) 5 indicated insulin was good for 28 days once opened and the pen should have been discarded because it was expired.Resident 16's record was reviewed on [DATE] at 9:29 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus with hyperglycemia (a chronic condition that happens when you have persistently high blood sugar levels). A physician order, dated [DATE], indicated to administer insulin lispro (insulin medication) 100 unit/ml (milliliter), give 5 units by subcutaneous (under the skin) injection before meals, three times a day. 2. On [DATE] at 8:29 a.m., the back 200 hall medication cart contained an opened multi-use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution and had an open date of [DATE]. The vial contained a pharmacy label that indicated the vial was to be refrigerated. During an interview, on [DATE] at 8:30 a.m., Certified Resident Medication Aide (CRMA) 5 indicated she was unaware of how long the Aplisol vial had been in the medication cart and when the vial was not in use it should be refrigerated. She indicated the vial would have to be disposed of since it was not refrigerated and she had no idea how long it hadn't been refrigerated.On [DATE] at 11:36 a.m., the Regional Nurse Consultant (RNC) provided a document with a revised date of 11/18, titled, Medication Storage in the Facility, and indicated it was the current policy being used by the facility. The policy indicated, .1) A date opened sticker shall be placed on the medication.The expiration date of the vial of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guideline require different dating.E. The medication administration personnel will check the expiration date of each medication before administering it. F. No expired medication will be administered to a resident. G. All expired medication will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.On [DATE] at 1:28 p.m., the RNC provided an undated document, titled, Tuberculin PPD-Aplisol Bioequivalent, and indicated it was the currently policy being used by the facility. The policy indicated, .The product should be stored between 2 degrees and 8 degrees Celsius (36- and 46-degrees Fahrenheit) and protected from light. 3.1-25(j)3.1-25(m)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician and resident representative of the unavailability of medication and refusal of medication by the resident for 1 of 5 residents reviewed for unnecessary medications (Resident 4). Findings include:On 8/22/25 at 11:01 a.m., the medical record of Resident 4 was reviewed. The record indicated the resident was admitted to the facility on [DATE]. Admitting diagnosis included but was not limited to, respiratory failure (a serious medical condition where the lungs are unable to provide enough oxygen to the body or remove enough carbon dioxide, or both) with hypoxia (a condition where the lungs can't get enough oxygen from the air into the blood), unspecified dementia (a group of brain disorders that cause a gradual decline in cognitive abilities), unspecified mood affective disorder (a category of mental illness where a person's persistent emotional state is significantly disturbed, leading to extreme highs or lows).A care plan, dated 2/17/25, indicated social aspects, Dementia. Interventions included but were not limited to administer medications per orders.A care plan, dated 7/2/25, indicated the resident was at risk for pain. Interventions included but were not limited to administer medications as ordered and notify MD (medical doctor) for any side effects observed or lack of effectiveness.A physician order indicated to administer Colace 100 mg (milligram) 1 tablet once daily, for constipation.A physician order indicated to administer a multivitamin tablet 1 daily.A physician order indicated to administer Eliquis 5 mg twice daily for anticoagulant (blood thinner)A physician order indicated to administer Lasix 20 mg once daily for edema (swelling)A physician order indicated to administer Sertraline 100 mg once daily for depressionA physician order indicated to administer Tramadol - Schedule IV (narcotic) 50 mg three times a day for pain.A physician order indicated to administer Ciloxan (Ciprofloxacin) ointment 3%, 1 drop each eye every 4 hours, antibiotic eye drops.Review of the Electronic Medication Administration Record (EMAR) from 6/1/25 to 6/30/25 indicated the resident refused 18 doses of Eliquis 5 mg, refused 5 doses of Lasix 20 mg, and refused 34 doses of Tramadol 50 mg.From 7/1/25 to 7/31/25, the resident refused 18 doses of Eliquis and refused 37 doses of Tramadol.From 8/1/25 to 8/22/25, the resident refused 12 doses of Ciloxan, and refused 8 doses were unavailable from the pharmacy. The resident refused 6 doses of Eliquis and refused 23 doses of Tramadol.The medical record lacked documentation the Physician or resident representative were notified of medication refusal or of the medication being unavailable from the pharmacy for July 2025 or August 2025.A quarterly Minimum Data Set Assessment, dated 8/18/25, indicated the resident was cognitively impaired.On 8/26/25 at 9:00 a.m., during interview the Regional Nurse Consultant (RNC) indicated the resident had refused antibiotic eye drops several times and the staff had difficulty administering them to her.On 8/26/25 at 9:15 a.m., during interview Licensed Practical Nurse (LPN) 4 indicated the policy was to notify the physician and the family if a resident refused medications.She indicated if it was a more serious medication she would notify the physician immediately of any refusals.On 8/25/2025 at 1:19 p.m., the RNC provided a document, titled, Physician-Provider notification Guidelines, dated 12/17/24, and indicated it was the policy currently being used by the facility. The policy indicated, . The purpose of this policy is to ensure the resident's physician or practitioner.is aware of all diagnostic testing or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care.11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record.3.1-5(a)

Based on observation, record review, and interview, the facility failed to ensure resident's confidential information was maintained in a secure and private manner for 3 of 3 random observations (Residents 18, 3, and 43). Findings include:1.During a random observation, on 8/26/25 at 11:01 a.m., the 200-hall medication cart was unattended. The computer screen was open and Resident 18's medication screen was exposed. At the same time, another resident was standing directly next to the medication cart, looking on top of the cart as if she was looking for something. Two visitors were speaking with a resident outside of a room directly across from the medication cart.
On 8/26/25 at 11:09 a.m., Certified Resident Medication Aide (CRMA) 5 returned to the medication cart, then immediately walked away from the cart again, and went into the pantry room to get a resident some ice, without closing the computer and securing Resident 18's personal information.
On 8/26/25 at 11:11 a.m., CRMA 5 returned to the medication cart and began assisting another resident. She failed to close the lid to the computer until the screen went to sleep mode.
Resident 18's record was reviewed on 8/26/25 at 11:23 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (a long-term condition where the lungs struggle to get enough oxygen into the blood, leading to a dangerously low oxygen level in the body's tissues and organs) and atrial fibrillation (a condition where the upper chambers of the heart [atria] beat irregularly and rapidly).
A quarterly Minimum Data Set (MDS) assessment, dated 7/24/25, indicated the resident had no cognitive deficit.
During an interview, on 8/26/25 at 11:20 a.m., the Regional Nurse Consult indicated the resident's private information should not have been exposed. The computer should be closed when the staff is not at the medication cart.
During an interview, on 8/26/25 at 11:39 a.m., Resident 18 indicated her privacy was very important to her and she did not want her personal information exposed for anyone to see.
2. During the medication administration pass, on 8/26/25 at 8:12 a.m., Certified Resident Medication Aide (CRMA) 5 walked away from the medication cart and entered a resident's room down the hallway. The computer screen was open and Resident 3's medication screen was exposed along with her name, date of birth , age, allergies, and code status. There were 2 residents sitting near the medication cart and other residents ambulating down the hallway at the time. The CRMA didn't return to the cart until 8:16 a.m.
Resident 3's record was reviewed on 8/27/25 at 8:23 a.m. The profile indicated the resident's diagnoses included, but were not limited to, metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance), meningitis (acute or chronic inflammation of the protective membranes covering the brain and spinal cord), and non-Hodgkin lymphoma (condition occurs when the body produces too many abnormal lymphocytes, a type of white blood cell).
An admission Minimum Data Set (MDS) assessment, dated 7/31/25, indicated the resident had moderate cognitive impairment.
3. During a random observation, on 8/26/25 at 1:19 p.m., the back 200 hall medication cart computer was open and Resident 43's medication screen was exposed along with her name, date of birth , age, allergies, and code status. There were no staff around at this time and 2 residents were in the sitting area by the medication cart. CRMA 5 returned to the cart at 1:20 p.m.
Resident 43's record was reviewed on 8/27/25 at 8:27 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (a condition where the lungs are unable to provide enough oxygen to the body over a prolonged period, leading to low oxygen levels in the blood) and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe).
A quarterly Minimum Data Set (MDS) assessment, dated 7/17/25, indicated the resident was cognitively intact.
During an interview, on 8/27/25 at 8:28 a.m., Licensed Practical Nurse (LPN) 12 indicated when she walked away from her medication cart, she would make sure that she minimized the computer screen, or hit the walk away button so that residents' private information wasn't exposed to anyone walking by.
On 8/25/25 at 1:19 p.m., the Regional Nurse Consultant (RNC) provided a document with a date of 11/21, titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.2. Our residents have a right to.C. Have their records containing personal and financial information kept confidential.
3.1-3(o)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident during a dressing removal resulting in a laceration to her left lower extremity caused by bandage scissors for 1 of 3 reviewed for nursing services (Resident B).
Findings include:
During a telephone interview on 6/19/25 at 1:20 p.m., Resident B's family member indicated the laceration sustained during a wound dressing change had become infected and was treated with an oral antibiotic. It was almost healed now and had a small scab at the end of the cut remaining. She was upset when the event occured and she felt the nurse was not competent regarding the dressing removal. The laceration should have never occurred and was another thing the resident had to heal from.
During an interview on 6/20/25 at 9:40 a.m., LPN 2 indicated she was in the middle of medpass on 4/1/25 when Resident B's family member asked her to come take off a dressing on the resident's left knee because she felt it was too tight. She paused her medpass and went to the resident's room. The dressing was gauze wrapped around her knee and was about 4-5 inches in width. She inserted the dull end of her bandage scissors under the dressing and to cut the dressing. The resident moaned a little as she was cutting the dressing. When she had finished and removed the gauze, she noted there was a superficial cut into the resident's skin that was about three inches long. The cut was scantly bleeding. She cleaned it with wound wash and covered it with a white bordered dressing. The gauze dressing that was removed was covering a small, V-shaped skin tear. She notified the ADON and the physician. The family member was very upset and LPN 2 apologized to the family member. She had not seen the wound since it happened and was unaware of the condition of the wound following the event. The resident had edema and the dressing was tight. She felt the skin was puffy under the dressing from the edema and caused the cut. She felt that since the dressing was so tight, she should have unwrapped the dressing as opposed to cutting through it.
A review of Resident B's clinical record was completed on 6/19/25 at 10:46 a.m. Diagnoses included liver disease, dementia, ascites, and edema.
An admission Minimum Data Set (MDS) assessment, dated 4/2/25, indicated the resident was severely cognitively impaired was dependent on staff for showering, lower body dressing, bed mobility, and moving from sit to stand.
A nursing progress note, dated 4/1/25 at 8:54 p.m., indicated LPN 2 was in Resident B's room when her family member pointed out a dressing on resident's left knee and indicated it was too tight and needed removed. The dressing was dated 3/30/25. LPN 2 cut off the old dressing to the left knee and the dressing scissors accidentally cut into resident's skin causing a cut 8 cm (centimeters) by 0.1 cm with scant bleeding. She cleansed the area and applied a dressing. The family member had been in the room and was very upset. The physician was notified by text message. The ADON was notified by phone call.
Wound Management Detail Reports regarding a left calf skin tear below a wound on her left knee, included the following:
a. Initial observation, dated 4/2/25, entered by LPN 2 indicated the resident had a cut to her left upper calf, measuring 8 cm by 0.1 cm.
b. Observation, dated 4/9/25, entered by the ADON indicated the wound was improving with some bruising around the site. The physician had ordered a prophylactic oral antibiotic and bacitracin to the site. The measurements remained the same.
c. Observation, dated 5/26/25, entered by the wound nurse, indicated the wound had healed. Measurements indicated 0 cm x 0 cm.
An interdisciplinary team (IDT) note, dated 4/2/25 at 10:05 p.m., indicated the nurse from the evening shift was asked by Resident B's family member to remove a bandage that was in place to her left knee. The family member had concerns regarding the bandage being tight related to swelling that was present to her left lower extremity. When the nurse removed the dressing, the bandage scissors came in contact with the resident's skin making a very superficial linear cut. The nurse was able to stop the bleeding and cleansed the area and applied a dressing. The physician was notified. The family member was present when this occurred. Education was provided to the nurse on removal method of a bandage. Area was assessed today by the wound nurse and a dressing order was updated accordingly for the area of impairment.
A nursing progress note, dated 4/6/25 at 8:17 a.m., indicated the physician observed the resident's wound to her left calf. The physician ordered laceration to be cleaned and bacitracin applied and covered with a dressing. The physician ordered Keflex (an antibiotic to treat infection) 500 mg (milligram), take three times daily for 10 days as a prevention measure to prevent infection. He ordered a tetanus booster to be administered. The resident's family member was notified.
An infection control event, dated 4/6/25, indicated the resident had a laceration to her left lower leg. Infection developed after admission on [DATE]. The signs and symptoms were identified as redness, warmth, and sanguineous drainage. Medications administered on 4/6/25, included Booster Tdap (diphtheria, pertussis, and tetanus) intramuscular injection and cephalexin (generic for Keflex) 500 mg.
A current facility policy, revised 2/23/23, titled, Guidelines for General Wound and Skin Care, provided by the DON on 6/20/25 at 5:53 p.m., included the following: Purpose Statement. The purpose of this policy is to: To provide measures that will promote and maintain good skin integrity .Procedure. The following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity .19. Use care when removing all dressings and tapes.
This citation relates to Complaint IN00461032.
3.1-45(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete thorough assessments for a resident with edema, lower extremity conditions, and weight gain for 1 of 3 residents reviewed for quality of care (Resident B).
Findings include:
A review of Resident B's clinical record was completed on 6/19/25 at 10:46 a.m. Diagnoses included liver disease, dementia, acute kidney failure, ascites, localized edema, and severe protein-calorie malnutrition. The resident was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) assessment, dated 4/2/25, indicated the resident was severely cognitively impaired, was dependent on staff for showering, lower body dressing, bed mobility, and moving from sit to stand.
The resident's weights were as follows:
a. admission weight was recorded on 4/4/25 at 85.4 lbs (pounds);
b. On 5/9/25, approximately 1 month post admission, the resident's weight had increased 15.22% to 98.4 lbs.
c. At the time of discharge, on 5/29/25, the resident's weight had increased 24.12% to 106 lbs.
Acute Care Hospital Progress note, dated 3/24/25, indicated Resident B had been admitted to the hospital on [DATE] following a right femur fracture as a result of a fall at home. The note included mild to moderate free fluid to right upper quadrant of the abdomen and moderate volume ascites (abnormal buildup of fluid in the abdomen, specifically within the peritoneal cavity), small-moderate left pleural effusion (fluid around the lung), difuse body wall edema complatible with anasarca (a severe, generalized swelling due to an excessive buildup of fluid in the body's tissues). The note included plans for further evaluation of ascites when medically ready following plan to discharge to the extended care facility.
A Clinically at Risk assessment, dated 5/9/25, indicated the resident had a significant weight gain. The potential cause was indicated as due to a change in meal intake and eating much better. The resident had been receiving fortified foods and nutritional supplements. The physician was notified and agreed to changes of condition, new orders, and plan of care. The resident's family was notified and agreed to changes of condition, new orders, and plan of care.
A New Onset of Edema Event, dated 5/25/25, indicated the resident had edema to her left and right legs and feet. The severity was indicated as 1 plus pitting edema and was present bilaterally. Interventions indicated to administer diuretic, apply elastic stockings, elevate extremities, and administer antibiotics.
During a telephone interview on 6/19/25 at 1:20 p.m., Resident B's family member indicated she had complained to staff multiple times about the resident's increasing abdominal size and swelling in her lower legs. This just fell on deaf ears. The physician indicated not to worry about it and just blew off the swelling in the resident's legs. The staff ended up putting compression stockings on the resident that caused hematomas and dark discoloration and were very painful. She refused to allow staff to apply the stockings after seeing what the stockings did to the resident's legs after just one day. She took the resident to her regular primary care physician and he had her transferred to a local emergency room for evaluation because of her condition. The local emergency department performed multiple tests before transferring her to a larger hospital for treatment. She indicated the hospital performed a procedure to drain a large amount of fluid from the resident's abdomen. Her biggest complaint about the facility was they would not listen to her concerns about the resident's increased fluid retention. The facility told her over and over, the resident was just gaining weight from better nutrition. The facility basically just ignored her concerns and the resident's discomfort. When the resident was transferred to the acute care hospital from the emergency department visit, she was admitted and eventually had three liters of fluid drained from her abdomen.
During an interview on 6/19/25 at 2:59 p.m., the Nurse Consultant indicated the resident had been see by the facility physician two times during her stay. When she first came into the facility she had swelling on her right lower extremity. She had some weight loss and was started on supplements. She began to develop edema in her bilateral lower extremeties and the physician was aware. She felt the physician was contacted and had provided orders.
A nursing progress note, dated 5/29/25 at 12:26 p.m., indicated the resident had no edema to her bilateral lower extremities.
The Emergency Department records were obtained on 6/20/25, and indicated on 5/29/25 at 5:11 p.m, the physician examined the resident's legs to be swollen and cold to touch. The resident had presented to the emergency room complaining of intermittent bilateral lower extremity swelling. The resident's family member indicated she was concerned about the resident's weight gain and development of a hematoma on the left lower extremity during her stay at the rehabilitation facility. The assessment indicated the resident had 2 to 3 plus pitting edema to her bilateral lower extremities. Her arms were equally cold to touch. There was a blood blister on the resident's left shin. The resident was sent to the emergency department by her primary care physician for concerns with leg swelling. The resident's family member had indicated she was treated for a femur fracture from a fall and had been at a nursing home for rehabilitation. She reported the resident had declined since being there, had bilateral lower extremity edema and a blister to her shin now. Her abdomen was more distended than usual per the resident. The resident was discharged to an another acute care hospital from the emergency department on 5/29/25 at 10:01 p.m. for further treatment.
The acute care hospital was contacted and additional hospital records requested with no response.
During an interview on 6/20/25 at 10:24 a.m., the Wound Nurse indicated the resident was examined 5/27/25. It had been reported that the resident had been having problems with edema in the evenings. She had 1 plus pitting edema to her bilateral lower extremities and her legs were discolored and a purpilish color for her entire stay. A blister developed after her compression stockings had been removed that had been applied on 5/25/25. She saw her on 5/26/25 and the blister had reabsorbed. She was not aware of any abdominal swelling or weight gain.
During an interview on 6/20/25 at 3:03 p.m., the Nurse Consultant indicated the resident's edema had been documented as present in some assessments and absent in some assessments. On 5/29/25, the documentation of no edema was entered for the nursing assessment. The resident's emergency department documentation of 2 to 3 plus edema on assessment on the day of her visit which was 5/29/25 and the documentation of no edema, as entered by the facility nurse assessment, could have been in error, and she could not say if it was present, but she had to go with what the nurse had documented as no edema.
A facility policy for Change of Condition was provided, but lacked a policy regarding this concern.
This citation relates to Complaint IN00461032.
3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper cleaning and storage of nasal cannula and CPAP (continuous positive airway pressure) mask and tubing for 1 of 2 residents reviewed for respiratory care (Residents 201).
Findings include:
On 7/7/24 at 12:05 p.m., observed Resident 201, lying down in his room, resting. Oxygen was being administered at 3 L (liters) per nasal cannula (a thin flexible tube device to provide supplemental oxygen therapy to people who have lower oxygen levels) there was no date indicated on oxygen tubing and did not observe a dated storage bag in the room.
On 7/8/24 at 2:52 p.m., during routine observation, Resident 201 was lying in bed. Oxygen was being administered per nasal cannula at 3 L. There was no date on the oxygen tubing and did not observe an oxygen or CPAP (continuous positive airway pressure) (a machine that uses mild air pressure to keep breathing airways open while you sleep) dated storage bag in the room.
On 7/9/24 9:13 a.m., observed the resident sitting in wheelchair. The oxygen nasal cannula tubing was lying on the couch next to the resident. Did not observe an oxygen or CPAP dated storage bag the room.
On 7/9/24 8:46 a.m., during an interview Licensed Practical Nurse (LPN) 4 indicated the night shift changed oxygen tubing and the nurse did not normally date the tubing.
On 7/9/24 at 9:30 a.m., during an interview the Director of Health Services (DHS) indicated the oxygen tubing was not dated; the bag was dated and changed monthly. She indicated the physician's order to clean the mask and place it in bag was for the CPAP mask not the oxygen mask.
On 7/9/24 at 10:18 a.m., the clinical record for Resident 201 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, 5/31/24 acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), 4/12/24 cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), unspecified, chronic atrial fibrillation (an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart), 11/4/20 chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), unspecified, obstructive sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep), dyspnea (difficult, painful breathing or shortness of breath). Type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (the kidneys are damaged and can't filter blood the way they should).
Physician orders included, but were not limited to, Albuterol sulfate solution for nebulization (used to treat shortness of breath and wheezing) 2.5 mg (milligrams)/3 mL (milliliters) (0.083 %); amount: 3 ml; inhalation admin as needed for SOB (shortness of breath or wheezing every 6 Hours - as needed. Eliquis (apixaban) (used to treat blood clots) tablet; 5 mg; amt: 5 mg; oral twice a day. Empty biliary drain every shift three times a day. O2(oxygen) - Change oxygen tubing monthly once a day on the 1st of the month. O2- CPAP at 14 cm H2O (water) pressure with oxygen at 3 liters at NOC (night) as needed during the day at bedtime (continuous positive airway pressure) a machine that uses mild air pressure to keep breathing airways open while you sleep. (Oxygen) O2- mask and tubing should be cleaned weekly with soapy water and rinsed. Air dry and place mask in clean setup bag once a day on Sun. O2- Oxygen at 3L (liters) per nasal canula continuous three times a day.
An admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact and required maximum assistance of two persons for (ADL) activities of daily living and required oxygen during the look back period.
A care plan dated 4/14/2024 indicated the resident had potential for complications, functional and cognitive status decline related to respiratory disease related to: COPD, sleep apnea. Interventions included, but were not limited to, Administer oxygen per orders. CPAP at night, Resident to wear CPAP machine at night.
On 7/9/2024 at 11:14 a.m., the Regional Nurse Consultant provided a document, titled, Respiratory Equipment, dated 12/31/23, and indicated it was the policy currently being used by the facility. The policy indicated, . SOP Details .2. j. Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use .3 .f. Store circuit in plastic bag, marked with date and resident's name between uses
3.1-47(a)(6)

Based on observations, interviews, and record review, the facility failed to ensure a medication self-administration assessment was completed for 1 of 3 residents reviewed for respiratory (Resident 11).
Findings include:
During an initial interview with Resident 11 on 7/7/24 11:12 a.m., observed an inhaler located on her bedside table. The label indicated it was Trelegy Elipta 100 micrograms (mcg)/62.5 micrograms (mcg)/ 25 mcg, and the dose indicator read to have 29 of 30 doses left. The resident indicated that the inhaler was hers, she always had it, and she also normally had her emergency inhaler in her room but could not find it, so staff were ordering her another one.
During a random observation on 7/9/24 at 2:32 p.m., observed two vials of nebulizer solution medication on Resident 11's bedside table. The resident indicated that it was her medication, normally she would set it up herself, but the wrist brace made it difficult to open the vials. When asked about the inhaler that was on her bedside table, she indicated that staff left the Trelegy Ellipta inhaler in her room every day for her to take, and she gave it back to them later, then mentioned again that she was supposed to have a rescue inhaler in her room, but she lost it, and seemed to lose everything.
A record review for Resident 11 was completed on 7/8/24 2:01 p.m. The profile indicated the resident's diagnoses included, but were not limited to, bipolar II (a form of mental illness), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), chronic obstructive pulmonary disorder (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A physician's order, dated 3/9/24, indicated to administer Trelegy Ellipta (fluticasone-umeclidin-vilanter )100-62.5-25 mcg blister with device (an inhaled combination medication that helps control symptoms of lung disease such as difficulty in breathing and shortness of breath), one puff, inhalation, once a day, rinse mouth with water after use.
A physician's order, dated 3/9/24, indicated to administer ipratropium-albuterol 0.5 milligram (mg) -3 mg (2.5 mg base) solution (an inhaled medication that helps control symptoms of lung disease such as difficulty in breathing and shortness of breath) for nebulization, one unit dose, inhalation, four times a day for cough or shortness of breath.
A physician's order, dated 3/9/24, indicated to administer albuterol sulfate 90 micrograms (mcg)/actuation, hydrofluoroalkane (HFA) aerosol inhaler (a quick-relief inhaled medication used to treat symptoms of lung disease), 2 inhalations every 6 hours and as needed (PRN).
A care plan, dated 6/18/24, indicated Resident 11 had potential for complications, functional, and cognitive status decline related to respiratory disease, COPD. Interventions included, but were not limited to, respiratory therapy per orders.
A quarterly minimum data set (MDS) assessment, dated 6/21/24, indicated Resident 11 had a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact.
During an interview on 7/9/24 at 10:40 a.m., Licensed Practical Nurse (LPN) 9 indicated they did not have any residents who self-administer their own medications.
On 7/9/24 at 2:58 p.m., during an observation with LPN 9, she observed two vials of solution on Resident 11's bedside table and indicated them to be medication vials for breathing treatment used in the nebulizer machine. She indicated that she knew Resident 11 would ask staff to bring extra to her but did not think they were leaving them in the room. The LPN confirmed again that no resident had an order to self-administer medications and for Resident 11, they never knew how she was going to be, so she should not do them on her own.
During an interview on 7/9/24 at 3:28 p.m., the Director of Health Services (DHS) indicated she could not explain the medications at bedside for Resident 11. She could not locate a current or historical assessment to self-administer medications. The DHS indicated that Resident 11's daughter was moving to Florida, so the resident had been asking for certain things to be brought in to her. She was not sure what they had brought in but thought it was possible they could have brought her medications from home, so she wanted to check the expiration dates.
During an interview on 7/9/24 at 3:30 p.m. with the Regional Director of Clinical Services (RDCS), she reviewed Resident 11's record and indicated that the resident receives nebulizer treatments four times daily, and could not find any current, or historical, documentation from the physician indicating the Resident could self-administer medications. The order was to administer one dose, which was one vial. She was not sure if it was possible that the nurse had accidentally laid the medications down and left them there. She also suggested checking the expiration dates on the vials.
On 7/9/24 at 3:47 p.m., with the DHS, observed the two medication vials that LPN 4 indicated to be the ones removed from Resident 11's room. The expiration dates on both vials read 12/2025 with a lot number of 41a0022x2. This information was compared to Resident 11's package of medication in the facilities medication cart. The package in the facilities medication cart also read that the expiration date was 12/2025 with a lot number of 41a0022x2. The DHS indicated the information matched, and that the vials that were on the resident's bedside table had come from the facilities medication cart.
On 7/10/24 at 3:11 p.m., the RDCS provided a document dated 12/31/23, titled, Guidelines for Self-Administration of Medications, and indicated it was the policy currently being used by the facility. The policy indicated, .To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is part of their plan of care .Procedures .1. Residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication .3. The medication will be kept in a locked drawer in the residents' room. The resident will maintain the key, as well as, a key will be maintained by the licensed nurse and or QMA .8. The assessment will be documented in the EHR
On 7/10/24 at 3:11 p.m., the RDCS provided a document dated 11/18, titled, Specific Medication Administration Procedures, and indicated it was the policy currently being used by the facility. The policy indicated, .F. Administer medication and remain with resident .Do not leave medications at bedside, unless specifically ordered by prescriber
3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 2:11 p.m., a brief review of the clinical record for resident 196 was completed. The record indicated the resident was to be DNR (Do Not Resuscitate). The physician order indicated Code Status no other information was provided with the order. On [DATE] the resident signed a DNR form. On the same date, [DATE] a CPR (Cardiopulmonary Resuscitation) consent form was signed by the resident and indicated initiate CPR.
On [DATE] at 9:30 a.m., during an interview with the Director of Health Services (DHS) she indicated she had noted the discrepancy with the code status for the resident and acknowledged the two different directives created a confusing situation regarding the residents advanced directives.
On [DATE] at 1:00 p.m., review of medical record of resident 196. The resident was admitted on [DATE]. Diagnosis included but were not limited to, unilateral primary osteoarthritis, right knee, (a degenerative joint disease, in which the tissues in the joint break down over time), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), aftercare following joint replacement surgery, type 2 diabetes mellitus without complications (a disease that occurs when your blood glucose, also called blood sugar, is too high).
Physician orders included but were not limited to. [DATE], Code Status.
An admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact and required assistance from the staff for activities of daily living.
The medical record lacked a care plan for advanced directives.
On [DATE] at 11:14 a.m., the Regional Nurse Consultant provided a document, titled, Guidelines for Advanced Directives, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: to ensure facility staff obtains and follows resident's advanced directives regarding end-of-life care .Procedures .1. Advanced Directives will be reviewed with resident and or resident representative by the Customer Service representative or designee at the time of admission .2. The resident or representative will advise the CSR/designee regarding wishes for end-of-life directives and code status. The DNR form will be completed documenting these desires and scanned into the medical record .6. The nursing staff will obtain an order from the attending physician for the desired code status .8. Designation of code status and obtainment of physician order will be part of the medical record
3.1-4(f)(4)(ii)
3.1-4(f)(5)
Based on record reviews and interviews, the facility failed to ensure a choice of code status was accurately documented in the medical record for 2 of 2 residents reviewed for code status (Residents 34 and 196).
Findings include:
1. On [DATE] at 11:04 a.m., a basic review of Resident 34's record was conducted. The face sheet indicated the code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) was do not resuscitate (DNR). A physician's order, dated [DATE], indicated the resident was a DNR. In the documents section, the most recent physicians order for scope and treatment (POST) form, signed and completed on [DATE], indicated the resident was a full code and resuscitation/cardiopulmonary resuscitation (CPR) was to be attempted.
On [DATE] at 10:00 a.m. Resident 34's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), malignant neoplasm of the colon (cancerous growth in the colon), stage 3 chronic kidney disease (kidneys do not work as well as they should to filter waste and extra fluid out of the blood), chronic ischemic heart disease (heart weakening caused by reduced blood flow to the heart), and psychotic disorder with hallucinations (seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them).
A care plan, dated [DATE], indicated that the resident or resident representative had chosen the following advanced directives: code status, with a problem start date of [DATE]. Interventions had an approach start date of [DATE] and included, but were not limited to, review the resident's code status quarterly and as needed, honor the residents right to change advanced directives at any time, provide information, education, and assistance to resident and family regarding advance directives, and provide treating entities with updated notification of advance directives.
A quarterly minimum data set (MDS), dated [DATE], indicated Resident 34 had severe cognitive impairment with a brief interview for mental status (BIMS) score of 5.
During an interview on [DATE] at 10:34 a.m., when asked what Resident 34's code status was, Licensed Practical Nurse (LPN) 9 checked Resident 34's record and indicated that, on the face sheet, he was a DNR. She checked the documents, and on the POST form, he was a full code. She indicated that was weird because she remembered it being a discussion when he signed up for hospice care. When she went to check the hospice binder, it could not be located.
On [DATE] at 11:18 a.m., the hospice services binder was reviewed. The first page was a form titled, Facility Document Delivery dated [DATE], indicated copy of advanced directives, as applicable to patient .DNR .Post. The next two pages included a copy of the signed POST form, dated [DATE], that indicated the resident was a full code.
During an interview on [DATE] at 12:02 p.m., the Regional Director of Clinical Services (RDCS) indicated she believed the discrepancy was a clerical error, they had a call out to hospice and were going to call the resident's wife to verify Resident 34's code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plan meetings were held at least quarterly for 1 of 2 residents reviewed for care plan meetings (Resident 8).
Findings include:
During an interview, on 7/8/24 at 8:54 a.m., Resident 8 indicated she could not recall having a care plan meeting for quite some time.
Resident 8's record was reviewed on 7/9/24 at 9:05 a.m. The census indicated the resident had been admitted to the facility on [DATE], for diagnoses which included, but were not limited to, displaced bimalleolar fracture of right lower leg (a type of ankle fracture that involve the distal [the area away from the point of attachment] ends of the fibula and tibia, respectively) and type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel).
A quarterly Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident had no cognitive deficit.
Review of the Resident First Meeting Minutes (care plan meeting minutes) lacked documentation that a care plan meeting had been held since 11/1/23.
During an interview, on 7/9/24 at 9:46 a.m., the Resident Services Manager indicated the facility was behind in completing their care plan meetings. Meetings should be held every quarter for all residents.
During an interview, on 7/9/24 at 11:15 a.m., the Regional Director of Clinical Services indicated they were unable to locate any documentation that indicated the resident had a care plan meeting since November 2023.
On 7/9/24 at 11:15 a.m., the Regional Director of Clinical Services provided a document, dated 12/31/23, titled. Resident's First Meeting Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .2 .meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change. 3 .meetings for Medicare residents should be conducted minimally quarterly and prior to discontinuing Medicare services or being discharged from the facility
3.1-35(d)(2)(B)

Based on observations, record reviews, and interviews, the facility failed to assess and ensure that a physician was notified of a resident's change in condition related to edema for 1 of 1 resident's reviewed (Resident 7).
Finding includes:
On 7/7/24 at 11:08 a.m., Resident 7 was observed sitting up in her chair, the resident had edema (swelling) to her left foot and ankle. The resident indicated nothing really helps with the edema and she tried to elevate her feet as much as possible. She indicated she has had edema to her left foot off and on since she fractured it a couple years ago.
On 7/8/24 at 2:37 p.m., Resident 7 was sitting up in her chair reading a book with her legs elevated on the seat of her wheelchair. Edema was noted to her left foot and ankle.
On 7/8/24 at 10:23 a.m., Resident 7 was observed sitting in her chair in her room with her left foot on the floor and her right leg elevated on the wheelchair seat. The left foot was notably larger than the right foot.
On 7/10/24 at 8:36 a.m., Resident 7 was sitting in her chair in her room and both feet were touching the floor. Her left foot and ankle were noted to be swollen.
Resident 7's record was reviewed on 7/8/24 at 1:17 p.m. The profile indicated the resident's diagnosis included, but were not limited to, age-related osteoporosis without current pathological fracture (a bond disease that occurs when bone mass decreases, or when the structure or strength of the bone changes), history of DVT to left leg (occurs when a blood clot forms in one or more of the deep veins in the body), and chronic kidney disease, stage 3b (mild to moderate kidney damage and they are less able to filter waste and fluid out of your blood).
A quarterly Minimum Data Set (MDS) assessment, dated 5/22/24, indicated the resident was cognitively intact and required supervision with toilet use and moderate assistance with showers.
The record lacked a care plan related to edema to left foot/ankle.
A care plan, dated 10/19/22, indicated the resident has chronic kidney disease, stage 3b. Interventions included, but were not limited to, assess for fluid excess (edema, worsening of edema, and weight gain) and administer medication as ordered.
A progress note dated 4/29/24 indicated Resident 7 had edema to the left lower extremity. MD (medical doctor) was notified, and he ordered a venous doppler (a non-invasive diagnostic test that evaluates blood flow through the body's major veins and arteries).
A progress note, dated 5/3/24, indicated Resident 7 had a red, swollen left leg and the doppler showed a DVT. MD ordered Xarelto (blood thinner).
The record lacked any recent progress notes related to edema of the left foot/ankle.
A physician order, dated 5/24/24, indicated to administer Xarelto 15mg (milligrams) by mouth daily.
The record lacked continued monitoring of the edema and DVT by staff.
During an interview, on 7/8/24 at 1:52 p.m., Certified Resident Care Assistant (CRCA) 5 indicated Resident 7 would elevate her legs and feet as much as possible because she had issues with swelling off and on.
During an interview, on 7/8/24 at 1:53 p.m., Registered Nurse (RN) 6 indicated she had spoken to Resident 7 a couple months ago about the edema to her left foot, but she had not recently assessed the edema. The nurse indicated she had noticed in the past the swelling in her left foot is always worse than the right.
During an interview, on 7/10/24 at 9:45 a.m., Regional Director of Clinical Services (RDCS) indicated the edema should be addressed with the physician, and she would make sure the resident was added to his list to be seen.
During an interview, on 7/10/24 at 11:53 a.m., RDCS indicated a CAR (clinical assessment record) should have been completed on Resident 7 because it would have been a good way to ensure monitoring of the DVT had been completed and a good way to monitor for worsening or improving edema.
On 7/10/24 at 11:50 a.m., the RDCS provided a document dated 5/10/16, titled, Clinically at Risk Program Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Every effort will be made to identify those residents who are clinically at risk and provide proactive interventions to manage their medical needs and minimize/eliminate further decline when possible . Resident is to be discussed in CAR meeting until it is determined the resident's condition has stabilized .5. The CAR team will review current interventions for effectiveness and potential changes and make recommendations based on individual resident's needs
3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which was attached to a urinary drainage bag (a bag that collects urine) and a biliary drain (a thin plastic tube inserted into the gallbladder to drain fluid) bag, did not touch the floor for 1 of 1 resident reviewed for catheter care (Resident 201).
Findings include:
On 7/07/24 at 12:01 p.m., during routine observation, the resident lying in bed, the urinary drainage bag lying on the floor. No covering over the bag. The biliary drainage bag was lying on the floor. No covering over bag.
On 7/08/24 at 9:29 a.m., observed the biliary drainage bag drain touching the floor. No covering over the bag. The urinary drainage bag was attached to the side of the bed frame. No covering over the drainage bag.
On 7/09/24 at 8:40 a.m., during routine observation resident observed sitting up in a wheelchair. The foley drain bag was attached to the lower left side of the wheelchair. No covering over the drainage bag. The biliary drainage bag was attached to the upper right side of the wheelchair without a covering, the bag was half full of a dark colored liquid.
On 7/9/24 at 8:46 a.m., during an interview, Certified Resident Care Associate (CRCA) 3 indicated any resident with an indwelling catheter and or a drainage bag, both bags should always be covered. She indicated the drain bag for the biliary drain is covered with a pillowcase when the resident is up in a chair. She indicated the drainage bags should not touch the floor.
On 7/9/24 at 9:30 a.m., during an interview with the Director of Health Services (DHS) she indicated a urinary drain bag should be covered if the resident was in a wheelchair or using a walker.
Clinical record review completed on 7/9/24 at 11:00 a.m., for Resident 201. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, 5/31/24 acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), 4/12/24 cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), unspecified, chronic atrial fibrillation (an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart), 11/4/20 chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), unspecified, obstructive sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep), dyspnea (difficult, painful breathing or shortness of breath). Type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (the kidneys are damaged and can't filter blood the way they should).
Physician orders included but were not limited to. Albuterol sulfate solution for nebulization (used to prevent and treat wheezing, difficulty breathing); 2.5 mg (milligrams)/3 mL (milliliters) (0.083 %); amount: 3 ml; inhalation admin as needed for SOB (shortness of breath or wheezing every 6 Hours as needed. Eliquis (apixaban) tablet (used to treat blood clots) 5 mg; amt: 5 mg; oral twice a day. Empty biliary drain every shift three times a day. Change catheter bag PRN (as needed) based on clinical indications such as infection, obstruction, or when the closed system is compromised once a day PRN. Foley catheter care every shift three times a day, indwelling urinary catheter, medical reason BPH (benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland) with urinary retention (a condition in which you are unable to empty all the urine from your bladder).
An admission Minimum Data Set (MDS) assessment dated , 4/17/24 indicated the resident was cognitively intact and required maximum assist of two persons for activities of daily living and had an indwelling foley catheter during the look back period.
A care plan dated 6/24/2024 indicated the resident used a foley catheter. Interventions included, but were not limited to, maintaining a closed system with urinary bag below the resident's bladder and cover.
A care plan dated 4/14/24 indicated a risk for skin breakdown related to biliary drain. The record lacked interventions specific to the biliary drain.
The facility did not have a policy specific to biliary drain.
On 7/9/2024 at 11:15 a.m., the Regional Nurse Consultant provided a document, titled, Preserving Dignity with Indwelling Catheter, dated 12/31/23, and indicated it was the policy currently being used by the facility. The policy indicated, .SOP Details .1. General guidelines .a) Keep drain bag covered with an appropriate device .Urinary drainage bags and catheter tubing should be kept from touching the floor surface
3.1-41(a)(1)

Based on observations, interviews, and record reviews, the facility failed to ensure medications were labeled and stored properly for 2 of 2 medication carts reviewed for medication storage (Residents 8, 6, 19, and 146).
Findings include:
1. On 7/9/24 at 9:10 a.m., the 200 hall (front) medication cart contained an undated and opened Lantus (medication used to lower blood sugar) insulin pen. The insulin pen contained a label that indicated it was for Resident 8.
During an interview, on 7/9/24 at 9:12 a.m., Registered Nurse (RN) 6 indicated insulin pens should have an open date placed on them when they are used.
Resident 8's record was reviewed on 7/9/24 at 9:40 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).
A physician order, dated 5/1/24, indicated to administer Lantus Solostar (insulin medication) insulin pen 100 unit/ml (milliliter). Inject 25 units subcutaneously (under the skin) once a day in the morning.
A physician order, dated 5/1/24, indicated to administer Lantus Solostar insulin pen 100 units/ml. Inject 70 units subcutaneously once a day at bedtime.
2. On 7/9/24 at 9:15 a.m., the 200 hall (back) medication cart contained the following items:
a. An unopened and non-refrigerated box of 5 Basaglar (insulin medication) pens. The box of insulin pens contained a label that indicated it was for Resident 6.
b. An unopened and non-refrigerated vial of Humalog (insulin medication). The vial of insulin contained a label that indicated it was for facility stock and was delivered from the pharmacy on 7/8/24.
c. An unopened and non-refrigerated box of 5 Lantus (insulin mediation) pens. The box of insulin pens contained a label that indicated it was for Resident 19.
d. An unopened and non-refrigerated bottle of Latanoprost (eye drop medication) 0.005%. The bottle contained a label that indicated it was for Resident 146.
e. An unopened and non-refrigerated vial of Humalog. The vial contained a label that indicated it was for Resident 146.
During an interview, on 7/9/24 at 9:20 a.m., RN 6 indicated insulin and eye drops that were not opened, should be refrigerated until used. She indicated the night shift had a new nurse and she must not have known to refrigerate the medications until used.
Resident 6's record was reviewed on 7/9/24 at 9:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes (a chronic condition that affects the way the body processes blood sugar).
A physician order, dated 6/14/24, indicated to administer Basaglar Kwik-Pen 100 unit/milliliter. Inject 32 units subcutaneously (under the skin) at bedtime.
Resident 19's record was reviewed on 7/9/24 at 9:55 a.m. The profile indicated the resident's diagnosis included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease (a serious complication that occurs when the kidneys are not functioning properly to remove waste products and excess fluid from the body).
A physician order, dated 6/7/24, indicated to administer Lantus Solostar pen 100 unit/ml. Inject 55 units subcutaneously at bedtime.
Resident 146's record was reviewed on 7/9/24 at 10:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes and glaucoma (a group of eye conditions that can cause blindness).
A physician order, dated 7/5/24, indicated to administer Latanoprost 0.005%. Give 1 drop to each eye once a day.
A physician order, dated 7/6/24, indicated to administer Humalog 100 units/ml. Inject subcutaneously per sliding scale before meals and at bedtime.
During an interview on 7/9/24 at 11:00 a.m., the Regional Director of Clinical Services (RDCS) indicated the facility had a new nurse on night shift and needed to be educated on proper storage of medications.
On 7/9/24 at 11:10 a.m., the RDCS provided and identified a document as a current facility policy, titled, Vials and Ampules of Injectable Medications, revised date 11/18. The policy indicated, .at a minimum the date opened should be recorded
On 7/9/24 at 11:10 a.m., the RDCS provided and identified a document as a current facility policy, untitled, with a revised date of July 2021. The policy indicated, .Unused Pens: Store unused pens in the refrigerator
On 7/9/24 at 11:10 a.m., the RDCS provided and identified an undated document as a current facility policy, untitled. The policy indicated, .Store unused Lantus in a refrigerator
3.1-25(j)
3.1-25(m)

Based on record review and interview, the facility failed to ensure transportation to a medical appointment was set-up and completed for 1 of 1 resident reviewed for transportation (Resident B).
Findings include:
Review of a complaint intake form, dated 7/10/24, indicated Resident B had missed her appointment with her urologist (a physician who has special training in diagnosing and treating diseases of the urinary organs) because the facility had not scheduled transport services for her.
Resident B's record was reviewed on 7/11/24 at 8:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic kidney disease (damage to the kidneys which makes them unable to filter blood the way they should), hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys) and obstructive uropathy (a blockage or obstruction where the ureter [the tube that carries urine] connects to the kidney or bladder).
A care plan, dated 1/3/23, indicated the resident had an indwelling urinary catheter (a tube which is inserted into the bladder to drain urine) related to obstructive uropathy.
A physician's order, dated 7/10/24, dated one time 6:00 a.m., to 2:00 p.m., indicated to set up transport for a visit with the urology nurse practitioner (NP) for a treatment appointment at 12:30 p.m. The order indicated Lifeloop (a software system used to set up transport for residents) request had been put in.
During an interview, on 7/11/24 at 9:33 a.m., the Life Enrichment Director indicated she was responsible for the transport of the facility residents to their appointments. She did not have Resident B on her schedule to transport to an appointment on 7/10/24. Scheduling transport for appointments was set up by the nursing staff.
During an interview, on 7/11/24 at 9:36 a.m., Registered Nurse (RN) 17 indicated the nurses were responsible for transport requests when an appointment order was received. Setting up transport requests for the facility bus was very easy, but to set up for an outside transport, they now were required to use a process that takes them to a government website. This made it very time-consuming to set up. Resident B cannot be transported by the facility bus, because she required stretcher transport.
During an interview, on 7/11/24 at 10:10 a.m., the Regional Director of Clinical Services indicated she was not able to locate a specific policy on setting up transportation for resident appointments. The expectation would be that transportation would be set up by facility staff for any resident who had an appointment outside of the facility.
During an interview, on 7/11/24 at 10:47 a.m., the Executive Director (ED) indicated the facility policy was that transportation would be set up and provided for all residents who required transportation to any appointment.
This citation relates to Complaint IN00438476.
3.1-49(i)(3)

Based on observation and interview, the facility failed to maintain a safe and sanitary environment for food safety and failed to ensure beard covers were worn by an employee for 1 of 2 kitchen observations.
Findings Include:
1. On 7/10/24 at 12:00 p.m., observed raw hamburger meat on a tray on the bottom of the rolling cart outside of the cooler with prepared salads on the cart.
On 7/10/24 at 12:05 p.m., during an interview with Area Director of Food Services the director acknowledged the meat should not be on the cart and should have been in the cooler.
On 7/10/24 at 12:08 p.m., during an interview with the Director of Food Services he indicated he had removed the hamburger meat from the cooler and placed it on the cart with the salads. He indicated he did not recall how long the meat had been out of the cooler.
2. On 7/10/24 at 12:08 p.m., during an interview with the Director of Food Services it was noted the employee did not have a beard covering on. He indicated he had one on and had removed it.
On 7/10/2024 at 2:47 p.m., the Regional Nurse Consultant provided a document, titled, Food Production Guidelines, dated May 31, 2016, and indicated it was the policy currently being used by the facility. The policy indicated, . Policy .Safe and Sanitary handling of food will be employed during food production .7. Food prepared in advance must be covered, labeled, dated, and refrigerated .28. Potentially hazardous foods that have stood for more than (4) hours at room temperature are not considered safe from contamination and must be discarded
On 7/10/2024 at 2:47 p.m., the Regional Nurse Consultant provided a document, titled, Beard and Mustache policy, dated November 30, 2021, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Beard and mustache hair must be covered while in kitchen food product areas, Facial hair restraints are required in any production area .Purpose .Beards and mustache hair must be covered while in the kitchen food product areas .Procedures .Some common approaches include .cover all beard or mustache hair that is more than 1/8 of an inch growth
3.1-21(i)(1)
3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to ensure proper handling of the glucometer (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) meter during medication administration pass for 2 of 5 residents reviewed during medication administration (Residents 8 and 19).
Finding includes:
During a medication administration observation, on 7/9/24 at 11:43 a.m., Registered Nurse (RN) 6 had a glucometer meter in a drawer on the right side of the medication cart, she took the meter out of the drawer and placed it on top of the medication cart, no barrier was placed under the machine. The nurse obtained Resident 8's blood sugar at the nurse's station. The nurse placed the meter back on top of the medication cart, no barrier was placed under the machine. No satiation of the machine was observed. 5 minutes later the nurse picked up the meter from the medication cart and entered Resident 19's room. The nurse placed the meter on the resident's side table in her room, no barrier was placed under the machine. The nurse obtained Resident 19's blood sugar and placed the meter back onto the medication cart, no barrier placed under the machine.
Resident 8's record was reviewed on 7/9/24 at 12:10 p.m. The profile indicated the resident diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).
A physician order, dated 4/28/24, indicated to obtain Accu check (name of blood glucose monitoring system) before each meal and before bed.
Resident 19's record was reviewed on 7/9/24 at 12:15 p.m. The profile indicated the resident diagnoses included, but were not limited to, type 2 diabetes mellitus.
A physician order, dated 6/7/24, indicated to administer Humalog (insulin medication) 100 units/ml (milliliter). Inject 8 units subcutaneously (under the skin) before meals.
During an interview, on 7/9/24 at 12:32 p.m., Licensed Practical Nurse (LPN) 12 indicated nursing staff should place a barrier down underneath the glucose meter when being placed on surfaces. She also indicated the machine should be cleaned in between use. LPN 12 indicated the residents do not have their own meters; the glucose meter would be used for multiple residents.
On 7/9/24 at 2:38 p.m., the Regional Director of Clinical Services (RDCS) provided a document with a revised date of 12/2/21, titled, Glucometer Cleaning and Control Test Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .1. If glucometers are used from one resident to another, they should be cleaned and disinfected after each use
3.1-18(b)

Based on record review and interview, the facility failed to ensure a resident treated in a dignified manner during personal care for 1 of 4 residents reviewed for nursing services (Resident B).
Finding includes:
During an interview, on 2/1/24 at 11:08 a.m., Certified Resident Care Associate (CRCA) 4 indicated there had been an episode where she had been assisting a resident with personal care, the resident was very combative and was hitting her, she became frustrated and left the resident's room without telling any other staff on the unit she was leaving the resident unattended. She then gathered her personal items and was planning to leave the facility and going home. She ended up talking with the facility's Employee Experience Manager (EEM), who calmed her down. She returned to the unit shortly after to finish her shift.
During an interview, on 2/1/24 at 11:45 a.m., the Director of Health Services (DHS) indicated CRCA 4 had become frustrated while providing personal care to a resident and left the unit. She was speaking with the EEM who contacted her to come and speak with the CRCA also. She and the EEM took the CRCA outside and calmed her down. The CRCA returned to her unit after she calmed down. The CRCA had been disciplined for her actions.
During a telephone interview, on 2/1/24 at 1:30 p.m., Registered Nurse (RN) 5 indicated she was the nurse on the unit on the day that CRCA 4 left the unit and did not tell anyone she was leaving the resident unattended. CRCA 6 told the RN that CRCA 4 had left the resident unattended. The RN and CRCA 6 went to the resident's room and completed the personal care with the resident. The door to the resident's room was open when they entered to complete the personal care with the resident. When they completed the care, the RN went directly to the DHS to report what had happened.
During a telephone interview, on 2/1/24 at 1:38 p.m., CRCA 6 indicated she was working on the unit when she saw CRCA 4 walk out of Resident B's room and walk off the unit. She went to the resident's room, looked in and saw the resident's personal care had not been completed. She went and located RN 5, and the two of them completed the resident's personal care. CRNA 4 did not ask anyone to go in and help her with the resident, or to take over for her when she left the unit.
Resident B's record was reviewed on 2/1/24 at 1:52 p.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities with agitation including verbal and physical aggression, and wandering).
A quarterly Minimum Data Set (MDS) assessment, dated 12/28/23, indicated the resident had severe cognitive deficit.
During review of the resident's care plans, multiple interventions were observed which addressed the resident's aggressive behavior with all hands-on care.
A Social Services progress note, dated 9/8/23 at 1:57 p.m., indicated the resident's behaviors were reviewed by the interdisciplinary team (IDT). The resident was being followed by the facility contracted psychiatric services for behaviors and psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) use.
On 2/1/24 at 1:25 p.m., the Executive Director (ED) provided a document, dated 9/15/23, titled, Teachable Moment, and indicated it was the document reviewed with CRCA 4 following her leaving the unit on that date. The document indicated the CRCA had been counseled on when getting upset with a resident, she should separate herself from the resident, but should always ensure someone else goes into care for the resident. Residents cannot be left without care. The document had been signed by the DHS and CRCA 4.
On 2/2/24 at 2:20 p.m., the Regional Director of Clinical Operations (RDCO) provided a document, with a review date of 12/31/23, titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .2. Our residents have the right to .a. Be treated with dignity and respect
This citation relates to complaint IN00417618.
3.1-3(a)

Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen environment, clean food carts, labeled and dated food, beard restraints were worn when in the kitchen, and dishwasher temps were within acceptable ranges for 2 of 2 kitchen observations and 2 of 2 dining room observations. This had the potential to effect 36 residents who ate food from the kitchen.
Findings include:
1. On 5/16/23 at 9:15 a.m., during an initial kitchen tour with the Area Director of Food Services, the following issues were observed:
a. The stove was heavily soiled with dried food and grease buildup. The nobs on the stove were soiled with dark debris. A soiled spatula was on the floor in front of the stove.
b. A cart was sitting next to the stove was a foil lined tray covered with a thick layer of grease and brown debris. A fry basket, ladle, and a serving spoon were laying on the tray in the grease.
c. In the walk-in cooler, cooked poultry was on a shelf uncovered and undated. A plastic covered roll of raw ground beef was on a tray, underneath the poultry.
d. The Regional Dietary Manager was observed with uncovered facial hair entering the kitchen food service area multiple times during initial walk through and during the noon dining service observation.
e. The dish washer wash temperature was 138 degrees Fahrenheit (F), and the rinse temperature was 142 degrees F. The Area Director of Food Services indicated temperatures had just been checked and water temperature was 168 degrees F. She identified a document titled, dishwasher temp log, dated May 2023, and identified it as the current daily temperature log for May 2023. Daily recorded temperature logs indicated correct temperatures. Employee 4 indicated the dishwasher was a high temperature dishwasher, and the wash temperatures should be at least 150 degrees F and the rinse should be at least 180 degrees F. Employee 4 indicated the poultry should have been covered, dated, and labeled.
2. On 5/16/23 at 12:15 p.m., during an observation of the noon meal service in the dining room the following were observed:
a. The glass cover of the hot food serving cart was covered in a cloudy film, soiled with dried food debris, and grime.
b. The inside glass cover of the salad bar cart was covered in a cloudy film, dried food debris, and grime.
3. On 5/16/23 at 12:45 p.m., during an observation of the hall tray lunch meal service in the common area the following were observed:
a. The food cart containing cold food bottom edge base was soiled with a brown debris and rust colored debris. The glass cover on the front of the cart was soiled with food debris, grime, and a cloudy film.
b. The hot food cart was soiled with dried food on the inside bottom of the cart, on the outside track and on the inside of the glass door with, grime, dried food debris, and a cloudy film.
3. On 5/17/23 at 10:00 a.m., during a second kitchen observation, the following was observed:
a. The stove hood above the grill was soiled with grease and brown debris.
b. The stove from top to bottom was observed with dried food spilled down the front. The stove knobs were heavily soiled with a dark debris. There was a heavy buildup of grease like substance on the floor around the base of the stove.
c. A cart sitting next to the deep fryer, with a tray covered in foil, was heavily soiled with grease like substance and brown debris. A fry basket, ladle, and serving spoon was laying on the tray in the grease like substance. Area Director of Food Services indicated the tray was there from the day prior and needed to be cleaned.
d. The hot food cart was soiled with dried food on the inside bottom of the cart, on the outside track and on the inside of the glass door with, grime, dried food debris, and a cloudy film. Area Director of Food Services indicated it should have been cleaned.
4. On 05/17/23 at 10:00 a.m., Area Director of Food Services provided and identified a document as a current kitchen cleaning schedule, dated April 2023, titled, Aides cleaning list, and she indicated the document as the dietary aides cleaning schedule for the kitchen. The log lacked documentation that the cleaning had been completed for April 2023 as scheduled and unable to provide a May schedule. At the same time, she provided a document, dated 5/14 to 5/20, titled, Cooks Cleaning List, and identified the document as the cook's kitchen cleaning schedule. The log lacked documentation that the cleaning had been completed as scheduled for the months of April and May 2023.
On 5/19/23 at 11:15 a.m., Area Director of Food Services indicated, she had contacted the dishwasher service company and they had to replace the temperature thermostat due to it not working right.
On 5/19/23 at 11:40 a.m., the Executive Director (ED) provided and identified a document as a current facility policy, dated 01/2023, titled, Storage procedures, policies, and procedures culinary. The policy indicated, .Food, and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance.Procedures . Refrigerated storage 5. Food is covered, dated, and stored loosely to permit air circulation .8. Meat, fish, and poultry are stored on lower shelves below fruits, vegetables, juices, and breads to prevent contamination
On 5/19/23 at 11:40 a.m., the ED provided and identified a document as a current facility policy, titled, Beard Restraint Policy, dated 01/2023. The policy indicated, .Policy .Beard, and mustache hair will be neat and trimmed. [NAME] restraints are required in any production area .Keep beards and mustaches neat and trimmed. [NAME] restraints are required in any food production area. Facial hair is not exempt from the hair restraining standard. It is up to each campus to define which type of facial hair requires a beard net .Procedures .cover all facial hair below the corner of the mouth .More than a day or two of growth .More than 1/8 inch . Like hair covers, beard nets must be worn
On 5/19/23 at 11:40 a.m., the ED provided and identified a document as a current facility policy titled, Dish Machine, Policies, and Procedures Dining Services, dated 01/2023. The policy indicated, .High temperature dishwasher (heat sanitation) recommended guideline: Wash- 150-165 degrees F .Final Rinse - 180 degrees F
On 5/19/23 at 11:40 a.m., the ED provided and identified a document as a current facility policy titled, Food Labeling and Dating Policy, dated 01/2023. The policy indicated, .Policy .Any food product removed from its original container, has a broken seal, has been processed in any way must have a label .Purpose .To have food product properly labeled and dated .Procedures .Any food product removed from its original contained, has a broken seal, has been processed in any way must have a label that contains the following information: .1. Item Name .2. Date and time the food was labeled .3. Use by date .4. Initials of the person labeling the item .5. Securely cover the food item
On 5/22/23 at 2:27 p.m., the ED indicated, the facility did not have a kitchen cleaning schedule policy and procedure. The facility followed the Indiana retail food sanitation requirements.
3.1-21(i)(1)
3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure medication was stored properly for 1 of 2 medication carts reviewed for medication storage (200 hallway).
Findings include:
On 5/22/23 at 9:40 a.m., the back half of the 200 hallway medication cart contained an unopened vial of Humalog (medication used to lower blood sugar level). The insulin vial was in a pharmacy container and had a label that indicated it was ordered for Resident 203. The pharmacy container had a blue sticker on it, and indicated medication was to be refrigerated until opened.
During an interview, on 5/22/23 at 9:40 a.m., Licensed Practical nurse (LPN) 11 indicated the insulin vial should have been refrigerated until opened.
Resident 203's record was reviewed on 5/22/23 at 10:00 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).
A physician order, dated 5/21/23, indicated Humalog (insulin medication) 100 unit/ml (milliliter), by subcutaneous (under the skin) injection per sliding scale before meals every day.
On 5/22/23 at 11:02 a.m., the Clinical Support nurse provided and identified a document as a current facility policy, titled Medication Storage in the Facility, revised date 11/18. The policy indicated, .Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations .k. Refrigerated medications are kept in closed and labeled containers
3.1-25(m)

3. Resident 28's record was reviewed on 5/17/23 at 11:43 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified intracranial injury with loss of consciousness of unspecified duration (a medical classification under the range - Injury, poisoning and certain other consequences of external causes), traumatic brain injury (TBI-a sudden injury that causes damage to the brain), and ataxic gait (an unsteady, staggering gait).
A care plan, dated 1/28/22 and revised on 3/7/23, indicated the resident had a traumatic brain injury.
A historical review of the resident's physician's orders, indicated an order for Amantadine (a medication used to treat dyskinesia [involuntary, erratic, writhing movements of the face, arms, legs or trunk]), 100 milligrams (mg) twice daily (BID), since his admission to the facility on 1/17/22.
A Pharmacy recommendation, dated 6/15/22, indicated to consider weaning from Amantadine 100 mg BID to 100 mg once daily times 1 week and then discontinue (DC), due to concerns of central nervous system (CNS) side effects with TBI. The recommendation form had a check mark next to No which followed a statement which indicated the physician agreed with all the recommendations. The form lacked documentation of a rationale by the physician to justify the declination, the signature of the physician, or a date the physician checked No on the recommendation.
A progress note, dated 6/16/22 at 9:23 a.m., indicated the interdisciplinary team (IDT) review had been completed with this nurse, Director of Health services (DHS), Director of Social Services (DSS), and Executive Director (ED) present. The Pharmacist reviewed with a recommendation and noted it would be communicated with the physician.
On 5/18/23 at 10:15 a.m., the DHS provided a copy of the Pharmacy recommendation, dated 6/15/23. The form had the physician's initials at the bottom. At the same time the DHS indicated the physician had made symbols next to his initials which indicated no changes. The form lacked documentation of a rationale by the physician to justify the declination and a date the physician had made the symbols and initialed the form.
A Pharmacy recommendation, dated 9/26/22, indicated a second recommendation to consider weaning from Amantadine 100 mg BID to 100 mg once daily times 1 week and then discontinue (DC), due to concerns of central nervous system (CNS) side effects with TBI. The form indicated the recommendation had been agreed to by the physician, by a check mark next to Yes at the bottom of the form. A documented statement indicated medication reduced for 7 (seven) days and then DC. A historical review of the resident's physician's orders indicated the Amantadine had been changed from BID to daily on 10/18/22, then discontinued on 10/24/22.
During an interview, on 5/19/23 at 1:56 p.m., the Clinical Support indicated she was not able to locate a specific policy related to the physician addressing the pharmacy recommendations. They would follow the State and Federal regulations. It was expected that all pharmacy recommendations would be addressed timely by the physician and any decision by the physician would include a written rationale and be signed and dated by the physician at the time the decision was made.
On 5/19/23 at 1:50 p.m., the Clinical Support provided a document, dated 12/31/22, titled, Guidelines for Medication Orders, and indicated it was the policy currently used by the facility. The policy indicated, .Procedures .3. Physician orders/progress notes must be signed and dated in accordance with state regulations
3.1-48(a)(3)
Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed, addressed, and dated in a timely manner, and failed to ensure documented physician rationale for a declination of pharmacy recommendations for 3 of 5 residents reviewed for unnecessary medications (Resident 9, 21, and 28).
Finding include:
1. Resident 9's record was reviewed on 5/18/23 at 10:45 a.m. The profile indicated that the resident's diagnoses included, but were not limited to, encephalopathy (a term for any diseases of the brain that alters brain function or structure), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and hypotension (low blood pressure).
A pharmacy recommendation, dated 11/21/22, recommended to avoid dosing midodrine (a medication used to treat low blood pressure that causes severe dizziness or fainting) medication after the evening meal or within 4 hours of bedtime. Recommended to change the second daily dose administration time to 3 to 6 p.m. The pharmacy recommendation indicated the resident's second dose of the medication was currently being given at bedtime.
A pharmacy recommendation, dated 1/13/23, recommended to avoid dosing midodrine medication after the evening meal or within 4 hours of bedtime. Recommended to change the second daily dose administration time to 3 to 6 p.m. The pharmacy recommendation indicated the resident's second dose of the medication was currently being given at bedtime.
A pharmacy recommendation, dated 2/23/23, recommended to avoid dosing midodrine medication after the evening meal or within 4 hours of bedtime. Recommended to change the second daily dose administration time to 3 to 6 p.m. The pharmacy recommendation indicated the resident's second dose of the medication was currently being given at bedtime.
During an interview on 5/18/23 at 3:00 p.m., the Administrator indicated that they were unable to provide documentation where the pharmacy recommendation had been addressed until the current physician order of 4/18/23 for the midodrine medication.
A physician order, dated 4/18/23 indicated an order for midodrine 10 milligrams(mg) three times daily to be given at 6 to 8:00 a.m., 11:00 a.m. to 1:00 p.m., and 4 to 6:00 p.m.
2. Resident 21's record was reviewed on 5/19/23 at 10:25 a.m. The profile indicated the resident's diagnoses included, but not limited to, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), and vascular disease with behavioral disturbances (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).
A pharmacy recommendation, dated 3/14/23, indicated Resident 21 was receiving Depakote (a mood stabilizer medication) 250 milligram (mg) twice daily. Recommended to attempt a reduction to 125 mg twice daily. The physician signed with a symbol that indicated no change. The form lacked documentation of a rationale by the physician to justify the decline, or a date the physician signed the pharmacy recommendation.
A physician order dated 4/24/23, indicated Depakote 250 mg twice daily.
During an interview, on 5/19/23 at 11:50 a.m., the Clinical Support nurse indicated that they were aware the provider was not dating and or including a rationale on the pharmacy recommendation forms.

Based on observation, record review, and interview, the facility failed to ensure proper labeling of respiratory equipment, and failed to obtain and follow physician orders for 2 of 4 residents reviewed for respiratory care (Resident 5 & 19).
Findings include:
1. On 5/16/23 at 10:16 a.m., Resident 5 was observed to be sitting up in her bed eating breakfast. Her oxygen tubing was laying on top of the oxygen concentrator (a medical device that gives you oxygen) and the tubing was dated 4/14. The oxygen concentrator was turned off.
On 5/17/23 at 9:30 a.m., Resident 5 was observed to be sitting up in her bed working a word search puzzle. Her oxygen tubing was laying on top of the oxygen concentrator and the tubing was dated 4/14. The oxygen concentrator was turned off.
On 5/17/23 at 1:36 p.m., Resident 5 was observed to be sitting up in her bed watching TV. Her oxygen tubing was laying on top of the oxygen concentrator and the tubing was dated 4/14. The oxygen concentrator was turned off.
On 5/18/23 at 10:32 a.m., Resident 5 was observed to be sitting up in her bed working on a word search puzzle. Her oxygen tubing was lying on the floor next to the oxygen concentrator. The oxygen tubing was dated 4/14 and the oxygen concentrator was turned off.
Resident 5's record was reviewed on 5/17/23 at 11:47 a.m. The profile indicated the resident's diagnoses included, but were not limited to, encephalopathy (a term for any diseases of the brain that alters brain function or structure), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), and Alzheimer's (a progressive disease that destroys memory and other important mental functions).
A quarterly Minimum Data Set (MDS) assessment, dated 5/8/23, indicated the resident had moderate cognitive deficit and received oxygen therapy.
A care plan, dated 5/17/23, indicated the resident had potential for complications, functional, and cognitive status decline related to respiratory disease related to pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). Interventions included, but were not limited to, Administer oxygen per orders.
A physician order, dated 12/12/18, indicated change oxygen tubing monthly. The Medication Administration Record (MAR) lacked documentation of resident's refusal.
A physician order, dated 3/16/23, indicated to administer oxygen at 2 liters (L) per nasal canula (device used to deliver supplemental oxygen through the nose) continuously to maintain oxygen (O2) saturation (sat) greater than 90% three times a day. The MAR lacked documentation of resident's refusal.
Review of vital signs obtained, dated 5/15/23 at 9:10 a.m., indicated Resident 5 had a O2 saturation of 93% and was marked no for oxygen use.
Review of vital signs obtained, dated 5/16/23 at 3:34 p.m., indicated Resident 5 had a O2 saturation of 99% and was marked no for oxygen use.
Review of skilled nursing note, dated 5/17/23 at 12:50 p.m., Resident 5 was marked no for oxygen use.
During an interview, on 5/16/23 at 10:16 a.m., Resident 5 indicated she had oxygen if she needed it, but she did not need it all the time.
During an interview, on 5/17/23 at 1:43 p.m., Certified Residential Medication Aide (CRMA) 8 indicated Resident 5 had a physician's order for continuous oxygen.
During an interview, on 5/18/23 at 1:44 p.m., the Administrator indicated Resident 5 had never used the oxygen on a continuous basis. The resident had returned from the hospital with the order for oxygen. She was unsure why she had an order for continuous oxygen.
During an interview, on 5/18/23 at 1:51 p.m., the Clinical Support Nurse indicated the oxygen tubing should be changed monthly.
2. During an observation on 5/16/23 at 10:10 a.m., Resident 19 was sitting in recliner next to the bed. Oxygen (O2) was being administered at 3.5 Liters (L) via nasal cannula (NC), per concentrator. There was no date on the bag. The attached humidifier bottle was empty.
During an observation on 5/16/23 at 3:08 p.m., the resident had O2 administered at 2 L via NC, through a concentrator. The humidifier bottle was filled with water. No date was on the bottle. A small piece of tape on the tubing indicated 5/5.
During an observation on 5/18/23 at 11:54 a.m., the resident was in her room with O2 off. At the same time, Licensed Practical Nurse (LPN) 7 indicated the order was now for as needed (PRN). She indicated she would clarify the order in the chart to reflect this change.
Resident 19's record was reviewed on 5/16/23 at 11:32 a.m. The profile indicated diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems).
The record lacked an order for O2 administration.
A care plan, dated 1/24/23, indicated the resident had potential for shortness of breath (SOB) while lying flat.
The record lacked a care plan for oxygen use or care plan for diagnosis of and effects of COPD.
A physician's order, dated 5/16/23, indicated to change O2 tubing monthly, once a day on the 1st of the month.
A physician's order, dated 5/16/23, indicated clean external concentrator filter every two weeks. Once a day on Sunday.
Hospice documentation indicated, the resident had been admitted under hospice services, related to terminal diagnosis of atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery).
A hospice physician's order, dated 7/22/22, indicated to administer O2 at 3 L per NC continuously.
A review of a hospice document titled, Hospice/Facility Coordinated Task Plan of Care, dated 5/11/23, indicated the resident was on oxygen with a diagnosis of COPD.
A hospice nurse's note, dated 5/11/23, indicated durable medical equipment (DME) provided an O2 concentrator.
During an interview, on 5/16/23 at 11:32 a.m., LPN 7 indicated she could not find an order for the O2. The resident only had it on in her room. She would call the physician to clarify the order for the O2.
During an interview, on 5/16/23 at 11:35 a.m., the Director of Health Service (DHS) was informed that the medical record did not indicate an order for O2 via NC at 3.5 L. She indicated would check into the concern.
During an interview, on 5/16/23 at 3:05 p.m., LPN 7 indicated an order had been received for O2 to be administered at 2 L per NC.
During a telephone interview, on 5/18/23 at 1:30 p.m., Hospice Registered Nurse (RN) 15 indicated she visited the resident two times per week. The resident was placed on O2 at 3 L PRN when they began services. The facility was to call her and let her know when any orders were received or changed. She had not been made aware of any changes in the order. The only time hospice would administer oxygen was for comfort only. They provided the concentrator, and the facility changed the tubing and humidifiers.
During an interview, on 5/18/23 at 1:45 p.m., DHS indicated orders and changes were told to the hospice nurse when they visited the resident.
The Cleveland Clinic: Hypercapnia, dated 3/9/23, retrieved from internet on 5/22/23, indicated,
The administration of oxygen at a higher liter flow could result in Hypercapnia (respiratory failure-when there is too much carbon dioxide in the blood, and near normal or not enough oxygen in the blood), which could be fatal. It commonly occurred in people with COPD who were given too much or uncontrolled amounts of oxygen.
On 5/19/23 at 11:40 a.m., the Executive Director (ED) provided a document, dated 5/2018, titled, Administration of Oxygen, and indicated it was the policy currently being used by the facility. The policy indicated, .Standard Operating Procedures (SOP) Details. 1. Verify physician's order for the procedure .13. Date the tubing for the date it was initiated. A. Tubing should be changed monthly and PRN .19. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order .Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through
3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a resident had participated in care plan meetings for 1 of 1 resident reviewed for care plan meetings (Resident 29).
Findings include:
During an interview, on 5/16/23 at 10:42 a.m., Resident 29 indicated she could not remember if she had attended any of her care plan meetings.
Resident 29's record was reviewed on 5/22/23 at 1:17 p.m. The profile indicated the resident's diagnoses included, but were not limited to, atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).
An annual Minimum Data Set (MDS-a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessment, dated 3/28/23, indicated the resident had no cognitive deficit.
The resident's Face Sheet indicated the resident's daughter was her financial representative and her initial contact person. The Face Sheet lacked any documentation of any designated Power of Attorney (POA-gives authority to act for another person in specified or all legal or financial matters) or guardianship (legal process, utilized when a person can no longer make or communicate safe or sound decisions about his/her person and/or property or has become susceptible to fraud or undue influence).
Review of care plan conference forms, indicated the following:
a. A care plan conference, dated 9/30/22, indicated the resident's representative had attended the meeting. The note lacked documentation of the resident attending or declining to attend.
b. A care plan conference, dated 12/30/22, indicated the resident's representative had attended the meeting. The note lacked documentation of the resident attending or declining to attend.
c. A care plan conference, dated 2/10/23, indicated the resident's representative had participated via electronic device. The note lacked documentation of the resident attending or declining to attend.
During an interview, on 5/22/23 at 2:30 p.m., the Executive Director (ED) indicated she was unable to find any documentation that the resident had attended, or declined to attend, the care plan meetings, or any documented explanation of why the resident had not attended. She indicated the expectation was that the resident and their representative should attend each meeting, if possible. A note would be placed in the resident's record of who attended the meeting.
On 5/22/23 at 2:51 p.m., the ED provided a document, with a revision dated of 4/25/22, titled, Resident First Meeting Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures .6. Director of Social Service or designee should send invitations to the resident and/or representative notifying them of the date and time of the conference as far in advance as possible .17. A record of the meeting should be documented within the electronic health record .It must list all attendees present .18. Resident/Resident Representative to e-sign .if present
3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to accurately code a resident's discharge location on the Discharge Return not Anticipated Minimum Data Set (MDS) assessment for 1 of 14 residents reviewed for MDS assessments (Resident 52).
Finding includes:
The record for Resident 52 was reviewed on 5/22/23 at 10:15 a.m., The profile indicated the resident's diagnosis included but was not limited to, fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (a fracture is described as a broken bone that occurs when the physical force on the bone is stronger than the bone itself).
A discharge Minimum Data Set (MDS) assessment, dated 3/17/23, indicated Resident 52 was discharged to a psychiatric hospital.
A Social Services observation comprehensive note, dated 3/17/23 at 9:05 a.m., indicated the resident was discharged to home with her husband.
The medical record lacked documentation of the actual discharge from the facility.
During a telephone interview with Resident 52, on 5/22/23 at 10:42 a.m., she indicated she had a planned discharge and went home with home health care services.
During an interview with the MDS Coordinator, on 5/22/23 at 1:50 p.m., she indicated according to the social services progress note, the resident was discharged home. She obtained the information related to a discharge from documentation in the resident's chart, including the nurse's notes and social service's notes. The MDS Coordinator indicated Resident 52's discharge MDS assessment was incorrectly coded.
On 5/22/23 at 2:20 p.m., the MDS Coordinator provided and identified a document as a current facility policy, titled CMS's (Center for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019. The manual indicated, .A2100: OBRA Discharge Status .1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location .Coding Instructions .Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home