**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's dignity and provide privacy during a random observation of personal care. (Resident 46) Findings include: Resident 46's clinical record was reviewed on 12/3/24 at 9:50 a.m. Current diagnoses included morbid (severe) obesity, multiple sclerosis, depression, anxiety, chronic pain syndrome, overactive bladder, constipation, muscle weakness, paresthesia of skin, and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], indicated the resident was frequently incontinent of both bowel and bladder. The resident was cognitively intact and required total assistance for personal hygiene, including pericare. A current care plan, initiated 9/20/24, indicated the resident had impairment in functional status and required assistance with all activities of daily living (ADLs). During a personal care observation on 12/4/24 at 11:45 a.m., CNA 11 and CNA 12 were performing pericare for Resident 46 in her room. Resident 46 was fully undressed, with an adult brief open. CNA 12 assisted the resident to her side and CNA 11 removed the adult brief from underneath the resident. The two CNAs continued to assist the resident. During that time, the resident remained without any clothing or covering. The resident's sheet and blanket were observed on the chair next to her bed. At 11:52 a.m., the resident was left lying flat on top of her brief. CNA 11 indicated to Resident 46 to finish moving her bowels and that they (the CNAs) would return to complete peri care after she was finished. At that time, CNA 12 helped the resident put on her shirt. No other coverings were provided to the resident. During an interview with CNAs 11 and 12, on 12/4/24 at 12:00 p.m., CNA 12 indicated she had forgotten to cover the resident up with a sheet. It was not her practice to leave the resident exposed during peri care, and she should have put the resident's shirt on before continuing. A facility policy, titled Perineal Care for Incontinence, was provided by the Nurse Consultant on 12/6/24 at 11:40 a.m. The policy did not address ensuring dignity was maintained during the procedure. The Indiana State Department of Health Nurse Aide Curriculum, retrieved from https://www.in.gov/health/files/Indiana_Nurse_Aide_Curriculum.pdf indicated the following instructions for bed baths and perineal care on Page 196 - .3) Provide resident privacy - Maintains resident's dignity and right to privacy by not exposing body. Keeps resident warm .13) Place towel over chest and abdomen - Maintains resident's right to privacy .14) Exposing only the area of the body necessary to do the procedure maintains resident's dignity and right to privacy 3.1-3(a)

Based on record review and interview, the facility failed to ensure a resident with a change in condition was assessed prior to hospitalization for 1 of 1 residents reviewed for hospitalization (Resident 51). Findings include: During an interview, on 12/2/24 at 10:04 a.m., Resident 51 sat in her recliner with her feet elevated. The resident indicated she had been hospitalized shortly after she had been admitted because she had become incoherent. Her blood sugar had been very low. Resident 51's clinical record was reviewed on 12/3/24 at 11:05 a.m. Diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for close fracture with routine healing (9/23/24), type 2 diabetes mellitus with diabetic chronic kidney disease (9/23/24), and anxiety disorder, unspecified (9/23/24). Physician orders included glimepiride (for high blood sugar) 2 milligrams (mg) daily (started 9/23/24 and discontinued 9/30/24), metformin (for high blood sugar) 500 mg twice a day (started 9/23/24 and discontinued 9/30/24), and pioglitazone (for high blood sugar) 15 mg daily (started 9/23/24 and discontinued 9/30/24). An admission Minimum Data Set (MDS) assessment, dated 10/7/24, indicated the resident was cognitively intact. A current care plan for hypoglycemic (lower blood sugar) medications was initiated on 9/24/24 with a long-term goal to be free from adverse effects associated with hypoglycemic medications. The interventions included the following: Monitor blood sugar as ordered or as needed (9/24/24) and observe for and report signs and symptoms of adverse effects of medication such as dizziness, drowsiness, nausea, and hypoglycemia (9/24/24). A current care plan for a risk for hypo/hyperglycemia related to diabetes mellitus was initiated on 9/24/24. The interventions included observe the resident for hypoglycemia such as sweating, cold, clammy skin, numbness of the fingers, toes, mouth, rapid heartbeat, tremors, and dizziness. A Nurses Note, dated 9/28/24 at 5:32 p.m., indicated the resident was alert and oriented to person, place, time, and event. A Nurses Note, dated 9/28/24 at 9:53 p.m., indicated the resident was lying in her bed and put on her call light. She was unable to tell the certified nurse aide (CNA) what she needed. She did not know why she turned on the call light. The resident turned on her call light again within five minutes. Another CNA entered her room and asked what she needed, and she did not know what she needed. The resident put on her call light after five more minutes. The nurse obtained vital signs. The resident stared into space with pinpoint slow reactive pupils and with involuntary twitching all over her body. The resident was unable to answer any questions or speak any clear words. The resident was sent to the hospital via emergency medical services for evaluation. A Nurses Note, dated 9/29/24 at 5:01 a.m., indicated the resident was admitted to the hospital for hypoglycemia. The resident's clinical record lacked blood sugar tests taken by the facility during the change in condition and prior to hospitalization. A hospital history and physical with the hospital admission paperwork on 10/1/24 indicated the resident presented with aphasia to the hospital on 9/28/24. She was normally alert and oriented but around 9:30 the staff stated the resident was unable to speak, had jerky movements and had pinpoint pupils. The medics obtained a blood sugar of 29 mg/dL (milligrams per deciliter). During an interview, on 12/4/24 at 9:46 a.m., LPN 4 indicated Resident 51 had a lot of anxiety when she was first admitted . The change in the resident's condition started as increasing anxiety, and LPN 4 tried to calm the resident. When LPN 4 went to check on the resident she had body shakes, and her blood pressure was low. The resident's family wanted her sent to the hospital. LPN 4 had not realized the resident's diabetes was not stable. LPN 4 indicated it did not register for her to check the resident's blood sugar. During an interview, on 12/4/24 at 12:31 p.m., NP 10 indicated she remembered the resident had several hypoglycemics ordered when she was admitted . She did not recall seeing the resident prior to the rehospitalization as she had been at the facility for only a few days before going back to the hospital. She would not have typically ordered routine blood sugars for a resident on oral hypoglycemics if there was not a history of problems with the blood sugar. During an interview, on 12/4/24 at 2:25 p.m., the Director of Nursing (DON) indicated she would expect a blood sugar to be obtained with a change in condition of a resident with diabetes. A facility policy, dated 12/31/23, provided by the Corporate Nurse Consultant on 12/6/24 at 11:41 a.m., titled HYPER/HYPOGLYCEMIA, indicated the following: .All residents diagnosed with diabetes mellitus, will receive interventions according to their physician orders. If the attending physician (s) have not provided specific orders on what treatment is to be provided to treat hypoglycemic episodes, the following guidelines will be followed until the attending physician can be contacted .Symptoms of hypoglycemia (<60) may consist of (not necessarily limited to) the following: 1. tremors .anxiety .altered mental capacity such as confusion or abnormal behaviors .PROCEDURE: 1. Finger stick blood glucose will be done when the resident exhibits signs of hyper/hypoglycemia. 2. Notify the physician of the result of the resident's finger stick glucose level and report the resident's condition .If the resident does not have specific order for treatment, the following procedure will be followed: .BLOOD GLUCOSE < 50 MG/DL and ALERT - Give 30-gram carbohydrate oral feeding of one of the following: 2 tubes of glucose gel, 8 ounces of any juice without added sugar, 8 ounces of regular soda pop. Wait 15 minutes and recheck blood sugar. If resident continues to have hypoglycemic symptoms or blood sugar < 70, repeat 15-gram carbohydrate oral feeding. Recheck blood sugar every 15 minutes and repeat 15-gram carbohydrate oral feeding until symptoms are resolved or blood sugar is >70. Notify resident's primary physician of condition and what has been done (including current diabetes medication, blood glucose results at the time of discovery and past treatment, vital signs at the time of discovery and past treatment, signs and symptoms, action taken and response .BLOOD GLUCOSE < 50 MG/DL AND UNABLE TO SWALLOW - If a resident has a decreased level of consciousness and is unable to safely take oral treatment: Administer 1 mg glucagon IM. Resident should awaken within a couple of minutes. If resident continues to be unresponsive, administer additional 1 mg glucagon IM and call emergency assistance. Notify resident's primary physician of condition and what has been done (including current diabetes medication, blood glucose results at the time of discovery and past treatment, vital signs at the time of discovery and past treatment, signs and symptoms, action taken and response 3.1-35(g)(1)

2. During an observation, on 12/2/24 at 10:10 a.m., Resident 37 was wearing support hose on her bilateral lower legs. Resident 37's clinical record was reviewed on 12/03/24 at 10:30 a.m. Diagnoses included hypertension, heart failure, shortness of breath, chronic obstructive pulmonary disease, and sepsis. Resident 37 had a past physician order for support hose to be applied in the morning and removed at bedtime, initiated 10/4/22 and discontinued on 7/23/24. A nursing progress note, dated 9/18/24 at 10:54 p.m., indicated the resident stated this morning when staff applied the support hose, her right lower leg was scratched, and a small scab was intact without drainage or edema. During an observation, on 12/3/24 at 11:18 a.m., Resident 37 walked out of her room wearing support hose on her bilateral lower legs. Resident 37 indicated the staff put support hose on her legs every morning. During an interview, on 12/3/24 at 11:19 p.m., LPN 6 indicated the resident was wearing her support hose, but she was unsure why she didn't have an order for them. During an interview, on 12/3/24 at 11:26 a.m., CNA 13 indicated Resident 37 normally wore support hose and staff applied them daily. A new physician order, dated 12/3/24 at 12:05 p.m., indicated the resident was to wear support hose. During an interview, on 12/6/24 at 2:22 p.m., the DON indicated the resident wanted staff to put the support hose on so the facility got the order for them. A current facility policy, dated 5/2016, Titled Guidelines for Medication Orders, provided by the corporate nurse, on 12/6/24 at 3:23 p.m., indicated the following: .Treatment orders: When recording treatment orders specify what is to be done, location, frequency and duration of treatment Based on record review, and interview, the facility failed to ensure physician's orders were followed for 3 of 18 residents reviewed for medications (Resident 29, 37, and 44). Findings include: 1. Resident 29's clinical record was reviewed on 12/4/24 at 9:46 a.m. Diagnoses included, but were not limited to, unspecified dementia with unspecified severity or behavioral disturbances, anxiety, respiratory failure with hypoxia (oxygen deficiency), hypertensive heart disease, and restlessness and agitation. A current physician's order, dated 7/30/21, indicated the resident's head of bed (HOB) should be elevated to alleviate/reduce shortness of breath while lying flat related to a diagnosis of emphysema, and low oxygen saturations. A current care plan, dated 7/30/21 and last reviewed on 10/25/24, indicated the resident had a potential for shortness of breath while lying flat. Shortness of breath was related to chronic obstructive pulmonary disease, emphysema, and a history of pneumonia. An intervention, dated 7/30/21, was to elevate the head of the bed or place in an upright position as needed. During an observation on 12/4/24 at 10:46 a.m., Resident 29 was observed lying flat on her back in bed. The head of the bed was not elevated. During an observation on 12/4/24 at 2:08 p.m., the resident's bed was in a low position and the head of the bed was flat. During an observation on 12/4/24 at 2:36 p.m., Certified Nursing Assistant (CNA) 14 and CNA 15 transferred the resident from chair to bed. The CNAs settled the resident in the bed and the bed remained flat when they left the room. During an interview, after the CNAs left the room, CNA 14 and CNA 15 both indicated they were not sure if the head of the bed was supposed to be elevated. During an observation on 12/5/24 at 10:59 a.m., Resident 29 was lying flat on her back in bed. The head of the bed was not elevated. During an interview with LPN 16 on 12/6/24 at 12:11 p.m., she indicated she was unsure whether the head of Resident 29's bed was supposed to be elevated. During an interview on 12/6/24 at 12:17 p.m., CNA 11 indicated there was nothing in the resident's profile in the clinical record to indicate the head of the bed should be elevated. A current facility document, titled Guidelines for Medication Orders, was provided by the nurse consultant on 12/6/24 at 3:23 p.m. The policy indicated the following: .2) A current list of orders will be maintained in the electronic clinical record for each resident .9) Treatment Orders - a. When recording treatment orders specify 1). What is to be done, location and frequency and duration of treatment The facility did not provide a policy regarding following physician orders not pertaining to medications 3. Resident 44's clinical record was reviewed on 12/3/24 at 12:25 p.m. Diagnoses included acute posthemorrhagic anemia and anemia. Current physician orders included apixaban (blood thinner) 5 milligrams (mg) twice a day (2/9/24) and occult blood fecal one time (4/9/24). A quarterly 11/7/24 Minimum Data Set (MDS) assessment indicated the resident had anemia and received an anticoagulant (blood thinner). A care plan for risk of excessive bleeding and bruising related to medications was initiated on 2/6/24. Interventions included labs as ordered and notify physician of abnormal labs (2/6/24). A Progress Note, dated 4/8/24 at 11:19 a.m., indicated the resident was seen by the Nurse Practitioner (NP) for multiple concerns including abdominal distention with an eight-pound weight gain over one month. The family was concerned about ongoing urinary and bowel and reported the resident's abdomen had been bloated and hard. The resident had been having dark, tarry stools. The resident was taking iron and apixaban. The resident had a positive fecal occult blood test on 9/25/23. The NP's assessment/plan included the resident had black, tarry stools with a history of melena (black, tarry stools indicating bleeding in the upper gastrointestinal tract). Hemoccult stools daily x 3 days and complete blood count (CBC) on the next day were ordered. For the abdominal distention with mild lower abdominal tenderness an abdominal X-ray was ordered. Orders were discussed with the family and nursing staff. A Nurses Note, dated 4/8/24 at 11:30 p.m., indicated written orders were received from the NP for hemoccult stools for 3 days, CBC 4/9/24, and abdominal X-ray. A Progress Note, dated 4/10/24 at 8:39 a.m., indicated the resident was seen by the NP. The abdominal X-ray was negative. Hemoccult stools and labs were still pending. A Progress Note, dated 4/25/24 at 7:46 a.m., indicated the resident was seen by the NP. The hemoccult stools were pending. CBC on 4/10/24 was stable. The resident's clinical record lacked indication of completion of hemoccult testing and the results. During an interview, on 12/4/24 at 2:45 p.m., the Nurse Consultant indicated she would look for the results of the resident's hemocult testing. During an interview, on 12/5/24 at 2:05 p.m., the Nurse Consultant indicated she had been unable to locate documentation of the resident having had the hemoccult testing completed. During an interview, on 12/6/24 at 2:22 p.m., the Director of Nursing (DON) indicated the facility did not have documentation of performing the hemoccult testing. The NP had given a verbal order to discontinue the hemoccult order when her labs came back okay, but no one had removed the order. During an interview, on 12/9/24 at 2:45 PM, the Nurse Consultant indicated she was unable to locate a facility policy for physician orders for labs and diagnostics. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with recurrent urinary tract infections received sufficient fluids for 1 of 2 residents reviewed for hydration. Findings include: During an observation, on 12/4/24 at 9:29 a.m., Resident 29 was not in her room. Her full water jug was on the table next to her bed, did not contain any ice, and was warm to the touch. Resident 29's clinical record was reviewed on 12/4/24 at 9:46 a.m. Diagnoses included anxiety disorder, paranoid personality disorder, hypertensive heart disease without heart failure, cognitive communication deficit, and urinary tract infection. A physician's order, dated 1/21/24 at 1:14 a.m., indicated regardless of urinalysis results, fluids were to be pushed. A current care plan, dated 3/1/22 and last reviewed on 12/4/24, indicated the resident had a history of urinary tract infections. Interventions included to encourage the resident to drink fluids. A current care plan, dated 8/10/21 and last reviewed on 10/25/24, indicated the resident had impairment in functional status in regards to bed mobility, transfers, toileting, and eating. Interventions included to encourage the resident to eat and drink as able. A current care plan, dated 8/10/21 and last reviewed on 12/4/24, indicated the resident experienced episodes of incontinence. Interventions included to encourage fluids, unless contraindicated. On 12/4/24 at 10:32 a.m., the full water jug remained in the same position on the table next to the resident's bed. There was no ice in the water and the jug was warm to the touch. On 12/4/24 at 2:08 p.m., the water jug had not been moved. It was in the same position, at the same (full) level, did not have ice, and was warm to the touch. On 12/5/24 at 10:59 a.m., the resident's water jug was on the table next to her bed. The water jug was full, with no ice, and was warm to the touch. On 12/6/24 at 12:02 p.m., the resident's water jug was on the table next to her bed. The water jug was full, with no ice, and was warm to the touch. The resident was diagnosed with urinary tract infections (UTI's) on the following dates: 12/14/23, 1/20/24, 3/23/24, 7/19/24, 8/16/24, and 9/21/24. During an interview with LPN 16 on 12/6/24, at 12:11 p.m., she indicated fresh water with ice was provided to residents at 6:00 a.m., 2:00 p.m., and 11:00 p.m. Resident 29 was able to hold a cup if offered to her. The resident was not able to reach from her bed to the side table to retrieve the water jug. During an interview with LPN 17, on 12/6/24 at 12:18 p.m., she indicated Resident 29 was not able to drink water independently. If handed the jug of water, the resident would drink from a straw. The resident would sometimes refuse the water, depending on her mood. A current facility policy, titled Guidelines for Hydration Management, provided by the Nurse Consultant on 12/6/24 at 3:56 p.m., indicated the following: .Purpose - To identify residents at risk for dehydration and implement individualized interventions which promote sufficient fluid intake to maintain proper hydration 3.1-46(2)(b)

Based on observation, interview, and record review, the facility failed to ensure a resident with dementia did not receive anti-psychotic medications without indication for 1 of 5 residents reviewed for unnecessary medications (Resident 5) Findings include: On 12/2/24 at 10:30 a.m., Resident 5 was sitting in her wheelchair near the main lounge on 200 hall. On 12/3/24 at 10:36 a.m., the resident was propelling herself around in her wheelchair. On 12/5/24 at 11:04 a.m., the resident was propelling herself in her wheelchair, smiling and talking to a resident near her. Resident 5's clinical record was reviewed on 12/3/24 at 10:57 a.m. Diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, psychotic disorder with delusions due to known physiological condition, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, anxiety disorder due to known physiological condition, and insomnia due to other mental disorder. She had current physician orders for sertraline (anti-depressant) 50 mg (milligram) daily, trazodone (anti-depressant) 12.5 mg daily, and olanzapine (antipsychotic) 5 mg daily. An annual Minimum Data Set (MDS) assessment, dated 12/6/23, indicated she had no hallucinations or delusions during the assessment period. A quarterly MDS assessment, dated 7/24/24, indicated she had no hallucinations or delusions during the assessment period. A quarterly MDS assessment, dated 11/1/24, indicated she had no hallucinations or delusions during the assessment period. A care plan, dated 3/28/22, indicated the resident demonstrated altered behaviors including delusions, such as (I have to go home to my parents and/or I have to go home to take care of my children). Interventions included checking for unmet needs, toiletings, thirst, and/or hunger, inform resident that the resident's parents wanted her to stay the night at the facility and they will get her tomorrow, observe for behavioral triggers and casual relationships to medical changes with all hands on care and contacts, offer diversionary activities, such as watching TV or doing a puzzle, offer to show resident to her room for the night and to orient to room. A care plan, dated 11/6/21, indicated the resident demonstrated exit-seeking behaviors. Interventions included assess need for wander guard and apply as appropriate, encourage regular family contact and/or visits with others, evaluate need for secured unit and transfer if needed, monitor for wandering triggers such as need for toileting, inactivity, time of day, etc, offer diversional activities as needed, provide structured routine to resident's day, re-direct resident away from doors/ exits as needed, and wander guard on right ankle. Review of a 12/6/24 Behavior Analysis Report indicated the resident had no behaviors noted in the last 120 days. Review of a 7/3/24 psychiatric Nurse Practitioner progress note indicated staff denied any new or worsening symptoms of delusions which was an improvement. The resident had intermittent delusional thoughts however symptoms were not distressing in any way. Review of a July 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. Review of an 8/29/24 psychiatric Nurse Practitioner progress note indicated staff denied any new or worsening symptoms of delusions. She did have intermittent delusional thoughts, however symptoms were not distressing in any way. Olanzapine was reported effective. No current concerns were voiced by staff or observed during the visit. Review of an August 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. Review of a 9/26/24 psychiatric Nurse Practitioner progress note indicated staff reported intermittent delusional thoughts. No reported changes in sleep. She did have intermittent delusional thoughts, however symptoms were not distressing in any way. Olanzapine was reported effective. No current concerns were voiced by staff or observed during the visit. Review of a September 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. Review of a 10/14/24 psychiatric Nurse Practitioner progress note indicated staff reported occasional nervousness. Staff reported that she did have delusional thoughts, however symptoms were not currently distressing. Olanzapine was reported effective. History of failed gradual dose reduction (GDR). No current concerns voiced during visit. A GDR for olanzapine was clinically contraindicated on 10/4/24. Review of an October 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, 1 out of 30 days but she was easily redirected. Review of an 11/20/24 psychiatric Nurse Practitioner progress note indicated staff reported that she had delusional thoughts, however symptoms were not currently distressing. Olanzapine was reported effective. History of failed GDR. No current concerns voiced during visit. A GDR for olanzapine was clinically contraindicated on 10/4/24. Review of a November 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. During an interview, on 12/5/24 at 10:57 a.m., RN 18 indicated resident states she wants to go home and doesn't understand why she was here. She was easily redirected. During an interview, on 12/5/24 at 11:20 a.m., QMA 19 indicated they were tracking behaviors for tearfulness. She had not displayed any recent hallucinations, and she was easily redirected. During an interview, on 12/6/24 at 2:00 p.m., the psychiatric Nurse Practitioner indicated the resident was admitted to the facility on olanzapine. The resident had failed prior GDR attempts of olanzapine. She had increased confusion, tearfulness, changes in mood, and continued with her intermittent delusional thoughts. The resident's family reported that she had a history of psychosis. Before prescribing a resident an antipsychotic, without a mental health history, she looked at symptoms lasting longer than 6 months. Then she would question are the symptoms distressing to the resident; has the facility tried any non-pharmacological interventions, etc. She reassesses the need for an antipsychotic at every visit, which is usually weekly. The resident's psychosis caused her frequent delusions, tearfulness, and difficulty calming her down. She contraindicated the GDR of olanzapine if she has supporting documentation and input from the staff to support why she wouldn't GDR a medication. A current policy, titled Psychotropic Medication Usage and Gradual Dose Reductions, provided by the Nurse Consultant, on 12/6/23 at 3:23 p.m., indicated the following: .Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage The Olanzapine manufacturer guidelines website at https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/020592s062021086s040021253s048lbl.pdf indicated olanzapine has a black box warning for elderly patients with dementia- related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa (olanzapine) is not approved for the treatment of patients with dementia- related psychosis. 3.1-37(a)

Based on record review and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by deficiencies cited and to ensure quality assurance procedures were followed and plans of action implemented to prevent deficiencies from re-occurring. This affected 1 of 3 residents reviewed for unnecessary medications. (Resident 5) Finding includes: Review of the Summary Statement of Deficiencies for the facility's last annual recertification and licensure survey completed on 12/7/24, indicated the facility had deficiencies related to failure to ensure a resident with dementia did not receive anti-psychotic medications without indication. During an interview, on 1/30/25 at 11:18 a.m., the Administrator indicated the Quality Assessment and Assurance (QAA) committee met monthly. Since the Plan of Correction, staff had been educated on properly documenting Resident 5's behaviors. A facility policy, revised on 11/14/19, titled, Quality Assessment and Assurance Committee/ Quality Assurance and Performance Improvement (QAPI) Program, provided by the Administrator on 1/30/25 at 11:18 a.m., indicated the following: . Performance Improvement plans (PIP) will include facility development, monitoring, and evaluation of performance indicators, and include the methodology and frequency for such development, monitoring an evaluation . Reporting to the Quality Assessment and Assurance Committee will include improvement/lack of improvement, with changes to the action plan as deemed necessary to meet compliance .The facility shall set priorities for its performance improvement activities, track adverse resident events, and perform an improvement project as indicated. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the campus' services and available resources, as reflected by the campus assessment Cross reference F744. 3.1-52(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 46's clinical record was reviewed on 12/3/24 at 9:50 a.m. Diagnoses included, but were not limited to, morbid (severe) obesity, multiple sclerosis, depression, anxiety, chronic pain syndrome, overactive bladder, constipation, muscle weakness, parasthesia of skin, and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], indicated the resident was frequently incontinent of both bowel and bladder. The resident was cognitively intact and required total assistance for personal hygiene, including peri-care. A current care plan, dated 9/20/24, indicated the Resident 46 had impairment in functional status and required assistance with all activities of daily living (ADLs). During an observation of incontinence care on 12/4/24, at 11:45 a.m., CNA 11 and CNA 12 began to perform perineal care for Resident 46. CNA 12 assisted the resident to a side-lying position. CNA 11 performed perineal care by cleansing the peri-area with wet wipes. She was observed to wipe from front to back and from back to front. The resident continued to be incontinent of bowel at that time. Each swipe with the wet wipes produced additional amounts of fecal matter. CNA 11 indicated they would leave the resident to finish the bowel movement before completing peri care. During an interview with CNA 11 on 12/4/24 at 12:00 p.m., she indicated it was not appropriate to wipe the peri-area from back to front. An undated facility policy, titled Perineal Care for Incontinence, provided by the Nurse Consultant on 12/6/24 at 11:40 a.m. indicated the following: The procedure included the following instruction(s): .7) Pay particular attention to infection prevention and control techniques when performing peri-care, to prevent introduction of contamination that may lead to a urinary tract infection The Indiana State Department of Health Nurse Aide Curriculum, retrieved from https://www.in.gov/health/files/Indiana_Nurse_Aide_Curriculum.pdf indicated the following: .Procedure 33 - Bed Bath/Perineal Care - Step 23) Wipe from front to back and from center of perineum to thighs. If washcloth is visibly soiled, change cloths. Rationale 23 - . Prevents spread of infection. Females: Removes secretions in skin folds which may cause infection or odor .Step 28) Clean anal area from front to back. Rinse and pat dry thoroughly. Rationale 28 - Prevents spread of infection 3.1-18(l) 3.1-18(a) Based on observation, interview, and record review, the facility failed to utilize infection prevention and control procedures during blood glucose testing for 2 of 4 residents reviewed for medication administration (Residents 51 and 106) and during perineal care for 1 of 1 residents observed during perineal care (Resident 46). Findings include: 1. During a random medication administration observation on 12/4/24 at 11:30 a.m. LPN 4 removed a bottle of glucometer strips from the top of the medication cart and a plastic bag containing Resident 51's glucometer from the right-side top drawer of the medication cart. When LPN 4 went into Resident 51's room, she placed the plastic bag and the bottle of glucometer strips on Resident 51's bedside table. No barrier was placed on the bedside table prior to placing the plastic bag and bottle of glucometer strips. LPN 4 performed hand hygiene, applied gloves, used an alcohol wipe to cleanse the resident's finger, performed a finger stick with a lancet, wiped off the first drop of blood, and used the next drop of blood for the blood sugar test. Upon completion of the blood sugar test, LPN 4 removed her gloves, washed her hands, and gathered the glucometer bottle and plastic bag with supplies. She placed the bottle of glucometer strips on top of the medication cart. The plastic bag was placed on top of the medication cart until the glucometer was disinfected, then the glucometer was put into the plastic bag and back into the top right drawer of the medication cart with other plastic bags. She did not clean or disinfect the bottle of glucometer strips or the plastic bag prior to placing on or in the medication cart. Resident 51's clinical record was reviewed on 12/4/24 at 2:30 p.m. Diagnoses included type 2 diabetes mellitus with diabetic chronic kidney disease. Physician's orders included blood sugar check before meals and at bedtime (10/1/24). 2. During a random medication administration observation on 12/4/24 at 11:52 a.m. LPN 4 removed a bottle of glucometer strips from the top of the medication cart and a plastic bag containing Resident 106's glucometer from the right-side top drawer of the medication cart. When LPN 4 went into Resident 106's room, she placed the plastic bag and the bottle of glucometer strips on Resident 106's bedside table. No barrier was placed on the bedside table prior to placing the plastic bag and bottle of glucometer strips. LPN 4 performed hand hygiene, applied gloves, used an alcohol wipe to cleanse the resident's finger, performed a finger stick with a lancet, wiped off the first drop of blood, and used the next drop of blood for the blood sugar test. Upon completion of the blood sugar test, she removed her gloves, washed her hands, and gathered the glucometer bottle and plastic bag with supplies. She placed the bottle of glucometer strips on top of the medication cart. The plastic bag was placed on top of the medication cart until the glucometer was disinfected, then the glucometer was put into the plastic bag and back into the top right drawer of the medication cart with other plastic bags. She did not clean or disinfect the bottle of glucometer strips or the plastic bag prior to placing on or in the medication cart. Resident 106's clinical record was reviewed on 12/4/24 at 2:35 p.m. Diagnoses included diabetes mellitus. Physician orders included insulin lispro (rapid acting insulin) 100 unit/milliliter (ml) per sliding scale. If blood sugar is 121 to 150, give 2 units. If blood sugar is 151 to 200, give 4 Units. If blood sugar is 201 to 250, give 6 Units. If blood sugar is 251 to 300, give 8 Units. If blood sugar is 301 to 350, give 10 Units. If blood sugar is greater than 350, call MD (physician). Give subcutaneously (12/2/24). During an interview, on 12/4/24 at 12:08 p.m., LPN 4 indicated she had not thought about putting the strips on the table then back onto the cart and should not have moved the supplies from dirty to clean. During an interview, on 12/6/24 at 2:05 p.m., the Director of Nursing (DON) indicated the bottle of glucometer strips and the plastic bags should not have been placed on the residents' tables without a barrier. A facility policy, dated 12/31/23, provided by the Nurse Consultant on 12/6/24 at 2:50 p.m., titled Glucometer SOP [standard operating procedure], indicated the following: .Appropriate infection control technique shall be followed during testing procedures

Based on interview and record review, the facility failed to ensure a resident was assisted with transfers in accordance with the plan of care for 1 of 5 residents reviewed for accidents. (Resident 36) Finding includes: Resident 36's clinical record was reviewed on 11/2/23 at 2:26 p.m. Diagnoses included hemiplegia and hemiparesis following non-traumatic subarachnoid hemorrhage affecting left non-dominant side (7/15/22), unspecified fracture of the lower end of left radius (7/24/23), age-related osteoporosis without current pathological fracture (7/10/23), morbid (severe) obesity due to excess calories (7/15/22), unsteadiness on feet (7/12/23), history of falling (7/12/23), muscle weakness (generalized) 7/12/23, and repeated falls (7/12/23). A quarterly Minimum Data Set (MDS) assessment, dated 5/3/23, indicated the resident was cognitively intact and required substantial/maximal assistance with the ability to safely come to a standing position from sitting in a chair or on the side of the bed, the ability to safely get on and off a toilet or commode, and walk 10 feet. A Nursing Progress Note, dated 3/15/23 at 4:30 a.m., indicated the resident was assisted to the bathroom and turned around before she was aligned with the toilet. She sat down onto the floor. No apparent injuries were identified. A fall care plan, initiated on 7/19/22, indicated the resident was at risk for falling related to required assistance. An intervention, dated 3/15/23, indicated the resident was to be verbally cued to sit on the toilet. A Nursing Progress Note, dated 4/6/23 at 8:15 p.m., indicated the resident was holding onto the bar in the bathroom with assistance of a nurse aide when her legs weakened. She was lowered to the floor by the nurse aide. No apparent injuries were identified. An intervention, added to the fall care plan on 4/7/23, indicated the resident required assistance of two staff members for transfers to the toilet. A Nursing Progress Note, dated 4/7/23 at 11:08 a.m., indicated the resident was assisted to the floor. The resident indicated her legs gave out when being transferred from bed to wheelchair. She complained of pain to her left knee and right toes. No apparent injuries were identified. An intervention, added to the fall care plan on 4/10/23, indicated the resident required assistance of two staff members for all transfers. A Point of Care Response, dated 5/17/23 at 8:13 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/17/23 at 3:32 p.m., indicated the resident was transferred with limited assistance of one person. A Point of Care Response, dated 5/18/23 at 12:34 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/18/23 at 10:28 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/19/23 at 12:18 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/19/23 at 11:07 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/19/23 at 3:19 p.m., indicated the resident was transferred with extensive assistance of one person. A Nursing Progress Note, dated 5/19/23 at 7:10 p.m., indicated when a nurse aide attempted to assist the resident to bed, the bed rolled due to being unlocked. The resident acquired a light purple bruise to her left buttock of 3 centimeters (cm) by 2 cm and a skin tear to her the front of her middle finger of 0.4 cm by 0.2 cm. A Point of Care Response, dated 5/19/23 at 11:20 p.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/20/23 at 10:07 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/20/23 at 2:53 p.m., indicated the resident was transferred with extensive assistance of one person. An intervention, added on 5/22/23 to the fall care plan, indicated the staff should ensure the bed was locked before transferring the resident. A Physical Therapy Discharge Summary for a discharge date of 6/20/23, provided by the Administrator on 11/8/23 at 9:50 a.m., indicated the resident required partial/moderate assistance with ambulation on level surfaces with hemi-walker and with transfers A Point of Care Response, dated 7/9/23 at 2:40 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 7/9/23 at 2:50 p.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 7/10/23 at 12:23 a.m., indicated the resident was transferred with total dependence on the assistance of one person. A Point of Care Response, dated 7/10/23 at 12:25 p.m., indicated the resident was transferred with extensive assistance of one person. A Nursing Progress Note, dated 7/10/23 at 5:00 p.m., indicated the resident was assisted by a nurse aide to the restroom via quad cane. As the resident turned, she fell forward onto the floor and landed on her affected side. Resident complained of left shoulder and wrist pain. A Point of Care Response, dated 7/11/23 at 2:47 a.m., indicated the resident was transferred with total dependence on the assistance of one person. A Nursing Progress Note, dated 7/11/23 at 10:01 a.m., indicated the Interdisciplinary Team reviewed the fall. Intervention was for the resident to use wheelchair for locomotion in room. A Progress Note, dated 7/12/23 at 10:31 a.m., indicated the NP saw the resident to follow up on pain after a fall. X-rays obtained on 7/10/23 indicated the left ankle had an avulsed (when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) fracture tip of lateral fibula, age indeterminate. The fracture was likely an old fracture as the resident no longer experienced left ankle pain. The resident continued to complain of left wrist pain of 10 of 10 on a 1 to 10 scale. The NP ordered ibuprofen (pain med) 400 mg by mouth every 8 hours for 7 days for left wrist pain and consider repeat imaging if needed. A Nursing Progress Note, dated 7/13/23 at 2:11 p.m., indicated the resident went to the orthopedic walk-in clinic in the morning regarding the left wrist and knee pain. The orthopedic clinic sent the resident back with a wrist splint for stabilization. The resident was given an injection to the left knee for the pain and swelling. The resident rated her pain a 10 out of 10 on a 1 to 10 scale and received ibuprofen. An annual Minimum Data Set (MDS) assessment, dated 7/22/23, indicated the resident was cognitively intact and required substantial/maximal assistance with the ability to safely come to a standing position from sitting in a chair or on the side of the bed, the ability to safely get on and off a toilet or commode, and walk 10 feet. A Physician's Note, from the orthopedic office, dated 7/24/23, indicated the resident had no acute ankle problems. The wrist was positive for fracture and would do well with continued treatment. The resident was to follow up with the orthopedic clinic as needed. An orthopedic office visit summary, dated 7/24/23, indicated the reason for the resident's visit was pain, swelling, an injury, and a fracture to the left ankle which had been present for two weeks. X-rays were taken of the left ankle and of the left wrist. The wrist x-rays indicated a non-displaced distal radius fracture. The ankle x-rays showed nothing acute. The brace to the left wrist was to be continued. During an interview, on 11/6/23 at 2:24 p.m., CNA 7 indicated the resident's profile on the computer told what kind of assistance was needed for the resident. Resident 36 required assistance of two for all transfers. During an interview, on 11/8/23 at 9:25 a.m., QMA 8 indicated the resident's profile in her electronic chart provided information on the assistance a resident required including specific orders and care plan interventions. Resident 26 required assistance of two for all transfers. During an interview, on 11/8/23 at 9:50 a.m., the Administrator indicated the resident required assistance of two with transfers, and not ambulation. She did not have assistance of two people with the fall on 5/19/23 during the transfer to bed. When the resident fell on 7/10/23, she was ambulating to the bathroom with her quad cane and one assist. The DON indicated the resident had received therapy between her falls in April and July with the intent to return home and once the resident was ambulating, she was fine. The current resident's profile from the resident's chart, provided on 11/8/23 at 3:50 p.m. by the Administrator, indicated the resident required assistance for transfers and two staff for all transfers. The Administrator indicated, when providing the profile, that the start dates for each intervention were not on the profile. All the dates on the profile were the original start date of the care plan. A current policy with a review date of 3/16/22, provided by the Administrator on 11/8/23 at 3:50 p.m., indicated .Trilogy health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure medications were available and provided as ordered for 1 of 1 residents reviewed for medication availability. (Resident 28) Findings include: During an interview with Resident 28's representative, on 11/2/23 at 11:50 a.m., they expressed concern regarding a three day period in which the resident was not administered her carbamazepine, a drug used to treat trigeminal neuralgia (TN). (TN is a chronic pain disorder which causes sudden, severe pain on one side of the face.) The daughter indicated her mother began to experience extreme discomfort and jaw pain by the third day. She thought the resident was having a seizure. The DON told her the reason the medication had not been administered was because it was not available. Resident 28's clinical record was reviewed on 11/2/23 at 3:30 p.m. Diagnoses included, but were not limited to, unspecified dementia and trigeminal neuralgia. A physician's order, dated 7/5/23, indicated carbamazepine tablet, extended release 12 hour, 200 mg, 1 tablet twice a day for trigeminal neuralgia. A physician's order, dated 8/16/23, indicated carbamazepine tablet, extended release 12 hour, 200 mg, 2 tablets every morning for trigeminal neuralgia. A progress note, dated 10/12/23 at 4:53 p.m., indicated a STAT request for carbamazepine from the pharmacy. The medication was to be delivered that evening. A progress note, dated 10/12/23 at 6:55 p.m., indicated the resident was complaining of jaw pain. The NP was notified and provided a new order for Ibuprofen 400 mg every eight hours. A progress note, dated 10/12/23 at 1:46 p.m., indicated the carbamazepine was received from the pharmacy and administered as ordered at 8:16 p.m. A progress note, dated 10/13/23 at 1:57 p.m., indicated the resident had ongoing, occasional jaw pain. She was encouraged to not drink cold liquids. Review of the 10/2023 medication administration report (MAR), on 11/2/23 at 3:32 p.m., indicated carbamazepine was not administered on 10/10/23, 10/11/23, and 10/12/23, and each entry indicated the Medication (was) Not Available. During an interview with LPN 2, on 11/3/23 at 10:53, she indicated she did witness the resident's pain on 10/12/23. Carbamazepine was a difficult medication to get because Resident 28 was the only resident who received that medication and it was not kept in the emergency drug kit. She did recognize the resident was in extreme pain and had received Tylenol for the pain. The resident was back to her normal self once the carbamazepine had been reintroduced. She could understand why the resident's family thought their mother might be having a seizure, because the resident was in extreme pain. During an interview with two of the resident's representatives, on 11/3/23 at 11:15 a.m., they indicated they felt the need to routinely check to make sure the facility had the carbamazepine in stock because they were concerned she might miss her medication again. They were fearful of a repeat of the events on 10/12/23. During an interview with the DON on 11/08/23 at 11:01 a.m., she indicated she found out on 10/12/23 that the medication was not available. A request was made to the pharmacy to resupply the medication. had spoken with the family and explained to them what she was doing to remedy the situation. There should be a way to re-order from the pharmacy. The current process for reordering medications did not provide a way to know when and if an order had gone through to the pharmacy. There was a system in place where the facility could get medications from a back-up pharmacy. She was aware of the potential adverse effects that could be triggered when the medication was missed. A document titled Miscellaneous Special Situations .Unavailable Medications, with a revised date of 11/2018, was provided by the DON on 11/8/23 at 3:52 p.m. and indicated the following: .Medications used by residents in the facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident B) Facility personnel shall: 1) Notify the attending physician of the situation and explain the circumstances, expected availability and option therapies that are available. a) If the facility personnel is unable to obtain a response from the attending physician, the personnel should notify the supervisor and contact the Facility Medical Director for orders and/or directions 3.1-25(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the screening for mental illness for 1 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR) (Resident 38). Finding includes: Resident 38's record was reviewed on [DATE] at 2:14 p.m. Diagnoses included major depressive disorder, hallucinations, and delusional disorders. Current physician orders included lorazepam (antianxiety) 0.5 milligrams (mg) daily at bedtime, quetiapine (antipsychotic) 25 mg on Wednesdays at bedtime, quetiapine 50 mg on Sunday, Monday, Tuesday, Thursday, Friday, and Saturday at bedtime, and sertraline (antidepressant) 100 mg daily. A current care plan, initiated on [DATE] and last reviewed on [DATE], indicated the resident demonstrated altered behaviors including delusions of wife texting other men and/or running around town and meeting other men. During an interview, on [DATE] at 9:47 a.m., the Social Services Director was unable to produce a PASARR for the resident. He indicated the resident's PASARR screening was expired, would have to be redone, and he should have caught the lack of a completed PASARR for the resident. The hospital, prior to the pandemic, would do the screenings, but now with the pandemic waiver he completed the PASARR screenings with the admission assessments. Review of an undated, current facility policy, titled Indiana PASRR, provided by the Corporate Clinical Support RN (Registered Nurse) on [DATE] at 4:45 p.m., indicated the following: .with admission from the hospital the facility ensures the hospital has completed the appropriate screenings. During the admission process, the facility logs into Ascend (the website for PASARR screening) and prints the outcome letter out. For changes in status and Level II (in-depth assessment determining if a person has a qualifying PASARR condition such as a serious mental illness, intellectual disability and/or developmental disability) follow up, Social Services ensures paperwork is submitted, prints outcome letter and uploads it to the resident's clinical record 3.1-16(d)(1)