Every finding on record at Allison Pointe Healthcare Center

Based on interview and record review, the facility failed to ensure resident documentation was complete and accurate for 1 of 4 residents reviewed for receipt of care and services (Resident B) Findings include:The clinical record for Resident B was reviewed on 7-9-26 at 11:18 a.m. His diagnoses included, but were not limited to nontraumatic intracerebral hemorrhage (brain bleeding not caused by a trauma or accident), acute respiratory failure and type 2 diabetes. An assessment of his cognitive function on 6-13-26, indicated he had a moderate impairment of his cognitive function. A review of Resident B's clinical record indicated he was sent out to an area hospital on 6-14-26 at 8:40 p.m., for evaluation. The records indicated the resident did not return to the facility. Entries into the clinical record on 6-15-26, identified the following information:-6-15-26 at 3:17 p.m., identified as a late entry for an unspecified date and entered into the clinical record by Social Services Designee (SSD) 4 indicated Resident B had been interviewed for cognitive function and was listed as scoring in the moderate impairment range and received dialysis (procedure to remove toxins from the blood) 3 times a week. -6-15-26 at 3:29 p.m., the clinical record by LPN 5, indicated Resident B had a sacral wound (area of lower back and/or upper buttocks), was alert and oriented to person, place and time, had a urinary catheter in place to drain his urine, was unable to walk independently, was a fall risk and Resident remains in the facility. In an interview with the Director of Nursing (DON) on 7-9-26 at 1:40 p.m., indicated she was unable to locate any information to suggest this resident received dialysis and the information stated he had been admitted to the hospital on [DATE] and would not have been at the facility on 6-15-26, the dates of the documentation was incorrect. The DON indicated the documentation may have been for another resident, but she was unsure. On 7-8-26 at 1:01 p.m., the Executive Director provided a copy of an undated policy entitled, Clinical Documentation Standards. This policy indicated, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for ourresidents, staff, and visitors. Maintaining the integrity, quality, and safety of medical records can help to provide an effective communication between practitioners that may serve to enhance resident outcomes. This facility uses both electronic medical records and paper medical records. A complete record contains an accurate and functional representation of actual experience of the resident and must contain enough information to show that the status of the individual resident is known, and a plan of care has been identified to meet the care needs identified in the medical record. Nurses will follow the basic standard of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical record .The primary purpose of the medical record(s) is to provide continuity of care. Other reasons also include: 1. Clinical evidence of care and treatment records as evidence of care. 2. Regulatory statutes that require maintaining and recording care. 3. Financial considerations of care provided. 4. Legal evidence. 5. Administrative considerations including demographic, contacts and insurance information including but not limited to face sheets. For the purpose of this policy, the term clinical documentation will reflect only that documentation that a licensed professional nurse enters into the record. 1. Other licensed professional and non-licensed personnel may make entries into the record that may not follow clinical nursing documentation standards .Document information specific to that resident in the record and not include another resident's information .Late entries must: 1. Be designated as a late entry. 2. Be dated and time stamped at the time of information was entered into the records and note the date and time of the event referenced a. This will include both paper or electronic entries. 3. The nurse must legibly sign both name and credentials to all late entries. 4. Electronic signatures are time-stamped upon entry; the nurse must clarifywhen the event occurred within the body of the note . This Federal tag relates to Intake 3013610. 410 IAC (Indiana Administrative Code) 3.1-50(a) (1)410 IAC (Indiana Administrative Code) 3.1-50(a) (2)

Based on interview and record review, the facility failed ensure a resident received timely foot care related to a referral for a vascular specialist and treatment for osteomyelitis, resulting in a hospitalization for intravenous antibiotics and subsequent toe removal for 1 of 3 residents reviewed for foot care. (Resident E) Findings include:The clinical record for Resident E was reviewed on 4/7/26 at 10:00 a.m. The resident's diagnosis included, but was not limited to, peripheral artery disease (circulatory condition caused by plaque buildup, narrowing arteries, and reduces blood flow to the limbs). The impaired skin integrity care plan, revised 3/31/26, indicated the resident had areas to his left fourth and fifth toes. A goal was for him to not exhibit complications from altered skin integrity. An intervention was to administer treatments as ordered by the medical provider. The progress note, dated 2/12/26 and written by Nurse Practitioner (NP) 5, indicated the resident had a wound to his left toe, fifth digit. The interpretation of a left arterial doppler of the lower extremity indicated the impression was mild trifurcation/outflow disease. The assessment and plan section of the note indicated, the resident had mild trifurcation/outflow disease on arterial Doppler, dated 2/10/2026. The NP ordered a referral for the resident to see a vascular specialist. The NP would continue to monitor, and the resident was to continue on the current antihypertensive medication and statin therapy. An interview was conducted with NP 5 on 4/8/26 at 12:07 p.m. She indicated she referred Resident E to a vascular specialist due to his Doppler results on his 2/10/26. The results indicated remote outflow disease, which were abnormal results. The facility needed to make the vascular appointment as soon as possible, within a week or so. The nursing note, dated 3/26/26, indicated Resident E had a follow-up vascular appointment scheduled for 4/7/26. There were no other progress notes that referenced a scheduled vascular appointment after the 2/12/26 progress note by NP 5. An interview was conducted with the Director of Nursing (DON) on 4/7/26 at 2:58 p.m. She indicated there was no verification they attempted to make a vascular appointment for Resident E after NP 5's referral on 2/12/26 until 3/25/26. On 4/7/26 at 2:58 p.m., the DON provided a faxed confirmation, dated 3/25/26, from a vascular surgery provider confirming a radiology appointment for 3/30/26 and office visit for 4/7/26. On 4/7/26 at 3:01 p.m., an interview was conducted with the Administrative Assistant for the above referenced vascular surgery provider. She indicated that their office received the referral from the facility on 3/24/26. Their office scheduled the appointment the next day, on 3/25/26; and the appointment was scheduled for 4/7/26 for a new patient exam, an ultrasound of the lower left extremity, and follow-up discussion of the 3/30/26 CT scan results. During an interview with NP 5, on 4/8/26 at 12:07 p.m., she indicated she was not aware of an issue with Resident E's fourth left toe until after the fact, but was unsure of when she was made aware. She never saw his left foot after the issue with his fourth toe was found. Her understanding was that the fifth toe was healed, but the fourth toe was necrotic. The Wound Nurse Practitioner was who would have been informed of any condition changes and responsible for treatment changes. An interview was conducted with the NP 7 from the facility's wound care provider on 4/8/26 at 12:28 p.m. She indicated she was notified on 3/26/26 of an injury of some sort to Resident E's left foot, so she saw Resident E in the facility on 3/31/26 to assess him. At that time, he had an open wound to his left fourth toe, with drainage. She didn't have a huge concern with infection at that time, but she had concerns that there was something underlying that needed further investigation. The resident was pending CT scan results at that time, and had a vascular appointment scheduled, so her understanding was everything was in place. Facility staff did not inform her the results of the 3/30/26 CT scan showed osteomyelitis until the next time she rounded at the facility, on 4/7/26. This was after Resident E was already in the hospital. As far as an antibiotic, that would have been ordered by the primary care nurse practitioner, as NP 7 only recommended treatment, but did not actually order treatments. If NP 7 had been able to confirm osteomyelitis, she would have recommended an antibiotic. Her treatment recommendation on 3/31/26, with the information she had, was to continue with betadine with calcium alginate between the toes and to change the dressing daily until seen by vascular. The Change of Condition assessment, dated 4/5/26, for Resident E indicated osteomyelitis of the left foot. He was on a leave of absence (LOA) with his family and admitted to the hospital for osteomyelitis. An interview was conducted with Family Member 9 on 4/6/26 at 3:24 p.m. He indicated Resident E was currently in the hospital. He was being treated for the wound to his left foot and there was a problem with his blood pressure. His foot was not getting the care it needed at the facility. He needed an antibiotic, but he was not given it. The facility said he didn't need it. The wound on his foot had been going on since September of 2025. Family Member 9 kept asking the facility what was going on with Resident E's foot. It looked black, and the hospital staff informed him he may have to have toes removed. Family Member 9 picked Resident E up from the facility on 4/5/26 and took him straight to the hospital. The first thing they did was give him an antibiotic. Resident E was currently in the Intensive Care Unit (ICU.) The hospital emergency department to hospital admission and discharge notes, dated 4/5/26 to 4/10/26, indicated the resident presented with a non-healing wound of the left foot. The resident initially developed symptoms consistent with athlete's foot on the left foot, which was treated as such at the facility. Over time, the condition worsened, and wound care specialists began debriding the area. The wound was first noted on the lateral aspect of the fifth toe and subsequently involved the fourth toe, particularly in the area between the fourth and fifth toes. Despite ongoing wound care, including debridement and dressing changes, the wound has continued to deteriorate and had not shown signs of healing. The wound care team at the facility had suggested that poor circulation may be contributing to the lack of healing. The patient had been wearing a boot on the affected foot. The resident had not been seen by a vascular specialist. An outpatient CT scan was performed on 03/31/2026, and a Doppler study was reportedly done. No fevers, chills, nausea, vomiting. the resident reported that he had not started on antibiotics at the facility. The notes indicated he was started on doxycycline 100 mg in sodium chloride 0.9% 100 mL, an intravenous (IV) antibiotic, on 4/5/26 at 4:14 p.m. at the hospital. A CT scan of the left lower extremity indicated a left fourth toe tuft ulceration with osseous cortical irregularity representing cellulitis and osteomyelitis and left fifth toe cutaneous thickening may be reactive or cellulitis. The clinical impression was acute osteomyelitis of left foot and cellulitis of left lower extremity. A progress note indicated, .presents with toe wound .had an open wound in his left foot that had been managed by wound care at the facility started on IV doxycycline in the ED [emergency department]. The hospital Discharge summary, dated [DATE], indicated resident was noted to have left 4th toe osteomyelitis. The resident was placed on a broad-spectrum (effective against a wide range of bacteria) antibiotic. The resident was evaluated by Podiatry (a medical specialist focused on diagnosing, treating conditions affecting the foot, ankle, and lower leg) and underwent amputation [removal of all or part of an extremity]. The Skin Care & Wound Management Overview policy was provided by the Executive Director on 4/7/26 at 11:22 a.m. The policy indicated, The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates, and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment .Skin care and wound management program includes, but is not limited to: Analysis of facility pressure ulcer data for quality improvement opportunities; Application of treatment protocols based on clinical best practice standards for promoting wound healing. This citation relates to Intake 2969435. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure meals were served with proper hand hygiene, coffee was covered when transported in hallways, food trays were air dried prior to storage, and the kitchen environment was clean related to ceiling vents potentially affecting 102 of 109 residents residing at the facility. Findings include: On 2/19/26 at 9:50 a.m., the facility kitchen was observed with the Head Chef (HC) and the Dietary Corporate Consultant (DCC). A dietary staff member was removing clean, wet food trays from a dishwashing rack and stacking them on a cart. The ceiling vents above the food preparation area and the food service area were noted to have dust built up. On 2/19/26 at 12:14 p.m., lunch service was observed on the Cambridge Unit. A coffee pitcher was on top of the food cart. The nursing staff were reaching up and taking the pitcher of coffee off the top of the food cart, pouring coffee for residents, and then placing the pitcher back on top of the food cart. The coffee pitcher did not have a lid and was open to air. The nursing staff indicated the coffee pitchers came down from the kitchen with a small plastic lid on them. The small plastic lids would fly off when the cart was moved and were not secured to the pitcher. The coffee pitchers usually came down from the kitchen that way without secured lids. During an interview on 2/19/26 at 12:50 p.m., Dietary Aide 22 indicated the coffee pitchers had little plastic lids that were not attached. During an interview on 2/19/26 at 2:01 p.m., the Head Chef (HC) indicated she had ordered lids for the coffee pitchers, but they had not come in yet. The kitchen put the plastic lids on the coffee pitchers prior to sending them to the hallways. During an interview on 2/19/26 at 2:02 p.m., the Dietary Corporate Consultant (DCC) indicated the coffee pitchers should be covered when in the hallway. On 2/23/26 at 12:10 p.m., the facility kitchen was observed. There was dust built up on the ceiling vents above the food preparation area and the food service area. The soiled dish area had splatters of dried food substances on the walls and a buildup of a black substance on the caulked area and black spatters on the tiled wall behind garbage disposal area. On 2/23/26 at 12:10 p.m., lunch service was observed in the facility kitchen. Dietary Aide (DA) 9 was observed placing food trays on the serving line. The food trays had drops of water on them. DA 9 had gloves on his hands. He adjusted his beard net strap on his head and pulled up his hood (clothing) over his head. DA 9 then used a cloth to dry the food trays on the food line. DA 9 did not perform hand hygiene or change his gloves after touching his clothing. On 2/23/26 at 3:10 p.m., the facility kitchen was observed with the DCC. The soiled dish area continued to have black substances on the caulk line and food substances splashed on the walls in the area. The air vents above the food preparation and distribution area continued to have dust built up on the ceiling vents. Dietary [NAME] 8 indicated the ceiling vents had built up dust on them. During an interview on 2/23/26 at 3:10 p.m., the DCC indicated the soiled dish area needed to be cleaned and wiped down. The DA 9 should have washed his hands and changed his gloves after touching his head, prior to wiping the food trays. The food trays should be air dried prior to being stored. On 2/19/26 at 2:49 p.m., the Executive Director (ED) provided the Meal Distribution policy, last revised 2/2023, that read . All food that is transported to dining areas that are not adjacent to the kitchen will be covered . On 2/23/26 at 3:57 p.m., the ED provided the Warewashing Policy, last revised 12/2024, that read .All dishware will be air dried and properly stored . 410 IAC (Indiana Administrative Code) 3.1-21(j)(3)

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 7 of 31 rooms, 1 of 2 exit doors, and 1 of 2 Nurse's Stations reviewed for environment. Doorknobs were loose, urine odor was present, designated smoking area exit door frame was pulled away from the wall, and a wall was in disrepair. (Cambridge Unit Rooms, 226, 228, 230, 231, 233, 210, Cambridge Bistro exit door, and [NAME] Nurse's Station). Findings include: On 2/19/26 at 12:27 p.m., the following was observed, the Cambridge Unit had an odor of urine and the [NAME] Unit had visible water damage (loosening paint, with a rippling effect, down the wall) to the wall behind the nurse's station. On 2/20/26 at 11:11 a.m., the following was observed, the doorknobs for the following resident rooms on Cambridge Unit were loose, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. On 2/24/26 at 1:17 p.m., the following was observed, an odor of urine was present at the Cambridge Unit's nurse's station and in the hall near room [ROOM NUMBER]. On 2/25/26 at 11:22 a.m., the following was observed, room [ROOM NUMBER] had an odor of urine odor detected from the hallway. On 2/25/26 at 1:39 p.m., the following was observed, the doorknobs for the following resident's rooms on Cambridge Unit were loose, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. On 2/25/26 at 1:42 p.m., during an interview with the Medical Records Coordinator, who was picking up room trays in room [ROOM NUMBER], indicated the urine odor was from the resident near the window. She believed he needed assistance with care. On 2/25/26 at 1:46 p.m., the following was observed, in the Cambridge Bistro, the designated smoking area's exit door was pulled away from the wall (the entire door frame was pulled away, allowed fingers to be placed behind the door frame and the wall) and the wall next to the door frame was marred (approximately 2 and one half feet) below the chair-rail with chunks of drywall missing (6 inches long). During an interview, on 2/25/26 at 2:13 p.m., the Maintenance Director indicated if something needed repaired, staff entered information into a building management electronic system. Routine rounds were done by the maintenance department to look for areas that needed repaired. There had been a water leak in the ceiling on the [NAME] Unit's nurse's station. The door frame in the Cambridge Bistro had been damaged from a resident using an electric scooter running into it. During an interview, on 2/25/26 at 2:20 p.m., the Administrator indicated the resident in room [ROOM NUMBER] refused care, care refusal was in his care plan, and his roommate had not complained of the odor. A current, undated, facility policy titled Resident Rights, was provided by the Executive Director on 2/24/26 at 1:15 p.m. The policy indicated .Dignity: a state worthy of honor or respect; includes but is not limited to speaking respectfully to resident, providing privacy for care and treatment, providing safe and secure housing 410 IAC (Indiana Administrative Code) 16.3.1-19(f)

Based on observation, interview and record review, the facility failed to assess and determine it was clinically appropriate for a resident to self-medicate for 1 of 1 resident randomly observed with medications at the bedside. (Resident 56) Findings include:The clinical record for Resident 56 was reviewed on 2/20/26 at 11:00 a.m. The diagnoses included, but were not limited to: end stage renal disease (below 15% [percent] functioning kidneys) An observation was made of Resident 56 on 2/23/26 at 12:00 p.m. The resident was observed lying in bed with a bedside table next to the bed. Two plastic cups were observed sitting on the bedside table. One cup had pill medications in it, and the second cup was sitting inside the cup with ice in it. Resident 56's clinical record did not include documentation she was able to safely self-medicate her medications. An interview was conducted with License Practical Nurse (LPN) 10 on 2/23/26 at 12:05 p.m. She indicated the pill medications were Resident 56's morning medications. The resident was scheduled to go to dialysis early that day. On dialysis days, the resident's morning medications are administered prior to going to dialysis by the night shift nurse. She was unsure why the resident's medications were sitting on the bedside table. An interview was conducted with Regional Nurse Consultant (RNC) 2 on 2/24/26 at 1:12 p.m. She indicated Resident 56 did not have a self-medication assessment that indicated she was able to self-medicate safely. The medications should not have been left on the resident's bedside table. A self-medication policy was provided by the RNC on 2/24/26 at 1:12 p.m. It indicated, .Procedures: 1. Determine if the resident desires to self-administer their own medication. a. Resident may not self-administer medication until the assessment is completed by the IDT team and determined to be safe to do so.c. Physician/Provider order is required for residents to self-administer medication.4. Assessments will include addressing the following and documenting in the care plan: a. Storage of the medication b. Responsible party for storage of medications (resident or nursing staff) c. Documenting the administration of drugs d. Location of where the drug will be administered. 410 IAC (Indiana Administrative Code) 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure a call light was in reach for 2 of 2 residents reviewed for call lights. (Residents 41 and 116) Findings include:1. The clinical record for Resident 41 was reviewed on 2/20/2026 at 2:23 p.m. The diagnoses included, but were not limited to, hemiplegia (severe weakness or total paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral vascular disease affecting the left dominant side, generalized anxiety disorder, and schizoaffective disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/25, indicated Resident 41 was moderately cognitively impaired, could usually make herself understood, and had the ability to usually understand others. The MDS indicated Resident 41 had impairment on one side to upper and lower extremity on one side, was dependent on toileting/hygiene, and required substantial/maximal assistance with rolling side to side, sitting up, and toileting transfers. During an observation and interview with Resident 41 on 2/19/26 at 2:33 p.m., no call light was visible in the resident's room. Resident 41 indicated she did not have a call light because they took it because she was calling out too much. She could not even get help to get something to drink. During an observation and interview on 2/20/26 at 1:34 p.m., Resident 41 was lying in bed with no call light in sight. Verified with Certified Nursing Assistant (CNA) 5 that Resident 41 did not have a call light in reach to use. CNA 5 then located two call lights placed inside of a bedside table with the drawer shut. The bedside table was located at the end of Resident 41's bed out of reach for the resident. One call light was not functioning and the other call light CNA then handed to Resident 41 to use. CNA 5 indicated she did not know why the call lights were placed into the drawers and out of reach for Resident 41. A plan of care, dated 2/10/22, indicated Resident 41 had Activities of Daily Living (ADL) self care performance deficit. The interventions included, but were not limited to, place call light within reach. 2.) The clinical record for Resident 116 was reviewed on 2/20/26 at 2:25 p.m. The diagnoses included, but were not limited to, seizures, depressive episodes, and anxiety disorder. The Annual Minimum Data Set (MDS) assessment, dated 2/8/26, indicated Resident 116 was severely cognitively impaired, had upper extremity impairment on one side, and was dependent with all activities of daily living (ADLS). During an observation on 2/19/26 at 2:43 p.m. and on 2/20/26 at 10:12 a.m., Resident 116 was lying in bed asleep with the call light on the floor behind the resident's bed. During an observation and interview on 2/20/26 at 1:44 p.m., Resident 116 was lying in bed asleep and the call light was out of reach for the resident, the call light cord was lying on a side chair underneath towels and blankets. Verified with the Social Service Director (SSD) that Resident 116's call light was out of reach lying on a chair. The SSD then placed the call light across Resident 116's lap. The SSD indicated he did not know why the resident did not have her call light in reach. An interview with the Executive Director (ED) was conducted on 2/24/26 at 1:20 pm. They indicated all staff were responsible to ensure residents had call lights readily available and in reach. The ED indicated the facility did not have a policy regarding call lights. 410 IAC (Indiana Administrative Code) 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to provide extra portions of oatmeal as preferred and ordered for 1 of 2 residents reviewed for choices. (Resident 51) Findings include:The clinical record for Resident 51 was reviewed on 2/20/26 at 2:19 p.m. The diagnoses included, but were not limited to, respiratory failure and cerebral infarction (death of brain tissue) affecting the left non-dominant side. A Quarterly Minimum Data Set (MDS) assessment, dated 1/28/26, indicated Resident 51 had moderate cognitive impairment. A physician's order, dated 10/14/25, indicated Resident 51 had a regular diet order and was to receive two servings of fortified oatmeal for breakfast. During an interview with Resident 51 on 2/19/26 at 12:42 p.m., they indicated they did not receive the daily double portions of oatmeal for breakfast. Resident 51 indicated he would have to always ask for another portion of oatmeal in the mornings. During an observation and interview on 2/23/2026 at 9:37 a.m., Resident 51 had his breakfast tray sitting in front of him. The food included two pieces of French toast, two pieces of bacon, syrup, one 6 oz (ounces) of fortified hot cereal (oatmeal), milk, coffee, and orange juice. The meal ticket on Resident 51's breakfast tray indicated there were two 6 oz. servings of fortified hot cereal on the tray but there was only one. Resident 51 indicated they only gave him one serving again today and he already had to ask for more. During an observation on 2/24/26 at 9:20 a.m., Resident 51's meal tray was delivered to his room. The meal ticket indicated 6 oz fortified hot cereal, 8 oz milk, 4 oz orange juice, and 4 oz of choice juice. Resident 51's tray contained one small, white bowl of oatmeal, biscuit, scoop of scrambled eggs, sausage patty, and a half of a cup of orange juice. A nutritional assessment, dated 1/27/26, indicated Resident 51 had a regular diet order with two portions of fortified oatmeal every morning. The nutritional assessment indicated Resident 51 reported a good appetite and especially enjoyed fortified oatmeal. A plan of care, dated 9/8/25, indicated Resident 51 was at risk for altered nutrition status. The interventions included, but were not limited to, identify resident food preferences and provide meals per diet order. During an interview with the Director of Nursing (DON) on 2/24/26 at 1:33 p.m., the DON indicated the kitchen staff was who was responsible to ensure diets were made and delivered as ordered. The dietary would sometimes serve larger portions of foods in one bowl for two servings, instead of one bowl for each serving. The small white fruit cup bowl holds 6 oz, and the large dark bowls hold 12 oz. During an interview with the Executive Director (ED) on 2/24/26 at 1:15 p.m., they indicated the facility did not have a policy regarding resident choices. 410 IAC (Indiana Administrative Code) 3.1-3(u)(3)

Based on observation, interview, and record review, the facility failed to timely develop dental care plans for 2 of 2 resident's reviewed for dental care (Resident 51 and Resident 12).Findings include: 1. The clinical record for Resident 51 was reviewed on 2/19/25 at 12:43 p.m. The resident's diagnosis included, but was not limited to, hypertension. A dental consult noted, dated 12/19/25, indicated Resident 51 required a referral to an oral surgeon to have two teeth extracted. He was missing multiple teeth, and his oral tissue was red and irritated. A Quarterly Minimum Data Set (MDS) Assessment, completed 1/28/26, indicated he had moderately impaired cognition, was usually able to make himself understood and to understand others, and needed set up assistance with oral hygiene. The clinical record did not contain a care plan addressing Resident 51's dental care needs.2. The clinical record for Resident 12 was reviewed on 2/20/26 at 10:24 a.m. The resident's diagnosis included, but were not limited to, diabetes and hypertension.An oral assessment, dated 1/15/25, indicated Resident 12 had natural teeth on the upper and lower arch and several broken teeth. An Annual MDS Assessment, completed 9/14/25, indicated Resident 12 was cognitively intact and had no dental concerns. On 2/20/26 at 10:24 a.m., Resident 12 was observed lying in her bed. Her teeth were jagged and had visible decay. Resident 12 indicated she needed to see the dentist for her broken teeth. She had pain at times due to her teeth. The clinical record did not contain a care plan addressing Resident 12 broken teeth or dental status. During an interview on 2/25/26 at 11:17 a.m., the Minimum Data Set Coordinator (MDSC) indicated the MDS and the care plan could be modified to include Resident 12's broken teeth. On 2/25/26 at 11:48 a.m., Regional Nurse Consultant (RNC) 2 provided the current Dental Services Policy that read .Care Plan a. Provide care planning specific to the resident for dental and oral health concerns .410 IAC (Indiana Administrative Code) 3.1-35(a)

Based on observation, interview and record review, the facility failed to hold a resident's medication when vital signs were outside parameters for 1 of 2 residents reviewed for Hospitalization, ensure an insulin flex pen was primed with 2 units of insulin prior to the administration of the insulin dosage, and administer lidocaine cream as ordered for 2 of 38 residents observed for quality of care. (Resident 92, Resident 115 and Resident 119)Findings include:1.The clinical record for Resident 119 was reviewed on 2/20/26 at 1:28 p.m. The resident's diagnosis included, but was not limited to, hypertension. A physician's order, dated 12/11/25, indicated he was to receive Coreg oral tablet (medication used to treat high blood pressure) 12.5 milligram (mg) twice daily. The staff were to hold the resident's medication for systolic blood pressure (upper number of blood pressure reading) less than or equal to 120. The December 2025 Medication Administration Record (MAR) indicated Resident 119 received Coreg when his systolic blood pressure was less than or equal to 120 on the following days: -On 12/16/25 at 5 p.m., the resident's systolic blood pressure reading was 114, -On 12/17/25 at 9 a.m., the resident's systolic blood pressure reading was 102, -On 12/17/25 at 5 p.m., the resident's systolic blood pressure reading was 97, -On 12/19/25 at 9 a.m., the resident's systolic blood pressure reading was 110, and -On 12/19/25 at 5 p.m., the resident's systolic blood pressure reading was 118. During an interview on 2/20/26 at 3:03 p.m., Regional Nurse Consultant 1 indicated medications should be held if outside the parameters specified in the physician's orders. 2.The clinical record for Resident 92 was reviewed on 2/23/26 at 9:00 a.m. The resident's diagnosis included, but was not limited to, hepatitis C. A Quarterly Minimum Data Set (MDS) Assessment, dated 1/15/26, indicated Resident 92 was cognitively intact. A physician's order, dated 4/2/25, indicated staff were to apply the resident's 4% (percent) lidocaine cream onto her back, three times a day. An observation was made of a medication administration for Resident 92 with Registered Nurse (RN) 12 on 2/23/26 at 9:06 a.m. RN 12 was at the medication cart preparing Resident 92's medications. During that time, RN 12 had indicated she was unable to locate the resident's lidocaine medication. She was observed picking up boxes and reading labels of lidocaine patches that were labeled for other residents. Then, she looked in the medication supply room. After, she looked in a treatment cart for the lidocaine medication. RN 12 indicated she would have to reorder the lidocaine medication. She was unable to locate the medication. The resident has chronic back pain, and the lidocaine was applied on her back. A medication administration note, written by RN 12, dated 2/23/2026 at 9:42 a.m., indicated Resident 92's 4% lidocaine cream was not available. RN 12 reordered the 4% lidocaine cream. An interview was conducted with the Director of Nursing on 2/24/26 at 10:22 a.m. She indicated Resident 92's 4% lidocaine cream was found in the treatment cart. The resident was asked later that day, 2/23/26, if she wanted the lidocaine cream applied. The resident had refused. An interview was conducted with Resident 92 and the Director of Nursing on 2/24/26 at 10:22 a.m. Resident 92 indicated the lidocaine patches were applied to her left shoulder and lower back daily to help with pain relief. She had not received the lidocaine patches for a couple of days. The nursing staff had never discussed the change from patches to cream nor applied lidocaine cream on her back. An interview was conducted with the Director of Nursing on 2/24/26 at 11:07 a.m. She indicated she had clarified the lidocaine medication order, dated 4/2/25 for Resident 92 with the medical doctor. The resident was to receive 4% of lidocaine cream not lidocaine patches. 3. The clinical record for Resident 115 was reviewed on 2/23/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus. A physician's order, dated 8/15/25, indicated Resident 115 was to receive a sliding scale of Humalog (fast acting) insulin before meals. An observation was made of an insulin administration for Resident 115 with License Practical Nurse (LPN) 10 on 2/23/26 at 11:40 a.m. LPN 10 had obtained Resident 115's blood sugar reading. The reading was 333. She returned to her cart and reviewed the Humalog sliding scale in the resident's medical record. After pulling the supplies from the medication cart, she entered Resident 115's room. During that time, LPN 10 was observed setting up the resident's Humalog insulin flex pen to administer the insulin dosage. LPN 10 utilized an alcohol wipe to wipe down the top of the pen and inserted a needle. After, she dialed up 3 units of Humalog insulin and LPN 10 administered the insulin dosage in the resident's left arm. There was no observation of LPN 10 priming the flex pen with 2 units of insulin. An interview was conducted with the Regional Nurse Consultant (RNC) on 2/24/26 at 8:55 a.m. She indicated the nursing staff should be priming the insulin flex pens with 2 units of insulin (to remove air from flex pen cartridge and needle) prior to dialing up the insulin dosage. An injectable medication administration policy was provided by the Executive Director on 2/25/26 at 9:19 a.m. It indicated, Policy: Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer injectable medications.Procedure:.Pen devices: dial the dose as instructed by the pen manufacturer. Instructions for use of Humalog flex pen at website https://pi.lilly.com dated 7/2023, was retrieved on 2/26/26. It indicated Prescribing information .Priming your pen: Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your pen, turn the dose knob to select 2 units. Step 7: Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needed. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. 410 IAC (Indiana Administrative Code) 3.1-37

Based on observation, interview, and record review, the facility failed to provide fluids at the bedside for 1 of 3 residents reviewed for hydration and a diet as ordered for 1 of 1 residents reviewed for nutrition/hydration. (Resident 56 and 116) Findings include: 1.The clinical record for Resident 116 was reviewed on 2/20/2026 at 2:25 p.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing, causing pain or choking), profound intellectual disabilities, and contractures (permanent, painful tightening of the muscles, tendons, ligaments or skin) of the right wrist and left elbow and hand. The Annual Minimum Data Set (MDS) assessment, dated 2/8/26, indicated Resident 116 was severely cognitively impaired, had upper extremity impairment on one side, was dependent with all activities of daily living (ADLS), and was on a mechanically altered diet. During an observation on 2/19/26 at 2:15 p.m. and on 2/20/26 at 1:28 p.m., Resident 116 was in her bed and did not have any fluids at the bedside. During an observation on 2/23/26 at 9:40 a.m., Resident 116 was lying in bed watching t.v. and had a clear cup with a small amount of water in the bottom of it, with a straw inside the cup. An interview with Certified Nursing Assistant (CNA) 5 was conducted on 2/23/26 at 9:46 a.m. CNA 5 indicated Resident 116 did not have any fluids to drink at the bedside. Resident 116 received fluids with meals, medications, and the CNA would go in often throughout the day and give Resident 116 drinks of thickened liquids. She had to go to the kitchen to get the thickener for Resident 116's water, but she had not gotten around to it yet. A physician's order, dated 10/21/25, indicated Resident 116 was on a regular diet with puree texture and nectar thickened liquids consistency. Resident 116 was to have liquids by spoon and may use a nosey cup ( an adaptive, u-shaped cutout cup designed for people with limited neck or upper extremity movement). A plan of care, revised 12/17/24, indicated Resident 116 had oral health problems related to poor oral hygiene and had a regular diet, puree texture, and nectar thickened liquids consistency. Resident 116 was to receive liquids by spoons. The interventions included, but were not limited to, provide nectar thickened liquids. During an interview with the Director of Nursing (DON) on 2/25/26 at 1:14 p.m., the DON indicated nursing was responsible to ensure residents had the proper fluids at the bedside and that fluids were offered throughout the day. Resident 116 had to be offered and given drinks of fluids by staff. 2. The clinical record for Resident 56 was reviewed on 2/20/26 at 11:00 a.m. The diagnoses included but were not limited to: end stage kidney disease (below 15% percent kidney function). A physician's order, dated 2/10/26, indicated the resident was to receive a regular diet. The resident was not to receive bananas, orange juice, or potato chips. An observation was made of Resident 56 on 2/23/26 at 12:00 p.m. The resident was observed lying in bed with a bedside table next to the bed. The resident's breakfast tray was sitting on the bedside table. A cup of orange juice was observed on the tray. The meal ticket sitting on the tray indicated the resident was not to receive bananas, orange juice or potato chips. An interview was conducted with License Practical Nurse (LPN) 10 on 2/23/26 at 12:03 p.m. She indicated the resident was not to receive orange juice. She was unsure why the meal tray was delivered with orange juice. A therapeutic diet policy was provided by the RNC on 2/24/26 at 8:57 a.m. It indicated, Policy Statement. All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines.Procedures.3. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. A General Hydration Services policy was provided by the Executive Director (ED) on 2/24/26 at 1:15 p.m. It indicated .The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs.5. Provide fresh water at bedside in the proper consistency and drinking device. 410 IAC (Indiana Administrative Code) 3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to timely obtain outside dental services and to timely inform the physician of dental pain for 1 of 2 resident's reviewed for dental services ( Resident 51). Findings include: The clinical record for Resident 51 was reviewed on 2/19/25 at 12:43 p.m. The resident's diagnosis included, but was not limited to, hypertension. A Quarterly Minimum Data Set (MDS) Assessment, completed 1/28/26, indicated he had moderately impaired cognition, was usually able to make himself understood and to understand others, and needed set up assistance with oral hygiene. A dental consult noted, dated 12/19/25, indicated Resident 51 required a referral to an oral surgeon to have two teeth extracted. A Social Services Note, dated 1/20/26, indicated an oral surgery office had been contacted for an appointment. Information had been faxed to the office, and the office would follow up with facility after the information was reviewed. A Social Services Note, dated 2/6/26, indicated the dental office had called and scheduled an appointment for July 30,2026. During an interview on 2/19/26 at 12:43 p.m., Resident 51 indicated he needed to see the dentist. His tooth was loose and had fallen out about a month ago. He had told someone but could not remember who he told. During an interview on 2/23/26 at 11:57 a.m., Resident 51 indicated when he bit down on something wrong he experienced pain like lightning' in his front tooth. During an interview on 2/23/26 at 11:59 a.m., the Social Services Designee (SSD) indicated he was aware of Resident 51's pain and that is why the dental appointment had been made. The July 2026 appointment was the first available and the facility had asked that Resident 51 be placed on the call list if a sooner appointment opened. On 2/23/26 at 3:00 p.m., Resident 51 was observed with Qualified Medication Aide (QMA) 7. Resident 51 wiggled his visibly loose front tooth. QMA 7 instructed Resident 51 not to move around too much. Resident 51 told QMA 7 that he had a shooting pain in his front tooth when he bit down on something wrong. During an interview on 2/25/26 at 10:39 a.m., Licensed Practical Nurse (LPN) 4 indicated tooth pain would be communicated to the physician. The facility had [NAME] health, or the Nurse Practitioner could be called. During an interview on 2/25/26 at 10:44 a.m., LPN 20 indicated she was Resident 51's nurse. She had been made aware that Resident 51 had tooth pain and that he had an upcoming dental appointment.During an interview on 2/25/26 at 10:45 a.m., SSD indicated Resident 51's upcoming dental appointment was the appointment scheduled on July 30, 2026. The clinical record did not include information that the physician or nurse practitioner had been informed of Resident 51's complaint of shooting dental pain on 2/23/26. During an interview on 2/25/26 at 11:03 a.m., Nurse Practitioner (NP) 21 indicated she would like to know if a resident has acute dental pain. She did not remember being informed of Resident 51's acute dental pain. On 2/25/26 at 11:48 a.m., Regional Nurse Consultant (RNC) 2 provided the current Dental Services Policy that read .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. Dental and Oral health can impact the physical as well as the mental/ emotional and psychological health of a resident. Poor dentition and/or poor oral health may impact nutritional and weight loss status .The facility will assist the resident in: a. Obtaining routine Dental Services b. Obtaining 24-hour Emergency Dental Services c. Obtaining services to the resident to meet the needs of each resident D. Making appointments . 410 IAC (Indiana Administrative Code) 3.1-24(a)(1)410 IAC 3.1-24(a)(2)

Based on observation, interview and record review, the facility failed to maintain infection control by not utilizing hand hygiene prior to donning gloves to administer eye medications for 2 of 38 residents observations for medication administrations and administered a pill medication that had dropped on the floor for 1 of 1 random observation related to infection control. (Residents 15, 92, and 113) Findings include:1.The clinical record for Resident 113 was reviewed on 2/20/26 at 10:45 a.m. The resident's diagnosis included, but were not limited to, heart failure( chronic progressive condition where the heart muscle becomes too weak or stiff to pump enough oxygen rich blood to meet the body's needs). An observation was made of a medication administration on 2/20/26 at 10:00 a.m. License Practical Nurse (LPN) 11 was administering pill medications to Resident 113. During that time, the resident dropped 1 pill medication from the medication cup onto the floor. LPN 11 was observed picking up the pill medication with her bare hands and handing it back to the resident. The resident placed the pill medication in her mouth after LPN 11 handed it to her. An interview was conducted with Resident 113 on 2/20/26 at 10:04 a.m. She indicated she did not want to take the pill medication that had fallen on the floor, but she had concerns if she requested to get a replacement; LPN 11 would not have returned with it.2. The clinical record for Resident 92 was reviewed on 2/23/26 at 9:00 a.m. The resident's diagnosis included, but was not limited to, hepatitis C (a contagious liver disease caused by the hepatitis C virus). A physician's order, dated 9/3/25, indicated Resident 92 was to receive 1 drop of refresh eye drops in each eye twice a day. An observation was made of a medication administration for Resident 92 with Registered Nurse (RN) 12 on 2/23/26 at 9:06 a.m. RN 12 was at the medication cart preparing Resident 92's medications. She had touched medication cart drawers, mouse to the computer lab top, medication packets, plastic cups, and water pitcher. Then, she knocked and entered the resident's room and administered pill medications. After, she donned gloves and administered eye drops to the resident. There was no observation of RN 12 utilizing hand hygiene prior to donning gloves. 3. The clinical record for Resident 15 was reviewed on 2/23/26 at 9:48 a.m. The resident's diagnosis included, but was not limited to, respiratory failure (a critical condition where the lungs cannot adequately supply oxygen to the blood). A physician's order, dated 1/19/26, indicated Resident 15 was to receive 0.2 % artificial tears twice a day. An observation was made of a medication administration for Resident 15 on 2/23/26 at 9:48 a.m. RN 12 was observed preparing the resident's medications at the medication cart. She had touched medication cart drawers, mouse to the computer, plastic cups, and water pitcher. Then, knocked on the resident's door and entered. After, RN 12 had donned gloves and administered eye drops to the resident. There was no hand hygiene observed prior to RN 12 donning gloves. An interview was conducted with Regional Nurse Consultant (RNC) 2 on 2/24/26 at 8:55 a.m. She indicated RN 12 should have utilized hand hygiene prior to donning gloves. Pill medications that fall on the floor should not be administered to the residents. A standard precautions policy as provided by the Executive Director on 2/25/26 at 9:19 a.m. It indicated, .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the change of infection. Proper cleaning of hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming resistant to antibiotics.II. When to perform hand hygiene.G. after glove removal. A medication administration policy was provided by the Executive Director on 2/25/26 at 9:19 p.m. It indicated, .The purpose of this policy is to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer. Procedure:.s. Do not touch the medication, either when opening a liquid or dose pack. i. Dropped medications will be discarded. 410 IAC (Indiana Administrative Code) 3.1-18(a)

Based on interview and record review, the facility failed to ensure 1 of 7 residents reviewed for resident rights had their resident's rights honored related to personal property request by a facility staff member. (Resident B) Findings include:In an interview with Resident B on 12-29-25 at 1:45 p.m., she indicated on 12-9-25 between 8:00 p.m. and 10:00 p.m., LPN 3 came to her and told me that she had heard I had a vehicle I might be interested in selling because she had heard that I might not be needing it anymore. For starters, why would she or any of the staff be discussing me or my business amongst themselves? Plus, with my diagnosis of breast cancer, that kind of makes me think they know something that I don't know. How is that appropriate in any manner? Resident B indicated LPN 3 told her that her family member was needing to buy a car to use for college. In an interview on 12-29-25 at 3:45 p.m., with the Executive Director (ED) she indicated she received a phone call from LPN 3 on the evening of 12-9-25, in which LPN 3 notified her she had inadvertently got a resident worked up. The ED indicated the nurse did not provide any details, but basically said that she said something that upset the resident. The facility was conducting a separate and unrelated investigation, which included Resident B. The Ed indicated during the course of that investigation, Resident B did not address anything about the car with the management team. She added the facility did offer Resident B psychiatric care services as she was dealing with multiple life-changing events, but the resident eventually chose not to participate with those services. In a telephone interview with LPN 3 on 12-30-25 at 2:33 p.m., she indicated earlier in the month, she had noticed a car in the facility's parking lot that had not been moved for a while and inquired of other employees if they knew who the vehicle belonged to and learned it belonged to Resident B. It looked like a pretty nice vehicle .So, I went and talked to her and asked if she would be interested in selling it because my daughter was needing a vehicle for school. She seemed nice enough about it and just told me, 'no.' Then about 10 minutes later, I heard she contacted the evening supervisor .about me wanting to buy her car. The last thing I wanted to do was upset her and I wanted to go and apologize to her, but was told not to do that, that I had upset her and I did not mean to upset her at all. In an interview with the ED and Director of Nursing (DON) on 12-30-25 at 9:30 a.m., they indicated they had limited knowledge of the staff member who had reached out about the car situation on 12-9-25. The ED indicated LPN 3 had written a statement regarding the situation and was concerned she had upset the resident. The ED indicated the action of an employee reaching out to a resident about purchasing an item from the resident was inappropriate and would not be an acceptable action and definitely would not be an appropriate resident rights type of thing to do. The DON indicated LPN 3 was educated regarding resident rights and inappropriate actions of trying to purchase something from a resident. The ED indicated she felt LPN 3 was unaware of Resident B's advanced cancer diagnosis or her other issues and did not think LPN 3 had any intention of doing anything inappropriate or upsetting the resident. On 12-30-25 at 10:35 a.m., the ED provided a copy of LPN 3's handwritten statement, dated 12-9-25, but untimed and was signed by LPN 3. The statement indicated, she had inquired about the ownership of a vehicle she had seen in the parking lot that had not been moved for some time and learned it belonged to Resident B. I went to this resident [sic] room and asked if the vehicle was for sale and the resident asked me why and I told her and I said I was thinking of buying a car for my daughter in college. Resident at the time did not appear upset by my question and I genuinely meant no harm It will never happen again. The clinical record of Resident B was reviewed on 12-30-25 at 12:05 p.m. Her diagnoses included, but were not limited to, right breast cancer with metastasis to the brain. Her most recent Minimum Data Set assessment, dated 11-22-25, indicated she was cognitively intact. On 12-29-25 at 2:10 p.m., the ED provided an undated copy of a policy entitled, Federal Resident Rights & Facility Responsibility. This policy indicated, It is the facility's policy to abide by all resident rights .The resident has a right to a dignified existence, self-determination .A facility must treat each resident with respect and dignity and care for each resident in a manner and in environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident .The resident has a right to be treated with respect and dignity, including .The right to retain and use personal possessions . This citation relates to Intake 2688478. 3.1-3(a)(1)3.1-3(a)(2)3.1-3(t)3.1-32(a)

Based on interview and record review, the facility failed to ensure a controlled substance medication received from the contracted pharmacy was properly processed and safely stored in the facility for 1 of 3 residents reviewed for pharmacy services. (Resident E) Findings include:A facility reported incident was received by the Indiana Department of Health's (IDOH) Long Term Care Division on 11-18-25 at 7:14 p.m. The report indicated the facility had received a delivery of a controlled medication, oxycodone, for Resident E on 11-15-25, but the medication was unable to be accounted for. It indicated notifications were made to the resident, resident representative, the Executive Director, the Director of Nursing, the attending physician, and the local law enforcement agency and an investigation was launched immediately. It indicated the nurse on duty for Resident E on the date of 11-15-25, was immediately suspended, pending results of the investigation. A medication reconciliation was initiated. Pain and skin assessments were initiated. Staff and resident interviews were initiated. A follow-up report was sent to the IDOH Long Term Care Division on 11-24-25, which indicated, the facility is unable to determine the disposition of the medication. It indicated the facility paid for a replacement of the identified missing controlled medication. It indicated, It was determined that the nurse [who] signed for the medication [receipt from the contracted pharmacy] and noted that it was for another unit and called the nurse over and the medication was released to [name of RN 6], who was the appropriate nurse.In an interview with the Director of Nursing (DON) on 12-10-25 at 12:20 p.m., she indicated the manner in which the facility became aware of the issue with Resident E's medications was one of the nurses had called the contracted pharmacy to request a refill of Resident E's oxycodone 20 milligrams (mg) on Monday, 11-17-25. The contracted pharmacy informed the staff member the controlled substance had been delivered on Saturday, 11-15-25. The nursing staff immediately notified the DON of the problem, because not only was there no medication, there was no record of the controlled substance in the facility's narcotic logbook. The pharmacy sent a copy of the contracted pharmacy's manifest documentation which indicated LPN 5, had signed for it on 11-15-25 between 11:00 a.m. and noon. The DON indicated a second staff signature was on the manifest documentation, but was illegible. We started an immediate investigation, in in which it was learned the received medication of oxycodone 20 mg was given to RN 6 on 11-15-25 by LPN 5. To be honest, we don't know what happened to the meds once he received them. There were several issues that were not done according to our policies. First, the controlled substance was not delivered to us in a purple plastic bag, but in a white gift bag. Our narcotics, per our policies, are to be delivered in a purple plastic bag as a quick visual alert the medication is a controlled substance. That did not happen. Secondly, the narcotic was not processed by the nurses, two of them, by our policies, with the count and the paperwork being done. In our talking with [name of RN 6], he indicated around the time of this occurrence, he was in the process of sending a resident out to the hospital and was possibly distracted by those things. He could not specifically recall receiving any medication during that time. There were two staff members that recalled seeing [name of RN 6] receive the medication from [name of LPN 5]. In our interview with [name of RN 6], he indicated he had never had anything like this happen before and even offered to come in and help look for the medication and offered to take a drug test to prove he was not taking this medication. We wonder if the medication [and the associated paperwork] may have mistakenly been thrown away, thinking it was just extra papers or trash, since it did come in a gift bag, not the purple plastic bag, and would have been very lightweight, almost light enough you would have thought it was an empty bag. We ended up terminating [name of RN 6] due to this. The med has not been located. It was replaced by the facility. To the best of my knowledge, he [Resident E] did not miss any doses of his pain med. He ended up being sent out on the same afternoon, 11-17-25, due to hypotension and chest pain. [Name of RN 6], was a long time employee and did not have any type of write ups prior to this. I honestly do not think he did anything maliciously, but [there were] several failures of our policies that contributed to this situation.On 12-10-25 at 12:50 p.m., the DON provided copies of the facility's investigation for the unaccounted controlled substance for Resident E. The packet of information included, but was not limited to, facility policies regarding how staff are to handle the receipt of narcotic medications, but none of the policies provided addressed the contracted pharmacy is to deliver controlled substances in a purple plastic bag. On 12-10-25 at 12:50 p.m., the DON provided an undated copy of a policy entitled, Chain of Custody for Controlled Substances, This policy indicated, .Receiving a Pharmacy Delivery: Nurses will not accept delivery of controlled substances including, but not limited to the following circumstances or indications: Discrepancies in type or quantity; Tampered packages; Unauthorized medications .If no discrepancies are noted, the nurse will accept delivery of controlled drugs from the pharmacy delivery driver. The driver and the nurse will sign the invoice. Two nurses will provide a count of controlled substances before placing in medication cart(s). Nurses will adjust the shift-to-shift count sheet to reflect addition of new medications. In the event a second nurse is unavailable, the nurse will secure the controlled substances in the double-locked drawer. When a second nurse is available or at the following shift change, two nurses will count and validate the delivery .This deficient practice was corrected on 11-19-25, prior to the start of the survey, and was therefore past noncompliance. The facility immediately began an investigation upon learning of the unaccounted controlled substance medication and associated paperwork. This included, but was not limited to, ensuring the resident's safety and physical well-being, notifications to the resident, resident representative, the Executive Director, the Director of Nursing, the attending physician, and the local law enforcement agency, immediate suspension of RN 6, pending results of the investigation, staff and resident interviews regarding receipt of medications and timeliness of receipt of pain medications, physical assessments of residents and completion of staff education related to the proper handling of controlled substance medications upon delivery from the contracted pharmacy. 3.1-25(e)(1)3.1-25(e)(2)3.1-25(e)(3)

Based on interview and record review, the facility failed to document controlled medications in sufficient detail to ensure an accurate reconciliation of the narcotic count for 4 of 5 residents reviewed for pain and ensure an intravenous (IV) antibiotic was administered timely for a newly admitted resident and completely for 2 of 4 residents reviewed for IV medications (Resident B, Resident L, Resident H, and Resident D). Findings include: 1. The clinical record for Resident L was reviewed on 6/12/25 at 3:10 p.m. The diagnoses included, but were not limited to, end stage renal disease, opioid dependence, low back pain, muscle weakness, and lumbago with sciatica (lower back pain accompanied by sciatic nerve pain). A care plan, revised 5/15/25, indicated Resident L was at risk for pain related to end stage renal disease. The goal was for Resident L to be able to verbalize relief of pain. The interventions included, but were not limited to, providing medication per physician's orders. A physician's order, dated 4/18/25 to 5/9/25, indicated the use of oxycodone 5 milligrams (mg) every four hours as needed for pain. A controlled drug administration record, dated 4/19/25 to 4/16/25, indicated one administration of the oxycodone 5 mg tablet was signed off without a date of when the medication was administered. The record consisted of handwritten dates and times the oxycodone was administered, and they were not legible to indicate the date or time of the administration of the oxycodone. It was not clear whether the time written on the controlled drug administration record indicated A.M. (before noon) or P.M. (after noon). A controlled drug administration record, dated 4/25/25 to 5/1/25, indicated one occasion where oxycodone 5 mg was signed off, as administered, but did not indicate the date or time the medication was given. The record consisted of handwritten dates and times the oxycodone was administered, and they were not legible to indicate the date or time the oxycodone was administered. The record indicated Resident L was given oxycodone 5 mg on 4/28/25 at 7:45 and the next administration was 4/28/25 at 8:00 a.m. There was no indication if the 4/28/25 at 7:45 was A.M. or P.M. A physician's order, dated 5/9/25 to 5/14/25, indicated the use of oxycodone 5 mg every four hours as needed for pain. A controlled drug administration record, dated 5/9/25 to 5/15/25, indicated Resident L was given oxycodone 5 mg on 5/10/25 at 4:00 a.m., 6:00 a.m., and 10:00 a.m. These administrations were inconsistent with the physician's order for as needed every four hours. The record also indicated Resident L was given oxycodone 5 mg on 5/10/25 at 10:00 p.m. and on 5/11/25 at 1:00 a.m. These administrations were inconsistent with the order for as needed every four hours. There was one administration, on 5/13/25, that did not indicate a time the oxycodone 5 mg was administered. The record indicated Resident L was given oxycodone 5 mg on 5/14/25 at 6:00 a.m., 8:00 a.m., 10:00 p.m., and 5/15/25 at midnight (12:00 a.m.). These administrations were inconsistent with the order for as needed every four hours. A physician's order, dated 5/14/25 to 5/19/25, indicated the use of oxycodone 5 mg every four hours for pain. A controlled drug administration record, dated 5/16/25 to 5/17/25, indicated six oxycodone 5 mg tablets were located on that card of medication. The record indicated Resident L was administered oxycodone 5 mg on 5/16/25 at 4:00 p.m., 8:00 p.m., 5/17/25 at 12:00 a.m., and 4:00 a.m. There were two blank rows that didn't have a date or time of the administration for the oxycodone 5 mg tablet. The count of oxycodone 5 mg tablets went from five tablets to two tablets left remaining without indication as to why. The last three administrations of the oxycodone 5 mg did not contain a staff signature as to who administered the oxycodone 5 mg on 5/16/25 at 8:00 p.m., 5/17/25 at 12:00 a.m., and 5/17/25 at 4:00 a.m. A controlled drug administration record, dated 5/17/25 to 5/18/25, indicated the oxycodone 5 mg tablets were not administered consistently every 4 hours as ordered. The medication administration record (MAR), dated May 2025, indicated the oxycodone was signed off every four hours, as ordered, on 5/17/25 and 5/18/25. 2. The clinical record for Resident B was reviewed on 6/12/25 at 3:05 p.m. The diagnoses included, but were not limited to, hypertension and lymphedema. A physician's order, dated 3/15/25, indicated the use of ceftriaxone solium (antibiotic); administer one gram intravenously (IV) every 12 hours for infection for seven days to equal 14 administrations. The March 2025 MAR indicated on 3/20/25 at 9:00 p.m. and 3/21/25 at 9:00 p.m., the IV ceftriaxone was not signed off as administered. Resident B received 12 out of 14 administrations for the IV antibiotic. 4. The clinical record for Resident D was reviewed on 6/12/25 at 2:10 p.m. The diagnoses included, but were not limited to, epilepsy and end stage renal disease. A Quarterly Minimum Data Set (MDS) Assessment, completed 5/29/25, indicated he was cognitively intact. A physician's order, dated 3/31/25, indicated he was to receive oxycodone (narcotic pain medication) 20 mg one tablet every four hours as needed for pain. A Controlled Drug Administration Record indicated, on 5/29/25, 30 tablets of oxycodone 20 mg were delivered to the facility. The Controlled Drug Administration Record indicated Resident D had received one oxycodone 20 mg tablet on 5/31/25 at 8:00 a.m., and one tablet on 5/31/25 at 8:00 p.m. There were 28 pills left. There was a notation on the Controlled Drug Administration Record that the count was corrected, and 30 tablets were available for use. The count correction notation did not contain a time or date and contained no signatures of who corrected the drug count. The Controlled Drug Administration Record also contained illegible dates that had been crossed out and in the amount remaining column the number 29 which was circled. There were no legible dates or times to indicate when a dose of oxycodone 20 mg had been given to Resident D. On 6/13/25 at 11:10 a.m., the District Director of Risk Management (DDRM) provided the current Medication Controlled Drugs and Security Policy which indicated .The Narcotic Count and Inventory a. Controlled drugs as well as the controlled drug count sheets and cards, are counted every shift change by the nurse reporting on duty with the nurse reporting off duty .discrepancies in count a. In the event a discrepancy is found, check the resident's medication sheets and chart to see if a narcotic has been administered and not recorded. b. Check previous recordings on the control sheets for mistakes in arithmetic. c. If the cause of the discrepancy cannot be located and/or count does not balance, report the matter to the supervisor for immediate investigation . This citation relates to Complaint IN00461164. 3.1-25(a) 3.1-25(b)(3) 3.1-25(e)(3) 3a. The clinical record for Resident H was reviewed on 6/12/25 at 10:30 a.m. The diagnoses included, but were not limited to, perforation of intestine and peritoneal abscess. She was admitted to the facility on [DATE]. The on-boarding clinical evaluation provided by the discharging facility indicated Resident H's diagnoses and reason for admission included, but were not limited to, multiple bowel perforations, intra-abdominal abscess, candidemia (fungal infection of the bloodstream), intravenous (IV) antibiotics. It also indicated Resident H was alert and oriented. Clinical needs included administration of Zosyn (antibiotic) 3.375 grams (gm), to be administered intravenously every 8 hours, Diflucan (antifungal) 400 milligrams (mg), to be administered intravenously once every 24 hours. The medication information included the resident was to continue receiving IV Zosyn and Diflucan until 6/11/25. On 6/12/25 at 1:07 p.m. an interview was conducted with Resident H. She indicated she arrived at the facility around 1:00 p.m. on 6/6/25. Resident H indicated she had asked facility staff when she was going to get her medications, and they kept telling her the pharmacy is on their way. Resident H indicated she was in pain and was vomiting and crying. An interview was conducted with Resident H's family member on 6/12/25 at 12:20 p.m. She indicated when she arrived at the facility, on 6/7/25, she asked Registered Nurse (RN) 3 when Resident H's next dose of IV antibiotics was due. RN 3 indicated to her that there were none (IV antibiotics) ordered nor on the medication list. Resident H's Order Summary Report was provided by the District Director of Risk Management (DDRM) on 6/12/25 at 2:32 p.m. The physician order for Zosyn and Diflucan were not entered until 6/7/25. During an interview with the Pharmacy Representative (PR) on 6/13/25 at 3:19 p.m., he indicated in their system Resident H was admitted on [DATE]th, 2025, at 3:19 p.m. During an interview with RN 3 on 6/12/25 at 3:58 p.m., he indicated, at around 10:00 a.m., he went through Resident H's medication lists and found she was supposed to have had IV antibiotics ordered and administered such along with her TPN. RN 3 indicated he was able to get the antibiotics [Zosyn] from the emergency drug kit that was due, and pharmacy brought the TPN via STAT delivery. Review of the Medication Administration Record (MAR) revealed Resident H received her IV Zosyn on 6/7/25 at 3:00 p.m., and did not receive the IV Diflucan. Resident H missed three doses of Zosyn and one dose of Diflucan while at the facility. The Emergency Drug Kit (EDK) inventory log provided by the DDRM, on 6/13/25 at 1:30 p.m., indicated two doses of IV Zosyn 3.375 gm were available on hand. 3b. A physician order for oxycodone hydrochloric acid (HCL) 10 (milligrams) mg was entered on 6/6/25 for Resident H. An additional order for Oxycodone HCL 10 mg was entered on 6/7/25. On 06/12/25 at 1:07 p.m., an interview was conducted with Resident H. She indicated she had asked facility staff when she was going to get her medications, and they kept telling her the pharmacy is on their way. Resident H indicated RN 3 had given her Oxycodone 20 mg on 6/7/25. During an interview with RN 3 on 6/12/25 3:58 p.m., he indicated Resident H complained of pain during his shift on 6/7/25. The resident's order for oxycodone 10 mg had not been filled yet so he called the facility physician, and a STAT order was put in that the pharmacy delivered. RN 3 indicated he administered one dose of oxycodone 10 mg to Resident H on 6/7/25. A delivery manifest from the pharmacy was provided by the DDRM on 6/12/25 at 4:32 p.m. It indicated lorazepam 0.5 mg (3 tablets), Fentanyl 25 micrograms (mcg) (1 patch), and oxycodone Immediate Release 10 mg (4 tablets) was delivered to the facility on 6/7/25 at 1:10 p.m. The Medication Administration Record (MAR) did not contain documentation of oxycodone 10 mg or lorazepam 0.5 mg being administered to Resident H. The MAR indicated one Fentanyl patch was applied to the resident on 6/7/25 at 2:00 p.m. The controlled drug administration record did not contain record of reconciliation of oxycodone 10 mg tablets or patches of Fentanyl 25 mcg. It did contain a reconciliation record for lorazepam 0.5 mg tablets indicating one tablet had been removed, and two tablets remained.

2. The clinical record for Resident M was reviewed on 6/12/25 at 2:20 p.m. The diagnoses included, but were not limited to, anxiety disorder, fracture of the right upper humerus (arm bone). He was admitted to the facility on [DATE]. The acute care hospital discharge instructions, dated [DATE], indicated Resident M was to receive the following medications upon admission to the facility: 1. Aspirin 81 milligram (mg) two times daily, 2. gabapentin (anti-seizure medication) 400 mg three times daily, 3. levetiracetam (anti-seizure medication) 500 mg two times daily, 4. lorazepam (anti-anxiety medication) one mg once daily, 5. methocarbamol (muscle relaxer) 500 mg, two tablets every six hours, 6. oxycodone-acetaminophen (narcotic pain medication) 10 mg - 325 mg, two tablets every four hours as needed for pain, 7. clonazepam (anti-anxiety medication) one mg tablet two times daily, 8. losartan (high blood pressure medication) 50 mg once daily, and 9. paroxetine (anti-depressant) 40 mg once daily. The June 2025 Medication Administration Record (MAR) indicated Resident M received the following medications: The gabapentin, levetiracetam, methocarbamol, and losartan had been administered as ordered, starting on 6/6/25. He received aspirin 81 mg one tablet daily on 6/7/25, 6/8/25, and 6/9/25. On 6/10/25, Resident M began receiving 81 mg aspirin twice daily. He did not receive any doses of clonazepam, one mg. The paroxetine 40 mg one tablet daily did not start until 6/9/25. His lorazepam one mg daily was not started until 6/9/25. During an interview on 6/13/25 at 11:55 a.m., Resident M indicated he had a horrible time getting his medications when he first arrived at the facility on 6/6/25. He had been admitted over a weekend, and no one seemed to be able to get his medications for him. He had missed doses of several of his pills. He was discharging from the facility and was glad to be going home. An undated Physician Orders Policy was provided by the DDRM on 6/13/25 at 12:52 p.m. It indicated .Execution of Order and Notifications a. The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse i. Contact laboratory services, radiology services, pharmacy services, therapy or other outside vendors as required to execute the medical order . This citation relates to Complaint IN00461164. 3.1-37(a) Based on interview and record review, the facility failed to ensure admission orders for medications and treatments were entered timely and accurately for 2 of 4 residents reviewed for medication administration (Resident H and Resident M). Findings include: 1. The clinical record for Resident H was reviewed on 6/12/25 at 10:30 a.m. The diagnoses included, but were not limited to, perforation of intestine and peritoneal abscess. She was admitted to the facility on [DATE]. The on-boarding clinical evaluation provided by the discharging facility indicated Resident H's diagnoses and reason for admission included multiple bowel perforations, intra-abdominal abscess, candidemia (fungal infection of the bloodstream), wound care, total parenteral nutrition (artificial nutrition administered intravenously), intravenous (IV) antibiotics, and physical/occupational therapy. It also indicated Resident H was alert and oriented. Clinical needs included administration of Total Parenteral Nutrition (TPN), ordered as Clinimix 8/14 to run intravenously at a continuous rate of 65 milliliters (ml)/hour, Zosyn (antibiotic) 3.375 grams (gm), to be administered intravenously every 8 hours, Diflucan (antifungal) 400 milligrams (mg), to be administered intravenously once every 24 hours. Wound care was noted for an abdominal surgical wound with wound manager, accordion drain, and coccyx (tailbone) stage 1 pressure ulcer. The medication information included the resident was to continue receiving IV Zosyn and IV Diflucan until 06/11/25. The following medications were listed on the hospital medication list from the discharging facility: 1. Clinimix (artificial nutrition) 8/14, to run intravenously at a continuous rate of 65 milliliters (mL)/hour, 2. Clinolipid (fat emulsion supplement), to run intravenously at a rate of 21 mL/hour, 3. Buspirone (antianxiety) twice a day for anxiety, 4. Quetiapine (antipsychotic) 150 mg at bedtime for depression, 5. Scopolamine (medication for nausea) patch one mg every three days, 6. Hydroxyzine (medication used to treat anxiety) 10 mg needed every six hours for anxiety, 7. Simethicone (antiflatulent) 80 mg; one tablet as needed four times a day for gas, 8. Nicotine (nicotine replacement therapy) patch, to be applied once daily, old patch to be removed once daily, 9. Pantoprazole (medication used to reduce stomach acid) 40 mg twice daily, 10. Sucralfate (medication gastric protection) 1 gram (gm) tablet four times daily, 11. Trazodone (antidepressant) 50 mg at bedtime, 12. Bupropion Hydrochloride (antidepressant) 100 mg, two tablets twice a day, 13. Oxycodone (opioid pain reliever) 10 mg, one tablet as needed every six hours for moderate to severe pain, 14. Naloxone Hydrochloride (opioid antagonist) 0.4 mg, for respiratory rate less than eight breaths per minute, 15. Calcium Carbonate (antacid) 500 mg, 1.5 tablets as needed twice a day, 16. Levetiracetam (antiseizure) 500 mg twice daily, 17. Methocarbamol (muscle relaxant) 500 mg, two tablets every eight hours, 18. Fentanyl Patch (opioid pain reliever) 25 micrograms (mcg), to be applied once every three days, 19. Lorazepam (antianxiety) 0.5 mg as needed for pain three times a day, and 20. Lovenox (blood thinner) 30 mg, inject 0.3 mL twice daily. Record review of the hospital medication list from the discharging facility revealed one page was missing. An interview was conducted with Resident H's family member on 6/12/25 at 12:20 p.m. She indicated when she arrived to the facility, on 6/7/25, she asked Registered Nurse (RN) 3 when Resident H's next dose of IV antibiotics was due. RN 3 indicated to her that there were none (IV antibiotics) ordered nor on the medication list. On 6/12/25 at 1:07 p.m., an interview was conducted with Resident H. She indicated nobody had done her admission evaluation, several times the resident asked staff about when she was going to get her medications and they kept telling her the pharmacy is on their way. Resident H indicated she was in pain and had been vomiting and crying. During an interview with Licensed Practical Nurse (LPN) 2 on 6/12/25 at 3:25 p.m., she indicated, on 6/6/25, she was the admitting nurse for Resident H and there were one or two other nurses assisting her with the admission. She indicated she entered all the medications and remembered there being three paper prescriptions that had to be faxed to the pharmacy for fulfillment. LPN 2 indicated she did not remember if IV antibiotics were included in the medications she entered. During an interview with RN 3 on 6/12/25 at 3:58 p.m., he indicated at around 10:00 a.m., he went through Resident H's medication lists and found she was supposed to have had IV antibiotics ordered and administered along with her TPN. Resident H's Order Summary Report was provided by the District Director of Risk Management (DDRM) on 6/12/25 at 2:32 p.m. The physician order for Zosyn and Diflucan were not entered until 6/7/25. An order for a wound care consult was entered on 6/6/25, however no orders for wound care treatment by facility staff were ever entered. During an interview with the Pharmacy Representative (PR) on 6/13/25 at 3:19 p.m., he indicated in their system Resident H was admitted on [DATE], at 3:19 p.m. The order for TPN was entered in as other instead of pharmacy as the source, and so the order was never transmitted to the pharmacy, and therefore never received. No notes could be found indicating communication from the facility to the pharmacy in regards to a STAT request for delivery on the evening of 6/6/25.

Based on interview and record review, the facility failed to timely obtain Total Parenteral Nutrition (TPN) for 1 of 4 residents reviewed for medication availability. (Resident H) Findings include: The clinical record for Resident H was reviewed on 6/12/25 at 10:30 a.m. The diagnoses included, but were not limited to, perforation of intestine and peritoneal abscess. She was admitted to the facility on [DATE]. The on-boarding clinical evaluation provided by the discharging facility indicated Resident H's diagnoses/reasons for admission included, but were not limited to, TPN (artificial nutrition to be administered intravenously). It also indicated Resident H was alert and oriented. An order for Clinimix (a variation of TPN) 8/14, and Clinolipid (fat emulsion supplement) were entered on 6/6/25. The Clinimix was to run intravenously at a continuous rate of 65 milliliters (mL)/hour, and the Clinolipid was to run intravenously at a rate of 21 mL/hour on the evenings of Monday, Wednesday, Friday, and Saturday. On 6/12/25 at 1:07 p.m., an interview was conducted with Resident H. She indicated she arrived at the facility around 1:00 p.m. on 6/6/25. Resident H indicated the day she arrived she had asked facility staff when she was going to get her medications, and they kept telling her the pharmacy is on their way. Resident H indicated she was in pain and had been vomiting and crying. An interview was conducted with Resident H's family member on 6/12/25 at 12:20 p.m. She indicated when she arrived to the facility, on 6/7/25, she asked Registered Nurse (RN) 3 when Resident H's next dose of IV antibiotics was due and why her TPN wasn't running. RN 3 indicated that there were no IV antibiotics ordered nor on the medication list. Resident H's family member indicated RN 3 administered a TPN solution along with one of Resident H's IV antibiotics a couple hours later. During an interview with RN 3 on 6/12/25 at 3:58 p.m., he indicated at around 10:00 a.m., on 6/7/25, he went through Resident H's medication lists and found she was supposed to have had IV antibiotics ordered and administered along with her TPN. RN 3 indicated he was able to get one of the IV antibiotics from the emergency drug kit that was due, and pharmacy brought the TPN via STAT delivery. The Medication Administration Record (MAR) indicated TPN was administered to Resident H on the day of 6/7/25. An interview was conducted, on 6/13/25 at 11:12 a.m., with the Unit Coordinator (UC). She indicated if we (facility staff) encounter a late admission, we can call the pharmacy to STAT order the Clinimix supplement, and then the pharmacy has a four-hour window to have it delivered. During an interview with the Pharmacy Representative (PR) on 6/13/25 at 3:19 p.m., he indicated in their system Resident H was admitted on [DATE]th, 2025, at 3:19 p.m. The pharmacy's cut off time for TPN orders was 2:00 p.m., Monday through Friday. The order for TPN was entered in as other instead of pharmacy as the source, and so the order was never transmitted to the pharmacy, and therefore never received. No notes could be found indicating communication from the facility to the pharmacy regarding a STAT request for delivery on the evening of 6/6/25. The PR indicated follow up communication from the facility staff would have prompted the pharmacy to process and deliver the order for TPN. The night shift nurse assigned to Resident H on 6/6/25 was unavailable for interview. During an interview on 6/13/25 at 1:54 p.m. with the Division Director of Risk Management (DDRM), she indicated the facility did not have a policy unique to TPN administration, it would fall under standard of practice. This citation relates to Complaint IN00461164. 3.1-46(a)(2)

Based on interview and record review, the facility failed to timely address a resident's pain for 1 of 5 residents reviewed for pain management. (Resident H) Findings include: The clinical record for Resident H was reviewed on 6/12/25 at 10:30 a.m. The diagnoses included, but were not limited to, perforation of intestine and peritoneal abscess. She was admitted to the facility on [DATE]. The on-boarding clinical evaluation provided by the discharging facility indicated Resident H was alert and oriented. An order was entered, on 6/6/25, for oxycodone immediate release (IR) 10 mg, one tablet as needed every six hours for moderate to severe pain. On 6/12/25 at 1:07 p.m., an interview was conducted with Resident H. She indicated on the day she arrived she asked staff several times about when she was going to get her medications and they kept telling her the pharmacy is on their way. Resident H indicated she was in pain and was vomiting and crying. She indicated Registered Nurse (RN) 3 had given her oxycodone the following day, on 6/7/25 at around 1:00 p.m. An interview was conducted with Resident H's family member on 6/12/25 at 12:20 p.m. She indicated Resident H had called her, on the evening of 6/6/25, crying saying the facility had not given her any of her medications, not even her pain medication. During an interview on 6/12/25 at 3:25 p.m. with Licensed Practical Nurse (LPN) 2, she indicated by the time she was leaving at the end of her shift, on 6/6/25, Resident H was asking about when her pain medication would be delivered. At 7:30 p.m., LPN 2 gave report and let the oncoming nurse know that the admission assessments needed to be completed and they needed to follow up with the pharmacy regarding her pain medication whether that be getting a STAT delivery or pulling it from the emergency drug kit. The Emergency Drug Kit (EDK) inventory log provided by the Division Director of Risk Management (DDRM), on 6/13/25 at 1:30 p.m., indicated five doses of oxycodone IR 10 mg were available on hand. The Medication Administration Record (MAR) did not contain documentation of oxycodone 10 mg being administered to Resident H on 6/6/25. The night shift nurse assigned to Resident H, on 6/6/25, was unavailable for interview. During an interview with RN 3 on 6/12/25 3:58 p.m., he indicated Resident H complained of pain during his shift on 6/7/25. The resident's order for oxycodone 10 mg had not been filled yet so he called the facility physician, and a STAT order was put in that the pharmacy delivered. RN 3 indicated he administered one dose of oxycodone 10 mg to Resident H on 6/7/25. An interview was conducted, on 6/13/25 at 2:30 p.m., with the DDRM. She indicated if a resident had complained of pain, and had as needed pain medication ordered, she would have expected nursing staff to pull the ordered pain medication from the emergency drug kit if their routine medication had not yet been delivered. An undated Pain Management and Assessment Policy was provided by the DDRM on 6/13/25 at 1:54 p.m. It indicated .The facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management . This citation relates to Complaint IN00461164. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident remained free from significant medication errors by receiving the incorrect narcotic pain medication on multiple occasions for 1 of 4 residents reviewed for medication administration. (Resident L) Findings include: The clinical record for Resident L was reviewed on 6/12/25 at 3:10 p.m. The diagnoses included, but were not limited to, end stage renal disease, opioid dependence, low back pain, muscle weakness, and lumbago with sciatica (lower back pain accompanied by sciatic nerve pain). A care plan, revised 5/15/25, indicated Resident L was at risk for pain related to end stage renal disease. The goal was for Resident L to be able to verbalize relief of pain. The interventions included, but were not limited to, providing medication per physician's orders. A physician order, dated 5/19/25 to 5/28/25, indicated the use of oxycodone 5 milligrams (mg); administer one tablet every four hours for pain. A physician order, dated 5/28/25 to 6/6/25, indicated the use of oxycodone-acetaminophen (narcotic pain medication; also known as Percocet) 5-325 (mg); administer one tablet every four hours for pain. The controlled drug administration record for Resident L's Percocet 5-325 mg tablets indicated the medication was not signed off, as ordered, every four hours per the physician's order. There were 12 administrations from 5/30/25 through 6/6/25. The controlled drug administration record for Resident L's oxycodone 5 mg tablets indicated the medication was signed off, as administered, 28 occasions from 5/29/25 to 6/6/25. Resident L had no active order for oxycodone 5 mg tablets from 5/29/25 to 6/6/25. A current physician order, dated 6/11/25, indicated the use of oxycodone 5 mg tablet; administer one tablet every four hours. The controlled drug administration record for Resident L's oxycodone 5 mg tablets indicated the medication was not consistently signed off, as administered, every four hours per the physician's order. The controlled drug administration record for Resident L's Percocet 5-325 mg tablets indicated the medication was signed off, as administered, on five occasions, from 6/11/25 to 6/12/25, when the order for oxycodone 5 mg was in place. A policy entitled Medication Controlled Drugs and Security, undated, was provided by the Divisional Director of Risk Management on 6/13/25 at 11:10 a.m. The policy indicated the following, .a. When the prescribed drug is discontinued, or the resident discharged , the container and control sheet must be removed for drug destruction . This citation is related to Complaint IN00461164. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to attempt non- pharmacological interventions for pain, to assess pain levels prior to administering an as needed pain medication, and to assess the effectiveness of as needed pain medication for 1 of 3 residents reviewed for pain (Resident C). Findings include: The clinical record for Resident C was reviewed on 4/3/25 at 11:00 a.m. The diagnoses included, but were not limited to, cerebral infarction (disrupted blood flow to the brain), aphasia (inability to swallow), and hemiplegia (inability to move one side of the body). He was admitted to the facility on [DATE]. A physician's order, dated 2/10/25, indicated to monitor pain every shift. A physician's order, dated 2/10/25, indicated to administer oxycodone (narcotic pain medication) immediate release (IR) 5 milligram (mg); give one tablet every six hours as needed for moderate to severe pain. A care plan, last revised on 2/11/25, indicated he was at risk for pain related to stroke, hemiplegia, and tracheostomy status. The goal was for him not to exhibit nonverbal signs or symptoms of pain such as grimacing, groaning, agitation, yelling, moaning, resisting care, crying, and refusal to eat. The interventions included administering non-pharmacological interventions such as repositioning, diversional activities, snacks and fluids, ice, heat, music therapy, relaxation techniques, and imagery. The care plan reflected the need to complete a pain assessment upon admission, quarterly, with significant changes and as needed, follow physician orders for complaints of pain, and observe for pain every shift. A physician's order, dated 2/12/25, indicated to administer acetaminophen (Tylenol) tablets 325 mg; give two tablets via gastric tube (G-tube) every four hours as needed for mild pain. The February and March 2025 Medication Administration Records (MAR) indicated Resident C's pain had been assessed each shift, but it did not include the level of pain assessed. The February 2025 MAR indicated oxycodone IR 5 mg had been administered on 2/11/25. The pain level was not recorded on the MAR. The MAR indicated the dose of pain medication had been effective. There were no doses of acetaminophen documented as received. The 2/10/25 Controlled Drug Administration Record for Resident C's oxycodone IR 5 mg indicated he had received one dose on 2/11/25, three doses on 2/12/25, one dose on 2/13/25, two doses on 2/15/25, and one dose 2/16/25. The 2/13/25 Controlled Drug Administration Record for Resident C's oxycodone IR 5 mg indicated he had received one dose on 2/20/25, two doses on 2/26/25, one dose on 2/27/25, and one dose on 2/28/25. The March 2025 MAR indicated oxycodone IR 5 mg had been administered on 3/10/25, 3/11/25, 3/16/25, and 3/20/25. The pain levels were not recorded on the MAR and the doses were documented as effective. There were no doses of acetaminophen documented as received. The 2/13/25 Controlled Drug Administration Record for Resident C's oxycodone IR 5 mg indicated he had received two doses on 3/1/25, and one dose on 3/2/25. The 3/1/25 Controlled Drug Administration Record for Resident C's oxycodone IR 5 mg indicated he had received one dose on 3/7/25, one dose on 3/8/25, and one dose on 3/11/25. The 3/10/25 Controlled Drug Administration Record for Resident C's oxycodone IR 5 mg indicated he had received one dose on 3/15/25, one dose on 3/16/25 and 3/18/25. The 3/26/25 Controlled Drug Administration Record for Resident C's oxycodone IR 5 mg indicated he had received one dose on 3/26/25, one dose on 3/27/25, one dose on 3/28/25, one dose on 3/29/25, two doses on 3/30/25, and one dose on 3/31/25. A Care Conference Note, dated 3/21/25, indicated a care planning meeting had been held with Resident C's family member, who would like to have Resident C's pain medication scheduled to be administered routinely instead of as needed. The pain management physician was to be notified. The clinical record did not contain the non-pharmacological pain interventions that had been attempted or the assessment of pain levels prior to administration of the oxycodone IR doses given. There was no documentation of the effectiveness of the doses received, with the exception on 2/11/25, 3/10/25, 3/11/25, 3/16/25, and 3/20/25. On 4/3/25 at 11:47 a.m., Resident C was observed lying in bed with his eyes closed. Family Member (FM) 5 was present at the bedside. During an interview on 4/3/25 at 11:47 a.m., FM 5 indicated she had requested the pain medication be scheduled instead of as needed due to Resident C not being able to verbalize his pain. FM 5 had informed the staff that when Resident C was in pain he would bite on his lip, grimace, tear up, shake his foot and tense up. She had requested the as needed oxycodone IR 5 mg to be given at least twice daily, however had been told by the facility nursing staff that Resident C would have to request the medication since the physician's order indicated it was as needed. FM 5 did not understand how he was to ask for the medication since he was not verbal. FM 5 had visited Resident C, on 4/2/25, and found that his top lip had dried blood on it from him biting down on it. FM 5 felt he was in pain when this happened and requested the oxycodone to be given, which had helped Resident C stop biting his lip. During an interview on 4/4/25 at 10:18 a.m., Licensed Practical Nurse (LPN) 4 indicated she monitored Resident C for pain using facial expressions and grimaces. Resident C had family that often visited and would inform the staff if Resident C appeared to be in pain. On 4/4/25 at 4:56 p.m., the Clinical Nurse Consultant provided the current Pain Management and Assessment which indicated .based on the comprehensive assessment of the resident, the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management .Pain Management Considerations a. To the extent possible and in consideration of cognitive abilities, the nurse will provide a thorough assessment by observation of activities and treatment/ relief for detection of pain and to attempt to identify location and limitations imposed by the pain .c. The use of the appropriated Pain Management Scale for the resident's ability to express pain .Documentation a. Medication pain relief and response b. non-pharmacological measures attempted, and the resident response c. care plan updated as needed This citation is related to Complaint IN00456573. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure admission orders were entered into the electronic medical record accurately, timely, and that such orders were administered as ordered by the physician for a resident with type 1 diabetes resulting in the resident experiencing a change in condition that included nausea and vomiting that was not documented in the medical record (Resident B); ensure a diabetic resident's sliding scale insulin order was continued upon admission to the facility; administer a resident's pain medication as ordered (Resident D); ensure weekly wound assessments were conducted; administer insulin as ordered (Resident C); provide geri-sleeves and Prevalon boots, as ordered (Resident 11); address a resident's low blood pressure (Resident 24); and apply a resident's Lidocaine patches, as ordered (Resident 26) for 1 of 2 residents reviewed for wounds, 1 of 1 resident reviewed for insulin, 1 of 3 residents reviewed for positioning and mobility, 1 of 2 residents reviewed for pain management, and 3 of 5 residents reviewed for change in condition. (Residents B, C, D, 11, 24, and 26) The deficient practice resulted in Resident B experiencing cardiac arrest and being admitted to an acute care hospital for type 1 diabetes mellitus with ketoacidotic coma (coma due to high blood sugar), metabolic acidosis (accumulation of too much acid in the body), acute respiratory failure, aspiration pneumonia, and cardiac arrest with a blood glucose level of 1,189. The immediate jeopardy began on [DATE] when admission orders were not entered into the electronic medical record accurately, timely, and that such orders were administered as ordered by the physician. The Executive Director, Director of Nursing, Executive Director of sister facility, and Registered Nurse were notified of the immediate jeopardy at 11:02 a.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy . Findings include: 1. The clinical record of Resident B was reviewed on [DATE] at 2:26 p.m. The Resident's diagnosis included, but were not limited to, type 1 diabetes mellitus, end stage renal disease, dysphagia (difficulty swallowing), pneumonia due to unspecified infectious organism, tracheostomy, and gastrostomy. She was admitted to the facility on [DATE] and discharged to the acute care hospital on [DATE] due to cardiac arrest. The clinical record for Resident B contained the Facility to Facility Report provided by the discharging Long Term Care Hospital, dated [DATE], which included the discharge medications Resident B was to receive upon admission to the facility. The discharge medication list included, but was not limited to, the following: - Insulin aspart (rapid acting insulin) to be given sq (subcutaneously) per sliding scale dependent on blood sugar levels every 6 hours. For blood sugar of 71 to 150- no units were to be given, blood sugar of ,d+[DATE]- 3 units were to be given, blood sugar of ,d+[DATE]- 6 units were to be given, ,d+[DATE]- 8 units were to be given, blood sugar of ,d+[DATE]- 12 units were to be given, blood sugar of 351- 400- 16 units were to be given. The physician was to be called if blood sugar results were greater 250 twice in 24 hours. The last dose received at the discharging facility was on [DATE] at 1:11 p.m. - Insulin aspart- 4 units sq at 6:00 a.m. daily. The last dose received at the discharging facility was on [DATE] at 5:40 a.m. - Insulin aspart- 4 units sq at 12:00 p.m. daily. The last dose received at the discharging facility was on [DATE] at 1:11 p.m. - Insulin aspart- 4 units sq at 6:00 p.m. daily. The last dose received at the discharging facility was on [DATE] at 6:03 p.m. - Insulin glargine (long-acting insulin) 18 units sq daily at 6 p.m. The last dose received at the discharging facility was on [DATE] at 6:03 p.m. The facility admission order did not include physician's orders for the insulin aspart per sliding scale dependent on blood sugars, orders to notify the physician if blood sugar readings were greater than 250 twice in 24 hours, physician's orders for insulin aspart 4 units scheduled daily at 6:00 a.m., 12:00 p.m., and 6:00 p.m., and there were no physician's order to obtain blood sugars. The Nursing Admission Evaluation, dated [DATE] at 7:10 p.m., indicated Resident B was alert and oriented to person, place, and time. She had clear speech and no behaviors. Her lung sounds were clear. A Social Services Note, dated [DATE] at 11:30 a.m., indicated Resident B had a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact). She was able to understand and be understood by others. She was a full code and wanted to discharge to her home with her family. Her family was very involved. A care plan, initiated [DATE], indicated Resident B had diabetes and retinopathy (eye disease). The goal was for her to be able to articulate potential complications of not following prescribed regimen and for her to be free from any signs or symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). The interventions, initiated [DATE], were to administer insulin injections as ordered, rotating injection sites, Educate resident and resident representative on medical management and importance of adherence, to prevent complications of the disease, glucose observation, nutritional requirements, weight management, smoking cessation, insulin administration, signs and symptoms of hypo/ hyperglycemia, close observation of skin integrity/ wound healing and foot care, to observe for signs and symptoms of hyperglycemia such as increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep and labored breathing pattern), acetone breath (fruity breath) stupor, coma. Report any abnormal findings to medical provider, resident and /or resident representative. Observe for signs and symptom of hypoglycemia such as sweating, tremors, increased heart rate, pallor, nervousness, confusion, blurred speech, lack of coordination, staggering gait, Report any abnormal findings to medical provider, resident and/ or resident representative. Obtain blood sugars per orders. Report abnormal findings to medical provider, resident and /or resident representative. Offer bedtime snack, weekly skin checks. A Nurses Note, dated [DATE] at 5:55 a.m. read . arrived in patient room at approximately 5am (sic) [DATE], found patient unresponsive and proceeded to do CPR [cardiopulmonary resuscitation] at 5:05 am (sic). patient was restless most of the night and stated that she felt very sick. got patients pulse back after 10 minutes of doing CPR and medics arrived shortly after and took over CPR and shortly after that took patient to .hospital. The clinical record did not contain any additional nursing assessment of Resident B's condition from the time of the Admission Evaluation until the Nurses Note which indicated she had been found unresponsive on [DATE] at 5:55 a.m. The [DATE] MAR (Medicine Administration Record) did not contain any recorded blood sugar readings or administrations of any insulin aspart. The insulin glargine had been administered once on [DATE] at HS (bedtime). The Emergency Department Provider note, dated [DATE] at 5:40 a.m., indicated Resident B presented at the emergency department from a long-term care facility. The long-term care facility staff had found resident with vomit around her, not breathing and pulseless. Resident B had received chest compressions for 30 minutes. When medics arrived, they found she had a pulse. She was unresponsive and unable to give any history. The acute care hospital History and Physical exam dated [DATE] at 8:14 a.m. read .History of Present Illness . Assessment/ Plan .1. DKA [Diabetic Ketoacidosis] with Hx of DM type 1: Glucose 1189 .2. Severe Metabolic Acidosis: ,d+[DATE] [secondary to] DKA and renal disease .4. Cardiac arrest: Unclear rhythm, approximately 20 minutes of CPR performed at facility. Posturing to pain, myoclonic jerking [quick jerking movements that are not controlled] .concern for anoxic [lack of oxygen] injury .5. Recent HCAP [Health Care Acquired Pneumonia]/ new Aspiration event: + [positive] aspiration at facility . During an interview on [DATE] at 8:41 a.m., FM (Family Member) 20 indicated Resident B was still in the hospital and not responding. FM 20 had last seen Resident B when she was admitted to the facility on [DATE], at that time Resident B had been smiling and interacting with the family and was hoping to be able to go home after her stay at the facility for rehabilitation. FM 20 had been informed by the acute care hospital that it was uncertain if Resident B would regain consciousness again. During an interview on [DATE] at 10:24 a.m., NP (Nurse Practitioner) 21 indicated the facility normally used the discharge medication orders sent by the discharging facility as the admission orders until the resident was seen by a physician at the facility. During an interview on [DATE] at 12:23 p.m., UM (Unit Manager) 22 indicated that she had assisted the admitting nurse with the physician's orders. Normally, the admission nurse would fax the medication orders received from the discharging facility to the Admission Order Entry service. The admitting nurse admits the patient into the electronic health record system and then faxes the orders so they can be data entered into the system by the Admission Order Entry service. If there are questions about the admission orders, the Admission Order Entry Service would call or fax the facility. UM 22 had no knowledge of the Admission Order Entry service calling or faxing with questions about Resident B's admission orders. When the Admission Order Entry service finished entering the orders, they inform the facility by sending a message on electronic health record to alert the facility that their portion was finished. The admitting nurse should have confirm and check the orders entered against the discharge orders. UM 22 normally would have compare the new resident's orders in the electronic health system with the orders sent from the discharging facility, but somehow there was a miscommunication with Resident B's orders. UM 22 was aware that Resident B was a diabetic. During an interview on [DATE] at 12:51 p.m., LPN (Licensed Practical Nurse) 23 indicated she had worked the night shift which began on [DATE] at 11 p.m. and ended the morning of [DATE]. LPN 23 did not recall any faxes or calls with questions about Resident B's admission orders. During an interview on [DATE] at 1:00 p.m., QMA (Qualified Medication Aide) 24 indicated he had been caring for Resident B on [DATE] when she was sent to the hospital. QMA 24 had been called to Resident B's room by a CNA (Certified Nursing Assistant) at around 3:00 a.m. because Resident B was sliding out of the bed and vomiting. QMA 24 had informed LPN 25 that Resident B was vomiting and asked if Resident B could have something for nausea. At around 4:00 a.m., QMA 24 had assisted a CNA in placing a mattress on the floor by Resident B's bed because QMA 24 was afraid Resident B was going to fall and hurt herself. At around 5:00 a.m. Resident B had been found unresponsive and LPN 25 had come to assist. CPR had been started and 911 was called. QMA 24 had not been spoken to about his care of Resident B on early morning on [DATE] by any of the facility management. On [DATE] at 1:45 p.m., the RVPRM (Regional [NAME] President of Risk Management) provided the Admission Order Entry Communication fax which was time stamped as being received on [DATE] at 9:22 p.m., which indicated Resident B had medication issues that needed further attention. Medication not entered was insulin aspart due to clarification being need for the directions and frequency. During an interview on [DATE] at 1:45 p.m., the RVPRM and DON indicated the fax had been sent to the copy room fax machine. The nurses on duty had access to the copy room fax machine. The copy room was located in the middle of the building, between the two units. During an interview on [DATE] at 2:21p.m., LPN 26 indicated she had worked on [DATE] from 6:00 p.m. until [DATE] at 6:00 a.m. To LPN 26's knowledge, Resident B's admission orders had been taken care of by UM 22. LPN 26 was a fairly new employee to the facility. She had not received report from the previous shift. LPN 26 had not received any requests for clarification of Resident B's admission orders. UM 22 had asked the other nurse working the unit with LPN 26 that assist her with completing Resident B's Nursing Admission Assessment, but the other nurse on duty was unable to assist due to being busy with her patients. UM 22 had phoned her around 12:30 a.m. to make sure the admission assessment had been completed. LPN 26 had not been made aware of any concerns with Resident B's admission orders. During an interview on [DATE] at 3:07 p.m., LPN 25 indicated she had worked with QMA 24 on [DATE] when Resident B was sent to the hospital. QMA 24 had gotten her to look at Resident B around 1:00 a.m. QMA 24 had told LPN 25 that Resident B was vomiting a lot. There was not vomit present when LPN 25 assessed Resident B. Resident B had been restless and was repositioned in bed. LPN 25 had wondered if QMA 24 had mistaken Resident B spitting up for vomiting and had looked in the medical record to see if Resident B had any medication for anxiety. LPN 25 had not taken Resident B vital signs or made the physician aware. LPN 25 was not aware that Resident B was a diabetic. LPN 25 indicated that if she had known Resident B was a diabetic, she would have taken her blood sugar. Around 5:00 a.m., a CNA had come up to LPN 25 and told her that Resident B was not responsive. LPN 25 had gone to Resident B's room and started CPR until the ambulance arrived and EMS took over her care. On [DATE] at 11:20 a.m., the ED provided the current Admission Evaluation policy which read .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. A systematic evaluation is completed by a licensed nurse upon admission/ readmission to assist in determining the most effective and appropriate care needs of each resident admitted to the center .2. Prioritize resident needs with appropriate interventions to include but not limited to .g. complete medication reconciliation .Communicate Care Plan Need to team . On [DATE] at 2:33 p.m., the DON provided the current Notification of Change of Condition Policy which read .Compliance Guidelines: The center must inform the resident, consult with the resident's physician and /or notify the residents' representative, authorized family member, or legal power of attorney/ guardian when there is a change requiring such notification .2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status including but not limited to: a. life-threatening conditions, or b. clinical complications. 3. Circumstances that require a need to alter treatment which may include: a. new treatment b. discontinuation of current treatment . 41129 2a The clinical record for Resident D was reviewed on [DATE] at 9:22 a.m. Resident D's diagnoses included, but not limited to, cancer of the tongue, diabetes mellitus Type II, hydrocephalus (extra fluid in the brain causing pressure) with VP shunt (Ventriculoperitoneal shunt, a tube inserted into a hole in the skull too drain excess fluid and relieve pressure on the brain) and status post laryngectomy (removal of larynx, voice box). A university hospital's discharge instructions for Resident D were provided by ED (Executive Director) on [DATE] at 2:24 p.m. The discharge instructions indicated, Resident D had tongue cancer and underwent surgery to remove his larynx (voice box), tongue, the lymph nodes from both sides of his neck and a VP shunt revision. The medication reconciliation indicated Resident D was on the following medications: Folic Acid 1 mg (milligram) once a day via G-tube (Gastrostomy, stomach tube used for medications, hydration, and enteral feeding) Lansoprazole ( a stomach ulcer medication) 3 mg/ml (milliliter)- give 10 milliliters once a day via G-tube Multivitamin with minerals -one tablet, once a day via G-tube Oxycodone ( a narcotic pain medication) 5 mg- one tablet three time a day via G-tube Apixaban (an anticoagulant) 5 mg - one tablet twice a day via G-tube Glargine insulin (slow acting insulin) 13 units at bed time subcutaneouly (under the skin in subcutaneous fat) Metoprolol (blood pressure medication) 50 mg given twice daily via G-tube Acetaminophen 325 mg - give 2 tablets via G-tube for fever Atorvastatin (cholesterol reducing medication) 20 mg via G-tube at bedtime Certrizine (anti-allergy medication) 10 mg tablet via G-tube every morning Cholecalciferol (vitamin D3) 1250 mcg (microgram) every Monday via G-tube Fentanyl (narcotic pain reliever) 12 mcg/hr patch -apply once every 3 days Fluoxetine (antidepressant) 20 mg/5 ml - give 5 ml via G-tube every morning Gabapentin 300 mg tablet via G-tube three times a day Guafenesin 100 mg/ 5 ml - give 10 ml via G-tube every four hours as needed for congestion Insulin Lispro 100 units/ml -give per sliding scale subcutaneously as needed for elevated blood glucose levels Loperamide (anti-diarrheal) 1 mg/ 7.5 ml -give 30 ml via feeding tube every 6 hours as needed for loose stool Melatonin 3 mg at bed time to aid with sleeping Metformin (diabetic medication) 500 mg tablet two time a day via G-tube Ondansetron 8 mg via G-tube every 8 hours as needed for nausea and vomiting Polyethylene glycol (stool softener) 17 grams via G-tube every morning Senna 8.8 mg/ 5 ml -give 5 ml via G-tube two times a day and to stop taking Omeprazole (stomach ulcer medication) A physician's progress note dated [DATE] at 1:00 a.m. indicated, Resident D's medications included: the medications listed above except for the Lispro insulin, Folic acid and multivitamin. The lansoprazole was replaced with Omeprazole. An interview with Resident D's NP (Nurse Practitioner) 21 was conducted on [DATE] at 1:53 p.m. NP 21 indicated, the medications listed on his discharge paperwork from the hospital were the medications which should have been continued here at the facility which included the Lispro insulin with the sliding scale. An interview with Resident D's Endocrinologist (a physician who specializes in the Endocrine system) conducted on [DATE] at 2:12 p.m. indicated, if Resident D was on Lispro insulin at the hospital, she would have continued him on the same medication and dosage as he had previously been on at hospital until there was more data collected to determine if any changes needed to occur. She also mentioned, in order to give an accurate dose of Lispro insulin the facility should check his blood glucose at least 3 times daily. A review of Resident D's orders from the time of admission to current did not include an order for Lispro insulin three times daily before meals. Resident D's blood glucose readings were provided by ED on [DATE] at 2:24 p.m. The blood glucose readings ranged from the lowest reading at 118 to the highest reading of 336. Most of the readings were greater than 200. The review of Resident D's August, September, and October MARs (medication administration record) received from ED on [DATE] at 2:24 p.m. indicated, he had not received any Lispro insulin with a sliding scale. The August MAR indicated, 2 b. The review of Resident D's August MAR indicated Resident D did not receive his Fentanyl pain patch on the following dates: [DATE], [DATE], [DATE], [DATE]. The chart code for the missed Fentanyl applications was 9 which indicated see nurse notes The Medication Administration note dated [DATE] indicated, pharmacy notified; [DATE] indicated, new order has to be received by pharmacy; [DATE] indicated, not available, still waiting for script; and [DATE] indicated, on order from pharmacy. 34850 3a. The clinical record for Resident C was reviewed on [DATE] at 2:00 p.m. The diagnoses included but were not limited to: chronic kidney disease and type 2 diabetes mellitus. The resident was admitted on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident C was cognitively intact. A care plan dated [DATE] indicated Resident C had diabetes. The staff was to administer insulin as ordered. A physician order dated [DATE] indicated the resident was to receive 10 units of Glargine (lantus) insulin at bed time. The order was discontinued on [DATE]. An Endocrinologist visit note dated [DATE] indicated Resident C's insulin was going to be changed to 6 units of lantus twice a day. A physician order dated [DATE] indicated the resident was to receive 6 units of lantus at bedtime. The order was discontinued on [DATE]. A physcian order dated [DATE] indicated the resident was to receive 6 units of lantus in the morning. The order was discontinued on [DATE]. A physician order [DATE] indicated the resident's 10 units of glargine at bedtime was to be discontinued. A physician order dated [DATE] indicated the resident was to receive 6 units of lantus in the morning and 6 units of lantus at bedtime. The [DATE] Medication Administration Record (MAR) indicated the following days Resident C received 16 units of glargine/lantus insulin at bedtime: [DATE], [DATE] and [DATE] An interview was conducted with Resident C on [DATE] at 1:59 p.m. She indicated the staff have not been giving her insulin correctly. An interview was conducted with Endocrinologist Nurse Practitioner (NP) 35 on [DATE] at 3:00 p.m. She indicated on [DATE], she had changed Resident C's insulin orders due to her chronic kidney disease. The long acting insulin would be more effective if it was split up. The resident would received some insulin in the morning and some insulin at night. On [DATE], she had noticed the resident was receiving 16 units of lantus at bedtime instead of 6 units. NP 35 had spoken with the nursing staff to claify the orders. The 10 units of glargine insulin to be given at bedtime that was originally ordered was to be discontinued on [DATE]. 3b. An at risk for altered skin integrity care plan with an initial date of [DATE] and a revision date of [DATE], indicated Resident C had impaired skin integrity. Weekly skin assessments dated [DATE] and [DATE] indicated the resident had no skin areas. A wound specialist visit note dated [DATE] indicated Resident C had an arterial ulcer to right lateral leg. The wound status assessment indicated the wound was full thickness measuring 10 centimeters in length and 2.5 centimeters in width. The periwound was intact, fragile and dry. The treatment plan was for staff to apply skin prep to the wound base daily; leave open to air. The staff was to monitor the wound and notify provider with changes to the skin. A physician order dated [DATE] indicated the staff was to apply skin prep to right lateral ankle once a day. The resident's clinical record did not include any additional weekly wound measurements completed for the resident's arterial ulcer on her right leg after [DATE]. An observation was made of Resident C on [DATE] at 1:59 p.m. Resident C's right outer leg was observed with a round area that was white, flakey and dry the size of a half dollar. An interview was conducted at that time with Resident C. She indicated the wound doctor came in and looked at her wound on her leg. He then took photos and ordered a treatment a few weeks ago. The staff nor the wound doctor has observed the wound since. An interview was conducted with the Wound Nurse 36 on [DATE] at 9:20 a.m. She indicated the wound doctor comes in weekly to do the wound assessments. The wound doctor sees all residents on admission and weekly with wounds. Resident C's initial visit with the wound doctor was on [DATE]. He had observed an arterial ulcer on the resident's right leg at that time. It was difficult for the wound doctor to see her due to the resident goes to dialysis and leaves LOA (leave of absence) a lot. The resident's wound was not assessed with measurements last week. A skin care and wound management policy was provided by the Director of Nursing on [DATE] at 12:14 p.m. It indicated .Policy: The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident/patient and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment. Each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition .Treatment 6. monitor and document progress . 30344 4. The clinical record for Resident 11 was reviewed on [DATE] at 2:30 p.m. His diagnoses included, but were not limited to: right hand contracture, left hand contracture, convulsions, and hypertension. The impaired skin integrity/at risk for altered skin integrity care plan, revised [DATE], indicated the goal was for him to be without impaired skin integrity through the next review date. An intervention was to administer treatments as ordered by medical provider. The ADL (activities of daily living) care plan, revised [DATE], indicated he required total assistance with ADLs related to limited physical mobility and impaired functional range of motion to extremities. The goal was for him to remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown and fall related injury through the next review date. The physician's orders read, 1) Staff to use: bilateral leg rest with foot buddy to support BLE [bilateral lower extremities,] when up in the wheelchair. 2)Staff to flip foot rest parts of both elevating leg rest away to prevent foot injury when up in wheelchair. 3) staff to put provolone [sic] boots [boots with a cushioned bottom that float the heel off the surface, helping to reduce pressure] on BLE to protect both feet when up in wheelchair. every shift for positioning, starting [DATE] and Geri-Sleeves [stocking sleeves to protect the arms from friction and shearing] for protection. every shift for protection, starting [DATE]. An observation of Resident 11 was made in the common area of the [NAME] Unit on [DATE] at 2:46 p.m. He was sitting in his chair in front of the television with his eyes closed. He was not wearing Prevalon boots or Geri-sleeves. The October, 2023 MAR (medication administration record) indicated Resident 11's Prevalon boots were on every shift on [DATE]. An observation of Resident 11 was made with UM (Unit Manager) 24 in the common area of the [NAME] Unit on [DATE] at 3:24 p.m. He was not wearing Prevalon boots or Geri-sleeves. An interview was conducted with UM 24 on [DATE] at 3:24 p.m. during the above observation. She indicated, if the order said Geri-sleeves, he should have them. An interview was conducted with the Wound Nurse on [DATE] at 11:15 p.m. She indicated Prevalon boots were a preventative measure and he should be wearing them. An observation of Resident 11 was made with the Wound Nurse in the common area of the [NAME] Unit on [DATE] at 11:17 p.m. He was sitting in his chair. He was not wearing Prevalon boots. An interview was conducted with the Wound Nurse on [DATE] at 11:25 a.m. She indicated she went ahead and applied Resident 11's Prevalon boots. The Skin Care and Wound Management policy was provided by the DON (Director of Nursing) on [DATE] at 12:14 p.m. It read, Procedure: Prevention .4. Develop a care plan with individualized interventions to address risk factors. 5. Communicate risk factors and interventions to the care giving team. 6. Evaluate for consistent implementation of interventions and effectiveness at clinical meeting. 5. The clinical record for Resident 26 was reviewed on [DATE] at 3:35 p.m. His diagnoses included, but were not limited to: hypotension, mild vascular dementia, alcoholic cirrhosis the of liver, and end stage renal disease. The orthostaatic hypotension care plan, revised [DATE], indicated interventions were vital signs as ordered/per facility protocol and to follow up as indicated. The Vitals section of the electronic health record indicated the following blood pressures on the following dates and times, taken by LPN (Licensed Practical Nurse) 37: [DATE] at 10:43 p.m. -,d+[DATE] mmHg taken while standing in his right arm and [DATE] at 10:40 p.m. - ,d+[DATE] mmHg taken while sitting in his right arm. There was no information in the clinical record, including the progress notes or assessments, to indicate how the above blood pressures were addressed on [DATE]. There were no blood pressures in the clinical record after the [DATE], 10:43 a.m. blood pressure of ,d+[DATE] until [DATE] at 11:25 a.m. It was a reading of ,d+[DATE]. The [DATE], 1:08 p.m. nurse's note read, Res. [Resident's] Nephrologist Called Stated Res HGB [hemoglobin] 6.5 Gave Order For Res To Go To [name of local hospital emergency room ] for Blood Transfusion, [NAME] [sic] He Had Notified Someone Via Text Last Evening, Res. Stated He Received A Text Last Evening, But Didn't See Text Until This Am [morning,] Res Denies SOB [shortness of breath,] No CP [complaints,] No Dizziness, Sister [name of sister] Notified, 911 Called, Report Given, Res. Transferred To [name of hospital emergency room ] NP Notified. An interview was conducted with NP (Nurse Practitioner) 21 on [DATE] at 1:57 p.m. She indicated she did not recall being notified of the [DATE] low blood pressures. Since it was after hours, another service provider would have received notification. This was her first time hearing about these blood pressures. She thought with blood pressures that low, he would have been lethargic and nursing would have seen a change in condition. She stated, That's really low. If the blood pressures were legit, she would like to know. Her treatment would depend on how symptomatic he was. An interview was conducted with the RVPRM (Regional [NAME] President of Risk Management) on [DATE] at 10:07 a.m. She indicated she couldn't' find any verification Resident 11's [DATE] low blood pressures were addressed. An interview was conduted with LPN 37 on [DATE] at 12:00 p.m. She indicated she did not notify anyone of Resident 11's blood pressure of ,d+[DATE]. She took his blood pressure again later and it was ,d+[DATE], she thought. She used another blood pressure cuff machine to recheck it. She should have crossed out the low blood pressure. She retook his blood pressure because the reading was strange. She did not document the new blood pressure reading in the clinical record. 6. The clinical record for Resident 24 was reviewed on [DATE] at 11:45 a.m. Her diagnoses included, but were not limited to, pelvic and perineal pain, morbid obesity, hypertension, pain in right hip, and pain in left hip. The complaints of chronic pain care plan, revised [DATE], indicated interventions were to provide mediation per orders; observe for signs and symptoms of side effects; and to evaluate effectiveness of medication. The physician's orders indicated to apply a Lidocaine Exte [TRUNCATED]

Based on interview and record review, the facility failed to administer residents' medications as ordered, timely address skin conditions, provide wound care as ordered, and administer treatments as ordered, resulting in debridement and delayed surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents B, F, 37, 82, 103, 229, and 233) Findings include: 1. The clinical record for Resident B was reviewed on 5/20/22 at 10:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the facility from the hospital on 3/10/22. He discharged from the facility on 4/27/22 for a planned surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] The 3/10/22 hospital discharge summary read, Condition on Discharge/Disposition: Stable condition will require extensive wound care and working with PT [Physical Therapy] and OT [Occupational Therapy.] The 3/10/22, 5:54 p.m. nurse's note indicated his wound vac was removed before being transported to the facility and had instructions to leave the wound vac off until Monday 3/14/22, as it would be put back on after his visit to the hospital wound clinic at 7:45am. He was currently using a wet to dry dressing. The 3/11/22, 5:11 p.m. Skin/Wound Note, written by the facility Wound Nurse, indicated Resident B had a surgical incision wound\line separation that went from his buttocks, perineum and left thigh region. The Wound Nurse was notified by the hospital emergency room nurse and EMT (emergency medical technicians) and family at bedside that resident's wound vac (vacuum) would be off until his 3/14/22, 7:45 a.m. hospital wound clinic appointment. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2022 TAR (treatment administration record indicated this was not done on 3/12/22, 3/13/22, or 3/14/22. An interview was conducted with the Wound Nurse in the presence of the DON on 5/23 at 3:57 p.m. She indicated Resident B was supposed to admit to the facility with a wound vac, but didn't, so they got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If they were completed, they should have been signed off on the TAR. There were no 3/14/22 hospital wound clinic notes. An interview was conducted with the facility Wound Nurse on 5/20/22 at 11:21 a.m. She indicated she was the wound nurse in March 2022 when Resident B admitted to the facility. They had issues with transportation getting him to his weekly wound appointments. The 3/16/22 hospital wound clinic note indicated it was his initial evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B and his parents were very concerned about the wound healing prognosis and had multiple questions. The wound assessment was described as a chronic full thickness [CONDITION(S)]. The measurements were 32 cm X 40 cm X 9 Cm, with an area of 1280 sq cm and a volume of cubic cm. There was a moderate amount of sero-sanguineous drainage noted. The wound pain level was 4/10. The wound margin was not attached to wound base. The wound bed had 11-20% slough and 81-90% granulation. The periwound skin color was normal, and the periwound skin exhibited maceration. The wound clinic attempted to call the facility and left a voicemail for the DON (Director of Nursing) at the time to discuss the patient's plan of care and scheduling, detailed instructions for the wound vac application, and activity limitations. They were going to fax this note to the facility. It read, Will see pt [patient] weekly in collaboration with SNF [skilled nursing facility] for wound care, next appointment Monday 3/21/22 at 10:30 a.m. Pt was given appointment card to give to the facility to arrange for transportation. The plan was for his NPWT (negative pressure wound therapy) to be changed twice a week or when soiled, once at the wound clinic on Mondays and once at the facility on Thursdays. An interview was conducted with the DON on 5/24/22 at 2:02 p.m. She indicated Resident B did not go to his wound clinic appointment on 3/21/22, due to transportation. The scheduled transportation canceled. The March 2022 TAR indicated the above order for his wound vac was completed every Thursday beginning 3/17/22, but it also indicated the previous order of wet to moist dressing continued to be done daily. An interview was conducted with the Wound Nurse in the presence of the DON on 5/23/22 at 3:57 p.m. She indicated she knew they were doing the wound vac treatments on Thursdays, as ordered, and was unsure why the daily wet to dry dressings continued to be signed off on the TAR. There was no 3/29/22 weekly wound clinic note. The 4/5/22 hospital wound clinic note indicated his wound was ready for combination of excision and complex closure as well as skin grafting. He could have his wound vac reapplied. They recommended a nonstick contact layer such as [MEDICATION(S)] or silver layer such as a product called UrgoTul which was like [MEDICATION(S)] with silver impregnated. They were going to place his order for surgery. In the meantime, they recommended continuing the wound vac dressing. The April 2022 TAR did not indicate the addition of a nonstick contact layer as recommended on 4/5/22, rather it indicated a continuing of the previous order of normal saline, pat dry, wet to moist dressing and border gauze from his admission. There was no 4/12/22 weekly wound clinic note. The 4/19/22 weekly wound clinic note indicated Resident B had not been getting regular dressing changes and the facility took him off the wound vac because there was bone present in the wound and the facility claimed bone in the wound was contraindicated to a vac. Resident B educated facility that is was not a contraindication; however the size of the wound with the location made it difficult on a non-hospital vac which was a more likely reason for doing the wet to dry dressings. Resident B's mother informed the dressings hadn't been changed for some time, then were changed at 12:30 a.m. and the dressings had thick yellow/green drainage. The note indicated there was no change noted in the wound progression. surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . It read, Patient is in a facility; however, will be at [name of hospital] for urology appointment so would like to keep wound appointment next week prior to surgery. Pt sated that would be fine. Patient and family nervous about anything messing up surgery. The 4/25/22 weekly wound clinic note indicated he was 2 days in advance of his anticipated procedure for complex closure of his wound. On presentation, he had strikethrough green drainage from his wound. Acetic acid was started. Instructions were issued to parent to bring to facility, and they would be faxed there. It stated, Do not anticipate further treatment is indicated at this time given plan for closure with [name of surgeon] on Wednesday. The plan read, Dressings: . Please change dressing twice per day at a minimum. Dressing was changed at 11:00 on 4/25, please change again in the evening. Apply acetic acid moistened gauze (acetic acid issued to patient) to wound and cover with ABD pads, secure with [MEDICATION(S)] tape. Again, change twice per day at a minimum, and more often if needed with strikethrough drainage. The 4/25/22 wound clinic orders for twice daily dressing changes were not added to the facility physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The April 2022 TAR indicated a second dressing change was not completed the evening of 4/25/22, nor was it completed twice daily on 4/26/22, as instructed in the 4/25/22 wound clinic note. The 4/26/22, 4:00 p.m., nurses note, written as a late entry on 5/6/22, read, Res father presented writer with wound dressing concerns, writer then went in and completed res wound [sic] dressing, wound shows no s/s [signs/symptoms] of bleeding or foul odor, no drainage. Res given clean linen, placed in comfortable position. Denies pain/discomfort. Father at bedside, thanked and appreciated writer. The 4/27/22, 5:00 a.m. nurse's note, written as a late entry on 5/9/22, read, writer and CNA [Certified Nursing Assistant] entered room together to meet patients needs before his scheduled transfer out. nurse offered drsg [dressing] change and pt declined, drsg still present and intact. offered [CONDITION(S)] bag empty/change, pt declined d/t [due to] not needed at the time. CNA emptied f/c [foley catheter] bag and pt did allow nurse to irrigate the cath [catheter.] CNA and nurse offered to change linens on bed, pt declined , pt was on clean linens with a lift sheet on it from shoulders to feet so that he could be transferred to cot. pt took his AM med with sips of water. pt declined getting a bed bath or washed up before he went. 4/27/22, 6:25 a.m. nurses note read, pt sent out per ambulance, stretcher, for scheduled surgery. mother and father at bedside. An interview was conducted with Family Member 33, Resident B's mother, on 5/23/22 at 2:50 p.m. She indicated Resident B's wound was so infected when he discharged the facility on 4/27/22 that he couldn't get the surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . He needed it debrided. It was delayed 2 days. It was infected. It had green drainage. She was concerned it was infected prior to leaving. They went to wound care on Monday, 4/25/22, and it was green then and they said that wasn't good. They were going to get it all cleaned up for surgery. By Wednesday, 4/27/22, it was all green again. The wound care center said they wanted the dressing changed twice daily, but the facility said no, they were only going to do it once daily. The nurse at the facility said he was the only nurse there and couldn't do it twice. It was truly, truly horrible. The 4/27/22-5/17/22 hospital notes indicated the planned procedure was debridement and skin graft plus complex closure on 4/27/22. The notes read, A tissue biopsy was obtained 4/25/2022 that was polymicrobial w/Acinetobacter baumannii, Group A strep, Pseudomonas aeruginosa, Corynebacterium, and 1 colony of Staph aureus. He was admitted [DATE] for planned surgery which ended up being a debridement only as his mother states his wound was not taken care of at [name of facility] and he presented with purulence. Following his debridement yesterday [4/27/22,] he has remained on IV [MEDICATION(S)] CT scan also revealed a concern for [CONDITION(S)] of the ischium. There are plans for him to return to the OR [operating room] tomorrow for possible wound coverage .Surgical History Internal 04/29/2022 [name and title of surgeon] Skin Graft Split Thickness. 02/27/2022 [name and title of surgeon] Wound Debridement. 2. The clinical record for Resident 229 was reviewed on 5/17/22 at 9:45 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the facility from the hospital on 5/12/22. An interview was conducted with Resident 229 on 5/17/22 at 9:52 a.m. He indicated he did not receive any his medication for the first 2 days after admission. The 5/12/22 hospital discharge medication list indicated to start taking one 150 mg capsule of [MEDICATION(S)] every 8 hours, and the last dose was given on 5/11/22 at 12:40 p.m.; one 75mg tablet of [MEDICATION(S)] daily, and the last dose was given on 5/11/22 at 10:03 a.m.; one 81mg tablet of aspirin daily, and the last dose given was on 5/11/22 at 10:01 a.m.; one 10 mg tablet of [MEDICATION(S)] daily, and the last time it was given was 5/11/22 at 10:02 a.m.; one 21 mg nicotine patch to be applied daily, and the last time it was applied was 5/11/22 at 10:08 a.m.; one multivitamin tablet daily; one 60 mg tablet of [MEDICATION(S)] daily; and one 400 mg tablet of [MEDICATION(S)] twice daily. The May, 2022 MAR (medication administration record) indicated the [MEDICATION(S)] was given only twice on 5/13/22 and twice on 5/14/22; the [MEDICATION(S)] was not given at the facility for the first time until 5/14/22; the aspirin was not given at the facility for the first time until 5/14/22; the [MEDICATION(S)] was not given for the first time until 5/14/22; the nicotine patch was not applied for the first time at the facility until 5/15/22; the multivitamin tablet was not administered for the first time at the facility until 5/14/22; the [MEDICATION(S)] was not given at the facility for the first time until 5/14/22; and the [MEDICATION(S)] was given at the facility only once on 5/13/22. The 5/13/22 physician note read, Patient is being admitted following a [CONDITION(S)] [chronic obstructive pulmonary disease] exacerbation and [CONDITION(S)]. Patient is being admitted for continued medical care and therapy. Patient has some peripheral [CONDITION(S)]. Patient has not gotten his [MEDICATION(S)] 20mg PO daily. Patient denies any other complaints or concerns An interview was conducted with UM (Unit Manager) 22 on 5/18/22 at 3:40 p.m. She indicated upon admission, the medication orders are faxed to the nurse practitioner on call, who enters the orders into the computer, which went straight to the pharmacy. Normally, Resident 229's medications would have been delivered to the facility the morning of 5/13/22, around 6:00 or 7:00 a.m. Some of the Resident 229's admission medications were in the emergency drug kit, like the Aspirin, but he should have received all of his medications on 5/13/22. The Medication Administration policy was provided by the DON (Director of Nursing) on 5/19/22 at 9:05 a.m. It read, Medication will be administered as prescribed. 3. The clinical record for Resident 233 was reviewed on 5/17/22 at 1:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the facility on [DATE]. The skin integrity care plan, revised 5/18/22, indicated he was at risk for altered skin integrity related to his disease process with an intervention to complete weekly skin checks. An interview was conducted with Resident 233 on 5/17/22 at 2:01 p.m. He indicated he found a knot on his stomach, on the lower left side. It was hard and knotty. He informed one of the NPs (nurse practitioners,) and was told he needed to tell his physician. He also had red, splotchy skin and red spots that were popping up on his chest since admission. On 5/17/22 at 2:01 p.m., an observation of Resident 233's upper chest was made when he pulled down the neck of his shirt. There were small, scattered, red, raised bumps. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2022 TAR (treatment administration record) indicated skin assessments were completed on 5/5/22, 5/11/22, and 5/19/22. There were no corresponding skin assessments in the EHR (electronic health record.) An interview was conducted with Resident 233 on 5/25/22 at 2:51 p.m. He indicated no one had addressed the knot on his stomach or the small red dots on his chest, nor had any nursing staff ever performed a skin assessment on him. An interview was conducted with UM (Unit Manager) 2 on 5/25/22 at 3:10 p.m. She indicated nurses are to physically do a head-to-toe skin assessment during a weekly skin assessment. She reviewed Resident 233's electronic clinical record and indicated no skin assessments triggered. Upon admission, the EHR is supposed to trigger a skin assessment to be completed and documented under the assessments section of the EHR. An interview was conducted with UM 2 on 5/26/22 at 10:53 a.m. She indicated she went in to see Resident 233, and he did have small pimples on his chest and an area on his stomach that was kind of hard. She informed the NP, who was going to look at him the next time they were in the facility. The 5/25/22, 12:18 p.m. nurse's note, recorded as a late entry on 5/26/22 at 9:22 a.m. read, .Writer also addressed res [resident] concern regarding his skin, skin assessment completed, notified in house NP. NP will follow up with res. Res complains of no pain/discomfort at this time. Family made aware. On 5/25/22, skin assessments were created under the assessments section of the EHR by UM 2 for 5/5/22, 5/12/22, and 5/19/22. All of the assessments indicated there were no skin conditions, or changes, ulcers, or injuries. 4. The clinical record for Resident 37 was reviewed on 5/16/22 at 2:31 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) Assessment, completed 2/23/22, indicated she was cognitively intact. She had no skin tears and did not display behaviors such as scratching herself. A care plan, last revised on 3/7/22, indicated she was at risk for altered skin integrity due to immobility. The goal, last revised on 3/17/22, was for her to be without impaired skin integrity. The interventions, initiated 2/11/22, were for her to have skin at risk assessments quarterly and as needed, weekly skin checks were to be completed and therapy was to evaluate and treat as needed. On 5/24/22 at 10:16 a.m., NC (Nurse Consultant) 3 provided the May shower records for Resident 37. They indicated that on 5/2/22 she had redness and skin tears, 5/7/22 she had an open area, redness, and skin tear, 5/9/22 she had skin tears, 5/14/22 she had an open area, redness and bleeding, and skin tears. The comments section of the shower sheet included that she suffers from severe itching on her body and that lotion was applied and linen changed, 5/16/22 shower record had redness and skin tear recorded and the comment section included that the nurse was aware of the areas. The skin sheets were signed by the Certified Assistant that provided the shower and Unit Manager 2. On 5/16/22 at 2:31 p.m., Resident 37 was observed lying in bed. She was scratching her arms. She had multiple open areas on her arms and legs. She indicated that she had itchy skin. On 5/24/22 at 11:00 a.m., she was observed laying in her bed. She had white sleeves present on both arms, which were spotted with blood. She had open, bleeding areas on her right shoulder, left arm and both hands. She was scratching at her skin. Her nails were long and had blood on the nail beds and under the nails. During an interview on 5/24/22 at 11:05 a.m., LPN (Licensed Practical Nurse) 30 indicated she had not noticed any skin areas when she had administered her medication earlier in the morning. During an interview on 5/24/22 at 12:04 p.m., Unit Manager 2 indicated she had a picking behavior. She would pick at her arms and when she did the staff would apply geri sleeves. There was lotion that was applied for it. During an interview on 5/24/22 at 12:15 p.m. SS (Social Service) 1 indicated that she was unaware of Resident 37 having a behavior of picking at her skin. On 5/24/22 at 12:20 p.m., she was observed with SS 1, who indicated she had not looked like that before. She was bleeding from several open areas and had blood on her hands. She would make sure the physician was made aware of the areas. During an interview on 5/24/22 at 2:10 p.m., NP (Nurse Practitioner) 6 indicated she had not been informed of her itching previously and that she would have wanted to know about the itching and open areas. 5. The clinical record for Resident 82 was reviewed on 5/17/22 at 10:37 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, last revised on 12/28/21, indicated she had impaired skin integrity due to a wound on her right lower leg. The goal, last revised on 3/17/22, was for her to have no complications to the right leg. An intervention, initiated 12/16/22, was to administer treatments as ordered by the medical provider. A Quarterly MDS Assessment, completed 3/23/22, indicated she was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change the dressing 3 times weekly and as needed. During an interview on 5/17/22 at 10:24 a.m., she indicated that she had a sore on her right leg that had been giving her trouble. The dressing did not always get changed. On 5/23/22 at 10:40 a.m., she was observed lying in bed in a hospital gown. She indicated the last time her dressing was changed was Saturday. She removed the sheet from her leg and there was a kerlix (gauze strip) dressing which was labeled with the date of 5/21/22. On 5/23/22 at 10:57 a.m., RN (Registered Nurse) 8 was observed changing her dressing to her right lower leg. The 5/21/22 kerlix dressing had been removed, revealing a boarder gauze dressing, dated 5/19/22. She removed the boarder gauze dressing with her gloved hands. The dressing had two 2 x 2 squares, which were stiff and covered with a dark red substance and had an oblong dark yellow area in the middle. She indicated the dressing was saturated with blood and puss. She then cleansed the area with a dry 4x4 gauze. She then changed her gloves, without performing hand hygiene, and sprayed wound cleanser on the wound. She covered the wound cleanser with silver alginate and applied a new border gauze dressing. The May 2022 TAR (Treatment Administration Record) indicated that the wet to dry dressing to right calf had been completed at least daily, except for on 5/13 and 5/14/22. The May 2022 TAR indicated the silver alginate dressing was to be changed on Tuesdays, Thursdays, and Saturdays. It had not been initialed as completed on 5/14 and 5/17/22. It had been initialed as completed on 5/21/22, however the silver alginate dressing present on her leg on 5/23/22 had been dated as completed on 5/19/22. During an interview on 5/24/22 at 3:47 p.m., the Wound Nurse indicated that silver alginate dressing to her right lower leg should have been completed as ordered. The order for the wet to dry dressing should have been discontinued. The area on her right calf had been healed for some time. 6. The clinical record for resident 103 was reviewed on 5/16/22 at 3:25 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated 12/17/21, indicated he was at risk for impaired skin integrity related to his disease process, immobility, poor nutrition, and poor vascularity. The goal, initiated 12/17/21, was for him to be without impaired skin integrity. The interventions, initiated 12/17/21, included, but were not limited to, complete skin at risk assessments upon admission/ readmission, quarterly and as needed and to complete weekly skin checks. A progress note, dated 1/28/22 at 1:25 p.m., indicated he was readmitted to the facility and appeared to have a patch of psoriasis noted on his face. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Assessment, completed 4/2/22, indicated he was cognitively intact. On 5/16/22 at 3:25 p.m., he was observed sitting on the side of his bed. He had flakey crusts of skin in his right ear and on his forehead. On 5/19/22 at 10:48 a.m., he was observed sitting in his room. Flakey crusts of skin were noted on forehead. On 5/23/22 at 10:54 a.m., he was observed laying sideways on bed. He was dressed in a black tee shirt and had been shaved. He had reddened areas on face. On 5/25/22 at 2:50 p.m., he was observed sitting in his room. He had red and scaly patches on his cheeks, chin, and forehead. He indicated he used to have some cream that the nurses put on his face. During an interview on 5/52/22 at 3:08 p.m., QMA (Qualified Medication Aide) indicated that a physician should have been informed of the red, crusty areas on his face. 7. The clinical record for Resident F was reviewed on 5/19/22 at 3:44 p.m. Resident F's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident F's annual MDS (Minimum Data Set) dated 3/9/22 indicated, Resident F was cognitively intact. An interview with Resident F was conducted on 5/17/22 at 10:11 a.m. Resident F indicated; they do not always get their insulin. Resident F's May 2022 MAR (Medication Administration Record) was reviewed on 5/24/22 at 2:05 p.m. from DON (Director of Nursing). The May MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Solo Star pen; give 13 units at bedtime - no administrations recorded for 5/12/22, 5/13/22, and 5/14/22. - [MEDICATION(S)] solution; 14 units in morning - no administrations recorded on 5/9/22. On 5/13/22 and 5/18/22 a NC was charted. NC was determined by DON to stand for no coverage given. - [MEDICATION(S)] solution; 7 units three times a day - no administrations recorded on 5/3/22 for p.m. dose, 5/9/22 for morning and afternoon doses, 5/12/22 p.m. dose, 5/13/22 p.m. dose. On 5/15/22, the morning dose was coded 9 for see nurses notes. On 5/18/22, the morning dose was coded as NC. The clinical record did not contain any additional information regarding the code 9 for 5/15/22 nor the NC for 5/18/22. - [MEDICATION(S)] solution sliding scale - no administrations or blood sugar readings recorded for 5/3/22 for 6 p.m.; 5/9/22 for 8 a.m. and 1 p.m.; 5/13/22 and 5/14/22 for 6 p.m. A Medication Administration Policy was received on 5/19/22 at 9:05 a.m. from DON. The policy indicated, The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner. Procedure: I. Administration Preparedness a. Medications will be administered as prescribed .If medication is not given, indicate on MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This Federal tag relates to complaints IN 287 and IN 008 3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely administer pain medications, as ordered by the physician, resulting in severe pain and refusal of wound care due to pain, for 4 of 8 resident reviewed for pain management (Residents 33, 68, 82, and 233). Findings include: 1. The clinical record for Resident 68 was reviewed on 5/18/22 at 9:48 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) Assessment, completed 3/16/22, indicated he was cognitively intact. He received scheduled and as needed pain medications daily and his pain made it hard for him to sleep and limited his daily activities. A care plan, revised on 4/22/22, indicated he had acute and chronic pain related to his [CONDITION(S)]. The goal, revised on 4/4/22, was for him to be able to verbalize relief of pain. The interventions included, but were not limited to, notify the medical provider if the interventions were unsuccessful, initiated 3/9/22, and provide medications as ordered, initiated 3/9/22. During an interview on 5/18/22 at 9:48 a.m., Resident 68 indicated he had run out of his scheduled [MEDICATION(S)] (narcotic pain medication). The prescription had needed refilled for a week, and without it his pain was horrible and out of control. He had been taking his as needed [MEDICATION(S)] (narcotic pain medications) which made it a little more bearable. When he ran out of his scheduled [MEDICATION(S)], it would take a day or two for his pain to get back under control once started receiving it again. The May 2022 MAR (Medication Administration Record) indicated he had not received doses his [MEDICATION(S)] on 5/14, 5/15, 5/16, 5/17, and 5/18. The controlled drug administration record for his [MEDICATION(S)] (brand name for [MEDICATION(S)]) CR (continuous release) 10 mg (milligram) indicated twenty tablets had been received by the facility on 5/2/22. He was to receive one tablet every 12 hours for chronic pain. On 5/13/22 at 9:00 p.m., he had received the last of the twenty tablets dispensed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The controlled drug administration record for his [MEDICATION(S)] ER (extended release) 10 mg indicated fifty-eight tablets had been received by the facility on 5/18/22. He had received the first tablet on 5/18/22 at 9:00 a.m. During an interview on 5/24/22 at 10:35 a.m., Registered Pharmacist 9 indicated the facility had sent an electronic refill request for the [MEDICATION(S)] ER 10mg to the pharmacy on 5/15/22 at 8:51 p.m. The pharmacy did not have a prescription authorizing refills, so a refill request had been sent out to the physician on 5/16/22 and 5/17/22. They had received the prescription to refill the medication on 5/18/22 and then sent the medication to the facility. The medication was available in the EDS (Emergency Drug System) but there not been any pulled for him during the dates of 5/13/22 through 5/18/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses note, dated 5/24/22 at 11:19 a.m., indicated he had been given his pain medication as scheduled, but refused his wound care. The controlled drug administration record for his [MEDICATION(S)]- apap (narcotic pain medication with acetaminophen) 10-325 mg indicated the facility had received thirty-six tablets on 5/14/22. He had received the last of the thirty-six tablets on 5/23/22 at 4:00 p.m. On 5/24/22, the facility received thirty more [MEDICATION(S)]- apap 10-325 mg tablets. He had received the first of those tablets on 5/24/22 at 4:00 p.m. During an interview on 5/25/22 at 10:59 a.m., Resident 68 indicated he had run out of his [MEDICATION(S)] (narcotic pain medication) and his pain had been off the charts. He had refused his wound dressing change because he was out of his [MEDICATION(S)] medication. He could not imagine how painful his dressing change would have been without receiving his [MEDICATION(S)]. During an interview on 5/25/22 at 11:10 a.m., LPN (Licensed Practical Nurse) 30 indicated when narcotic pain medication needed refilled, she called the pharmacy, if the resident was out of refills, then she would contact the physician or the nurse practitioner to send a refill prescription to the pharmacy. During an interview on 5/25/22 at 11:20 a.m., Nurse Practitioner 12 indicated she depended on the facility nurses to let her know when the residents needed their pain medications refilled. If a resident had been on narcotic pain medication for a long time, then she normally refilled it for 2 weeks at a time. She had been made aware of Resident 68 needing a refill of his [MEDICATION(S)]- apap late in the afternoon on 5/23/22 and had sent a prescription to the pharmacy. The resident's receiving narcotics long term were prescribed them to manage their pain. 2. The clinical record for Resident 82 was reviewed on 5/17/22 at 10:37 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised on 6/14/21, indicated she had acute and chronic pain related to her impaired mobility. The goal, revised on 3/17/22, was for her to be able to verbalize relief of pain. The interventions included, but were not limited to, provide medications as ordered by the physician, initiated 6/14/21. A Quarterly MDS Assessment, completed 3/23/22, indicated she was cognitively intact and received scheduled pain medications. During an interview on 5/17/22 10:24 a.m., she indicated that she had an open area on leg that had been giving her trouble. I get pain medication, but it is not enough sometimes. It hurts like a toothache. The May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/24/22 at 11:16 a.m., Registered Pharmacist 9 indicated that a refill request for the [MEDICATION(S)] ER 12-hour abuse-deterrent 10 mg had been electronically sent by the facility on 5/16/22. There were no refills left on the prescription. The physician sent a new prescription on 5/19/22 and it was delivered to the facility on that day. During an interview on 5/25/22 at 9:24 a.m., Resident 82 indicated she received scheduled pain medication each day when she went to bed and when she woke up. She could notice a difference in her pain level when she did not receive her scheduled pain medication. 3. The clinical record for Resident 33 was reviewed on 5/18/22 at 11:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain care plan, revised 2/28/22, indicated she had chronic pain and to administer her medications as ordered. An interview was conducted with Resident 33 on 5/18/22 at 11:25 a.m. She indicated she had back pain and was getting to the point where she had a hard time walking. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2022 MAR (medication administration record) indicated she did not receive the [MEDICATION(S)], as ordered, on the following dates and times: 5/18/22 at 9:00 p.m., 5/19/22 at 1:00 p.m., 5/19/22 at 5:00 p.m., 5/19/22 at 9:00 p.m., 5/20/22 at 1:00 p.m., and 5/20/22 at 5:00 p.m. There were 2 administrations, on 5/19/22 at 9:00 a.m. and 5/20/22 at 9:00 a.m. that indicated she received the medication as ordered. An interview was conducted with UM (Unit Manager) 22 on 5/24/22 at 10:26 a.m. She indicated she did not receive her [MEDICATION(S)], because she was out of the medication, and didn't have a prescription for more. She was unsure why there was no prescription, or how Resident 33 would have received the 9:00 a.m. administrations on 5/19/22 and 5/20/22, when the medication was unavailable. The 5/19/22, 11:36 p.m. nurse's note read, Resident was out of her [MEDICATION(S)]- (7.5-325 MG). Called pharmacy to verify her refill status but only to be told that she needs a script. Contacted in house NP [nurse practitioner] but was directed to [name of pain physician.] After talking to [name of pain physician] about the patient and the need to send her script to pharm-script pharmacy, he does not seem to have a good recollection of the patient. Consequently, he advised me to sent him a text message regarding this request. After sending a text message to him, I later followed it up with a call, unfortunately the Dr. [doctor] couldn't be reached. Will continue to follow up with resident request. An interview was conducted with the pain physician's NP (Nurse Practitioner,) NP 12, on 5/25/22 at 11:22 a.m. She indicated she did not like to send in a whole month's prescription at a time. She sent in for 2 weeks at a time. She depended on nursing to tell her which residents needed what medications. If a resident was on the same pain medication for a long time, she would send in a prescription for 2 weeks at a time. If a resident was receiving pain medication for a long time, they needed the medication to manage their pain, and if they didn't get it, they could go thru withdrawal symptoms like nausea, vomiting, sweating, and chills, like having a bad flu for 24 to 48 hours. She received a request for a refill of Resident 33's [MEDICATION(S)] on 5/20/21, and she sent in a prescription on 5/21/21. An interview was conducted with Resident 33 on 5/25/22 at 9:52 a.m. She indicated she did not receive her [MEDICATION(S)] for 3 days after her original 5/18/22, 11:25 a.m. interview. She felt horrible, when she wasn't getting the medication. She was in bed the whole day, either on 5/19/22 or 5/20/22, but couldn't remember which day. She was hurting in her middle and lower back. She felt like she couldn't stand for very long. She smoked cigarettes, and only went out to smoke once one of those days, as she normally went out to smoke 6 to 8 times a day, and she wasn't able to visit with her boyfriend, like she normally would. 4. The clinical record for Resident 233 was reviewed on 5/17/22 at 1:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain care plan, revised 5/18/22, indicated he had complaints of chronic pain with an intervention to provide medication peer orders. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2022 MAR (medication administration record) indicated he was not administered the [MEDICATION(S)] on once on 5/13/22, twice on 5/14/22, once on 5/15/22, and twice on 5/16/22. The electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Resident 233 on 5/17/22 at 1:51 p.m. He indicated he was prescribed [MEDICATION(S)] last week but did not receive his first dose until 5/17/22. He stated, It was horrible the whole last week. I couldn't sleep through the night at all. An interview was conducted with NP (Nurse Practitioner) 12 on 5/25/22 at 11:40 a.m. She indicated the first time she saw him, he said he was having a lot of pain, so she started him on the extended release. Later, the physician changed all of his medication and started him on [MEDICATION(S)]. The Medication Administration policy was provided by the DON (Director of Nursing) on 5/19/22 at 9:05 a.m. It read, Medication will be administered as prescribed. On 5/25/22 at 10:58 a.m , the Director of Nursing provided the Pain Management and Assessment Policy, last reviewed on 1/18/2022, which read .It is the purpose of this policy is to provide guidance to the clinical staff to support the intent .that based on the comprehensive assessment of the resident, the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. There is no objective test that can measure pain. The clinician must accept the resident's report of pain. Clinical observations clarify information from the resident. Site of discomfort may direct the nurse to specific types of pain- relief measures . 3.1-37(a)

Based on interview and record review, the facility failed to apply a [CONDITION(S)] (bilevel positive airway pressure) machine as ordered by the physician. This resulted in the respiratory distress and hospitalization of 1 of 3 residents reviewed for respiratory care (Resident B). Findings include: The clinical record for Resident B was reviewed on 10/27/21 at 11:45 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed 7/31/12, indicated that he needed extensive assistance with personal hygiene and did not exhibit episodes of rejection of care. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised on 5/11/21, indicated he had asthma related to chronic obstructive pulmonary disease with a goal to remain free of complication of asthma. The interventions included, but were not limited to, monitor vital signs, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicated [CONDITION(S)] (low oxygen in blood). A care plan, revised on 7/26/21, indicated that he was to receive [CONDITION(S)] therapy due to his obstructive sleep apnea and acute respiratory failure. The goal was for him to adhere to the [CONDITION(S)] regimen with interventions including, but not limited to, encourage resident's uses of [CONDITION(S)]. The October 2021 TAR (Treatment Administration Record) indicated that his [CONDITION(S)] machine had been used nightly except for on 10/16/21, when he had refused it, and 10/23/21, when there were no initials indicating it has been applied or refused. A nurses note, dated 10/24/21 at 5:48 a.m., indicated the LPN (Licensed Practical Nurse) 2 had been called to the room due to him being short of breath. She applied his [CONDITION(S)] machine. His oxygen saturation was 84%. Oxygen was placed on resident and his oxygen saturations increased to 90% and stayed between 90% and 91%. She had notified convergence (physician's service). A Convergence narrative note, dated 10/24/21 at 5:55 a.m., indicated Resident B was having dyspnea (shortness of breath). His oxygen saturation was 84%. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Even when the [CONDITION(S)] was applied the oxygen saturation was not above 90 so oxygen needed to be added. A stat (right away) chest x-ray and labs were ordered. A nurses note, dated 10/24/21 at 7:30 a.m., indicated he was having shortness of breath and was anxious. He had thick white secretions from his mouth ad his breathing was labored with abdominal distension. He was receiving 5 liters of oxygen and his oxygen saturation was 98%. He was being sent the emergency room for treatment. A Convergence note, written by PA (physician's assistant) 8 at 10/24/21 at 10:54 a.m., read In ER [sic] pending dispo[sic], may be admitted due to acute hypoxic respiratory failure. He needs to wear his [CONDITION(S)] at nighttime. He is at high risk for acute decompensation without the use of [CONDITION(S)] The acute care hospital history and physical, dated 10/24/21, was obtained on 10/28/21 at 9:00 a.m. It indicates that he was taken to the acute care hospital via ambulance on 10/24/21 due to extreme shortness of breath, abdominal distension, and increased oral secretion. The assessment and plan included problem 1 of acute hypoxic respiratory failure. He had arrived at the acute care hospital with dyspnea. A chest x-ray done in the emergency department showed bibasilar atelectasis (partial or complete collapse of the lung) and possible early infiltrates accentuated by low lung volumes. During an interview on 10/27/21 at 3:22 p.m., CNA (Certified Nursing Assistant) 6 indicated that Resident B could not really use his hands or arms. He uses a [CONDITION(S)] at night and he would be unable to place the [CONDITION(S)] mask on himself or remove it. During an interview on 10/28/21 at 8:42 a.m., CNA 4 indicated that she did not feel that he could completely remove the [CONDITION(S)] mask without assistance. During an interview on 10/28/21 at 9:46 a.m., the DNS (Director of Nursing Services) and the RDCO (Regional Director of Clinical Operations) indicated that the nurses were responsible for putting on the [CONDITION(S)] masks. During an interview on 10/28/21 at 1:25 p.m., LPN 2 indicated that she was the nurse who had gone to assist Resident B on 10/24/21 at 5:48 a.m. She had been the only licensed nurse in the facility for the night shift of 10/23/21 through the morning of 10/24/21. She had worked on the other unit that night but had informed the staff of his unit that if they needed any assistance, they could call her. She had been to his room to care for him prior to when the staff on the unit called her due to him having shortness of breath. When she entered the room his [CONDITION(S)] was not on, and the mask was not anywhere in his bed. She put it on him when she entered the room. She had a hard time getting his oxygen saturation to come up from 84% so she had also applied oxygen to assist him. His oxygen saturations came up to 90% with the use of the oxygen. She had stayed with him until he was stable and then called convergence to notify them of the change in his condition. She was not normally assigned to his unit, however had cared for him on occasions. He normally wore a his [CONDITION(S)] mask at night. She had seen him attempt to remove his [CONDITION(S)] by breaking the seal the mask forms by opening his mouth or turning his head from side to side, however, did not believe he could not remove the mask completely from his face due to his overall physical condition. When she cared for him, as his assigned nurse, she would assure his [CONDITION(S)] mask was on when she started her shift. At times the evening shift had already applied it and sometimes she would apply it. The order for the [CONDITION(S)] would come up on the computer screen telling the nurse to apply it on the night shift. There were usually 2 nurses for the night shift, however she was the only nurse that night, which was unusual. During an interview on 10/28/21 at 3:30 p.m., the Executive Director indicated the facility census on 10/23/21 was 126 residents in house. On 10/27/21 at 4:55 p.m., the RDCO provided the [CONDITION(S)]/ [CONDITION(S)] policy, effective 9/10/21, which read .Purpose: 1. A method for decreasing CO2 [[MEDICATION(S)]] sleep apnea 2. To prevent or correct atelectasis 3. to improve oxygenation 4. to assist in reducing pulmonary [CONDITION(S)]. Procedure: 1. Obtain the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Verify the correct order of the [CONDITION(S)]/ [CONDITION(S)] settings. 3. Check the resident identity. 4. Identify yourself and explain the procedure to the resident .6. Connect [CONDITION(S)]/ [CONDITION(S)] device delivery tubing to pressure generator .8. Set [CONDITION(S)]/ [CONDITION(S)] setting per order Evaluation .2. monitor pulse oximetry as ordered .4. Monitor resident's ability to manipulate device and face mask. Recording and Reporting: 1. Respiratory assessment findings. 2. [CONDITION(S)]/ [CONDITION(S)] settings. 3. Pulse oximetry. 4. Client Response. 5. Change in physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Report to physician: sudden changes in client's respiratory status and worsening pulse oximetry value . This Federal tag relates to Complaint IN 5813 3.1-47(a)(6)

Based on interview and record review, the facility failed to provide treatment and services for an indwelling urinary catheter to prevent the development of a urinary tract infection [MEDICAL CONDITIONS] for 1 of 3 residents reviewed for indwelling urinary catheters. (Resident C) Findings include: The clinical record for Resident C was reviewed on 9/4/19 at 3:23 p.m. The [DIAGNOSES REDACTED]. Resident C was admitted to the facility on [DATE]. An indwelling catheter care plan, revised 7/31/18, indicated the following, .Interventions .Monitor and document intake and output as per facility policy .Monitor for s/sx (signs and symptoms) of discomfort on urination and frequency A Quarterly Minimum Data Set (MDS) assessment, dated 2/18/19, did not mark the use of an indwelling urinary catheter for Resident C. A physician order, discontinued 2/8/19, noted to perform indwelling urinary catheter care by cleansing with soap and water every shift. Resident was hospitalized from [DATE] to 2/11/19. Urinary catheter care orders were not implemented upon his return to the facility on [DATE]. The progress notes, dated 3/18/19, indicated Resident C was sent out to the hospital due to an elevated temperature. He returned to the facility on [DATE]. The hospital records, dated 3/18/19, noted Resident C was admitted to the hospital related [MEDICAL CONDITION] (a life-threatening complication of an infection) due to a UTI. He was noted with an indwelling catheter with purulent (consisting of, containing, or discharging pus) drainage noted in the urinary catheter. There were no urinary catheter care physician orders [REDACTED]. The progress notes do not indicate Resident C having an indwelling urinary catheter or care being provided for such from 3/22/19 to 4/22/19. A set of care plans for Resident C, revised 4/1/19, did not have any focus pertaining to Resident C having an indwelling urinary catheter. A physician progress notes [REDACTED].patient with fever today. remainder of vitals stable. no specific complaints but some confusion .history of frequent UTI's [MEDICAL CONDITION] .Orders: .vitals q4 (every 4 hours) x 24 hours The electronic medication record (EMAR), dated (MONTH) of 2019, noted a set of vital signs for Resident C on 4/21/19 at 8:00 p.m., 4/22/19 at 12:00 a.m., and vital signs not completed for 4/22/19 at 4:00 a.m. A progress note, dated 4/22/19 at 7:26 a.m., indicated the following, .Writer went in to administer morning medication, upon assessment writer noted patient unable to communicate, vitals 88/52 (blood pressure) p (sic) 90% on room air, temperature 98.3 tympanic, p (pulse) 75, resident noted to have wheezing noted to bilateral lung sounds. On call paged new order to send resident to ER (emergency room ) for evaluation and treatment Hospital records, dated 4/22/19, indicated Resident C was admitted with [MEDICAL CONDITION] related to urosepsis (condition where a urinary tract infection spreads from the urinary tract to the bloodstream, causing a systemic infection that circulates through the body through the bloodstream. This type of blood infection is referred to [MEDICAL CONDITION]). He was discharged on [DATE] with a discharge [DIAGNOSES REDACTED]. An interview conducted with the Director of Nursing (DON), 9/6/19 at 4:00 p.m., she indicated an indwelling urinary catheter should be changed per physician orders. There should have been a care plan related to Resident C's use of an indwelling urinary catheter. The policy states for catheter care to be performed twice daily. A policy titled Catheter Care, revised 5/1/17, was provided by the DON on 9/6/19 at 3:35 p.m. The policy indicated the following, .Policy .It is the policy of this facility to provide resident care that meets the psychosocial, physical and emotional needs and concerns of the residents .CAUTI (Catheter Associated Urinary Tract Infections) is the most common adverse event associated with indwelling urinary catheters .Procedure .I. Catheter Care at the bedside is performed to promote cleanliness and dignity and is performed by the nursing staff twice daily for residents who have an indwelling catheter .a. Chronic indwelling catheters should not be changed routinely but replaced only for reasons of obstructions or other malfunction or prior to initiating antimicrobial treatments for symptomatic urinary infections This Federal tag relates to Complaint IN 193. 3.1-41(a)(2)

Based on interview and record review, the facility failed to provide treatment and services for a indwelling urinary catheter to prevent the development of a urinary tract infection [MEDICAL CONDITIONS] that resulted in a hospitalization for 1 of 3 residents reviewed for indwelling urinary catheters. (Resident K) Findings include: The clinical record for Resident K was reviewed on 12/6/17 at 4:00 p.m. The [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 10/7/17, showed a Brief Interview for Mental Status score was not completed due to resident being rarely understood. The Quarterly MDS also indicated Resident K was an extensive assist with two staff person for personal hygiene and physical help with two staff person for bathing. An interview conducted with Certified Nursing Assistant 9, on 12/6/17 at 11:36 a.m., indicated Resident K's penis was not circumcised. She worked with Resident K approximately a week ago and there was some drainage to the head of his penis and it was swollen. It appeared the staff were not cleaning his foreskin properly by pulling it back to clean it. Resident K did complain of pain during perineal care. He had an indwelling urinary catheter as well. An interview conducted with Resident Representative 8, on 12/6/17 at 12:20 p.m., indicated Resident K was sent to the hospital on [DATE] due to him running a temperature. The hospital staff was unsure when the last time his indwelling urinary catheter was changed or the drainage bag was emptied because there was urine backing up into his bladder. The indwelling catheter appeared to have not been changed recently and he [MEDICAL CONDITION] related to his urine. A physician order, dated 9/13/17, indicated the following, .Change 16fr (sic) (size of catheter) coude catheter monthly .per Urology of Indiana The order had a start date of 9/20/17 noted. The electronic treatment administration record (ETAR) for November, 2017 indicated the order to change the coude catheter monthly was not signed off as being administered on 11/20/17. The ETAR stated the following, .9 .9 = Other/See Nurses Notes The progress notes were reviewed for 11/20/17 with no indication as to why the coude catheter was not changed. A care plan related to an indwelling urinary catheter for Resident K, revised 1/19/17, indicated the following, .has Foley Catheter: related to urinary obstruction .Change drainage bag per policy There was no physician order to change the indwelling catheter drainage bag for Resident K. There were no indications there was a physician order to empty and record the amount of urine at a specific time or no documentation related to urine output from the indwelling urinary catheter. A progress note, dated 11/22/17 at 11:12 a.m., indicated the following, .Call made to urology of Indiana for appointment for resident related to foreskin. Message left to make appointment office was closed. Will continue to follow up when office is open . The progress note was electronically signed by Assistant Director of Nursing (ADON). An interview with the ADON, on 12/6/17 at 3:52 p.m., indicated indwelling urinary catheters are changed monthly or per Urologist recommendations. He indicated he didn't observe Resident K's penis on 11/22/17 to determine the need for calling the Urologist. A progress note, dated 11/22/17 at 9:00 p.m., indicated the following, .Change 16fr coude catheter monthly, one time a day every 1 month(s) starting on the 20th for 1 day(s) for cath change per Urology of Indiana Did not get around to changing the cath (sic) A Hospital document, dated 11/22/17, indicated the following, .Physical Exam .Smells of urine .[MEDICAL CONDITION] Comments: Foley catheter site with significant purulent drainage .ED (Emergency Department) Notes .Clinical Impression .Urinary tract infection [MEDICAL CONDITION] associated with indwelling urethral catheter,[MEDICAL CONDITION] secondary to UTI .ED Notes by (name of RN) .This RN looked at peri area and noted penis was red, inflamed, and had pus coming from opening. Upon removal of old foley (sic), large amount of pus exited penis as well as foul smelling cloudy urine Another Hospital document, dated 11/22/17, indicated the following, .History of Present Illness .(name of Resident K) is a pleasant 70 y.o. (year old) male with known PMH (medical history) of CP [MEDICAL CONDITIONS] disorder that presents to (name of Hospital) ED (emergency department) with chief complaint of AMS (altered mental status). Pt (patient) presents to ED from ECF (extended care facility) where he was found to have decreased mentation .Pt (patient) currently unresponsive. Pt (patient) was found in ED to have obstructed foley (sic). Foley was changed in ED with > (greater than) 1L (one liter) purulent urine in foley bag A policy titled Catheter Care, revised 5/1/17, was provided by Corporate Nurse 12 on 12/6/17 at 4:18 p.m. The policy indicated the following, .Policy .It is the policy of this facility to provide resident care that meets the psychosocial, physical and emotional needs and concerns of the residents .CAUTI (Catheter Associated Urinary Tract Infections) is the most common adverse event associated with indwelling urinary catheters .Procedure .I. Catheter Care at the bedside is performed to promote cleanliness and dignity and is performed by the nursing staff twice daily for residents who have an indwelling catheter .a. Chronic indwelling catheters should not be changed routinely but replaced only for reasons of obstructions or other malfunction or prior to initiating antimicrobial treatments for symptomatic urinary infections This federal tag relates to Complaint IN 441. 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure the monitoring of laboratory results in conjunction with the use of an anticoagulation therapy for 1 of 3 residents reviewed for medications with laboratory monitoring, physician notification and intervention. This deficient practice resulted in profuse bleeding and the resident transported to a local area hospital for intervention to reverse the effects of the anticoagulant. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 08-27-12 at 1:10 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the resident's current plan of care dated 07-28-12 and updated on 08-09-12, indicated "Anticoagulation - Risk for abnormal bleeding due to anticoagulant therapy." Interventions to this plan of care included "PT/INR ([MEDICATION NAME]/International Normalized Ratio) as ordered, report to MD (Medical Doctor) as indicated. Monitor for cloudy dark urine or black tarry stool, abdominal or lower back pain, bleeding gums with teeth brushing, increased bruising or sever <sic> headache. Report abnormal side effects to MD. Medications as ordered." The resident returned to the facility after a hospitalization at a local area hospital for wound therapy. Upon return, the resident had physician orders [REDACTED]. The resident had physician orders [REDACTED]. The resident's laboratory results dated [DATE] (Thursday) indicated the INR was 2.47. The physician order [REDACTED].> (greater than) 2.0." The resident had blood work drawn on 08-13-12 (Monday) and the result of the INR was 2.58. The nurses notes lacked documentation the physician had been notified. A subsequent laboratory result dated 08-16-12 (Thursday) indicated the resident's INR result was 4.42 (normal range .9 - 1.1). Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During interview on 08-28-12 at 9:50 a.m. the nurse practitioner indicated, "The aide came to get me (in reference to Friday 08-17-12). We turned (resident) to the right side and I lifted (resident) bottom while the aide held (resident). There was so much blood I couldn't see a thing. It (in reference to the bleeding) was coming from around the catheter. I couldn't even find where it was bleeding to apply pressure. (Resident) was sent out 911." During interview on 08-28-12 at 10:00 a.m., CNA employee #6 indicated "I noticed blood in the urine bag on Monday and as the week went on it got heavier and heavier. On that day, the first thing in the morning it was heavily red. Right before lunch I went to change (resident) and the pad was saturated (in reference to blood). It looked like the bleeding was coming from around the catheter and there was blood on the leg strap - it was bloody as well. (Name of nurse practitioner) was sitting at the desk at the nurses station so I asked her to come and take a look." The ambulance report, dated 08-17-12, indicated "Urethral bleeding - anatomic location genitalia. Taken to (Name of local area hospital) for urethral bleed for unknown amount of time. Transported due to urethral bleed. Referring nurse didn't have a proximate onset of time when bleeding began. Nurse stated they did take (resident) foley catheter out earlier. Not actively bleeding during transport." Review of the emergency room Physician Report, dated 08-17-12, indicated "chief complaint - vaginal bleeding or blood in the urine. The INR is elevated at 5.37." Review of a hospital "Consultation" report, dated 08-17-12, indicated, "The patient was brought to the ER (emergency room ) for gross hematuria which has been confirmed with catheter placement. The CT scan reveals a left internal double-J stent, which is in normal position and looks very similar to CT scan from 2008. Impression and Plan: Hematuria likely secondary to stent and urinary tract infection. The patient currently is on aspirin and [MEDICATION NAME] (an anticoagulant), which is exacerbating or hematuria. Current INR is 5.37." Review of the hospital "History and Physical," dated 08-17-12 indicated "Assessment" Supratherapeutic INR. We will hold [MEDICATION NAME] for right now. (Resident) is on [MEDICATION NAME] for what appears to be upper extremity [MEDICAL CONDITION]." The hospital emergency room Treatment Record, dated 08-17-12 indicated the resident received 5 mg of Vitamin K to reverse the effects of the anticoagulant. This Federal tag relates to Complaint IN 897. 3.1-48(a)(3)

Based on observation, record review and interview, the facility failed to ensure services to a resident with surgical wounds, in that when a resident had specific physician orders the nursing staff failed to implement the physician orders which resulted in a deterioration of the surgical area for 1 of 3 residents reviewed for wounds and the use of a wound V.A.C. (vascular assisted closure) in a sample of 7. (Resident "B"). Findings include: 1. The record for Resident "B" was reviewed on 08-15-12 at 9:20 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record also indicated the resident received care at a local wound care clinic. The resident's current plan of care, dated 06-05-12, indicated the resident had "alteration in skin integrity - surgical wounds to left ischium, right ischium and sacral areas." Interventions to the plan of care included "Report any drainage to MD (Medical Doctor) or increase s/s (signs and symptoms) of infection, treatment as ordered, NPWT (negative pressure wound therapy - a device which removed infectious material or other fluids from the wound)." Physician orders from the wound care clinic, dated 07-10-12, instructed the nursing staff to clean the resident's wounds with saline and apply Santyl (a medication to aid in the debridement of a wound) and continue with the wound V.A.C. The record indicated the resident was sent to a local area hospital on 07-31-12 due to a change in mental status. Review of the emergency room Report, dated 07-31-12, indicated the resident had "severe decubitus ulcer on (resident) back. Forensic nurse was called to evaluate the patient's wound care, decubitus condition. Pictures were taken and Adult Protective Agency was consulted. The hospital Nursing Assessment, dated 07-31-12, indicated "buttocks/coccyx wound vac disconnected when left ECF (extended care facility), dressing to coccyx not fully intact, smell noted - serous and bloody drainage noted at different areas of wound - forensic (name of forensic nurse) took pics. (pictures). Forensic nurse notified (name of physician) of pt's (patient's) wound issues and concern over smell of coccyx decub. (decubitus)." Interview on 08-13-12 at 9:00 a.m., the hospital forensic nurse indicated "there was a clear adhesive dressing all over (resident) buttocks and redness everywhere. The pictures show there was slimy and icky drainage under the dressing and the secretions had a foul odor." The hospital record indicated the resident received an [MEDICATION NAME] mg (milligrams) IV (intravenous) while at the hospital. The hospital record indicated the resident returned to the facility with a [DIAGNOSES REDACTED]. The resident had physician orders to continue with an oral [MEDICATION NAME] mg for 10 additional days due to the urinary tract infection. Review of the Facility "Weekly Non Pressure Skin Condition Report," on 08-13-12 at 12:00 p.m. and dated 05-30-12, indicated the following measurements: 1.) left ischium 5.6 cm by 2.2 cm by 0.1 cm. 2.) right ischium 4.0 cm (centimeters) by 1.0 cm by 3,6 cm 3.) sacrum/coccyx 9.5 cm by 2.5 cm by 1.5 cm. The 06-27-12 measurements noted on the "Weekly Non Pressure Skin Condition Report," indicated: 1.) left ischium 3.5 cm by 2.7 cm by 0.1 cm. 2.) right ischium 6.7 cm by 4.0 cm by 3.0 cm. 3.) sacrum/coccyx 3.8 cm by 3.0 cm by 0.1 cm The 07-25-12 "Weekly Non Pressure Skin Condition Report indicated the following measurements in regard to the resident's surgical wounds: 1.) left ischium 3.0 cm (centimeters) by 2.7 by 0.1 cm. 2.) right ischium 4.5 cm by 3.0 cm by 2.2 cm. 3.) sacrum/coccyx 3.0 cm by 3.0 cm by 0.1 cm. Further review of the facility record indicated the physician at the wound care clinic instructed the nursing staff on 08-02-12 to "Hold the Wound V.A.C. (vascular assisted closure) for one week." Resumption of care was noted on the treatment administration record as "08-09-12." During interview on 08-15-12 at 2:00 p.m., Licensed Nurse employee #4 indicated "at times the doctor will give the resident a 'vacation' from wound V.A.C. just like they do with some medications." The record lacked documentation the resident received the needed therapy/treatment for [REDACTED]. Review of the Facility "Non-Pressure Ulcer Weekly Log," on 08-13-12 at 12:00 p.m., and dated 08-10-12, included the following measurements in regard to the resident's surgical wounds: 1.) left ischium 2.5 cm (centimeters) by 2.0 by 0.1 cm. 2.) right ischium 5.0 cm by 3.0 cm by 0.9 cm. 3.) sacrum/coccyx 4.0 cm by 3.7 cm by 0.3 cm. The record indicated the resident was diagnosed with [REDACTED]. Prior to debridement the wounds measured as follows: 1.) left ischium 4.0 cm by 2.0 cm by 0.2 cm. 2.) right ischium 5.5 cm by 3.7 cm. by 0.4 cm. 3.) sacrum/coccyx 3.8 cm by 2.5 cm by 0.3 cm. The record indicated that the resident showed improvement in the surgical wounds until which time the nursing staff failed to re-institute the physician orders of wound V.A.C. therapy on 08-09-12. Observation on 08-15-12 at 3:05 p.m., with Licensed Nurse employee #4 (the Facility Wound Care Nurse) in attendance the resident was turned to the right side to view the wounds to bilateral ischium's and sacrum. Three thick white pads had been placed and taped to cover the resident's wounds. Licensed Nurse employee #4 removed the dressings and remarked that the wounds have continued to bleed despite the physician intervention of silver [MEDICATION NAME]. The Licensed Nurse indicated she could not perform the dressing change as ordered but would need to contact the physician due to the continued bleeding from all three wounds. During interview on 08-16-12 at 9:40 a.m., Licensed Nurse employee #4 verified the resident did not receive the resumption of treatment which included Wound V.A.C. therapy as ordered on 08-09-12. In addition, review of the wound care clinic "physician orders/patient instructions," dated 05-08-12, instructed the nursing staff of a change to the treatment. The original physician orders, dated 04-17-12, instructed the nursing staff to clean the wounds with acetic acid prior to application of the dressings and wound V.A.C. The 05-08-12 physician orders now instructed the nursing staff to "clean with saline, apply Santyl and continue with the wound V.A.C." Review of the July 2012 and August 2012 Treatment Administration Records continued to instruct the nursing staff to use "acetic acid" to clean the wounds prior to application of dressings and the wound V.A.C. Interview on 08-15-12 at 3:00 p.m., the Licensed Nurse employee #4 (the facility Wound Care Nurse) indicated when the resident returned from the wound care physician visit on 08-14-12, the physician orders for wound care included instructions to "clean with saline - (apply) Santyl and continue the wound V.A.C. on Monday - Wednesday - Friday," had not been "taken off or transcribed" and therefore the "Santyl had not been ordered from the pharmacy and the treatment had not been started on the day the resident returned" from the physician visit. The Licensed Nurse indicated she would need to call the physician and inform him the order had not been completed and would need to request a new order to "hold the Santyl until it comes from the pharmacy." Review of the facility policy on 08-16-12 at 8:30 a.m., provided by the Director of Nurses, titled "Negative Pressure Wound Therapy," dated 04-28-10, indicated the following: "RATIONALE (bold type) Residents are selected per criteria for the provision of Negative Pressure Wound Therapy (NPWT) which removes infectious material or other fluids from the wound under the influence of continuous and/or intermittent sub-atmospheric pressure to promote wound healing. NPWT may be implemented on chronic wounds that have failed to proceed through normal stages of healing and have filed with standard care for treatment." "15.) Clean wound with solution as ordered by physician." This Federal tag relates to IN 740 and IN 064. 3.1-37(a)

Based observation, record review and interview, the facility failed to ensure the safety and supervision of a dependent resident, in that a resident who was assessed as dependent on staff and bedridden, was positioned onto the side of the bed and then left unattended which resulted in the resident falling to the floor and sustaining multiple fractures. (Resident "B"). In addition, the facility failed to ensure the supervision of a visually impaired resident during meal times, and also failed to supervise and implement safety strategies for a resident who had a recent intracranial bleed, with subsequent vision impairment. (Residents "A" and "C"). This deficient practice affected 3 of 6 sampled residents. (Resident's "A", "B" and "C"). Findings include: 1.) The record for Resident "B" was reviewed on 12-27-11 at 1:50 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set summary dated 11-01-11, indicated the resident required total assistance with transfers and bed mobility and the assistance of two staff members. The Care Area Assessment, dated 11-01-11, indicated the resident was dependent for all transfers and mobility secondary to multiple sclerosis. The resident's plan of care, dated 10-26-11, indicated the resident was "at risk for falls related to multiple sclerosis, decreased mobility, bilateral foot contractures, weakness and inability to ambulate." Review of the "Physical Therapy Evaluation," dated 10-26-11, indicated the resident had "B (circled - bilateral)" foot contractures, confusion, "coordination impairment with poor safty <sic> awareness secondary to bedridden and cognition with maximum assistance with bed mobility." The Resident Progress note, dated 12-14-11, indicated the following incident with injury to the resident. "2:15 p.m. - Staff notified nurse that drsg. (dressing) to patient's bottom was soiled with urine and patient care was needed. Staff stuck her head out of the patient's room to notify nurse she was ready for the dsrg. to be changed and that the patient was laying flat in <sic> her stomach with her bottom up. When staff turned around, she screamed 'Oh my God, she's on the floor.' Nurses ran to the room. When entering the room found resident on the floor between bed and wall with pillow under her head. Bed was rolled away from pt. (patient) for assessment. Pt was laying on her right side. Able to verbalize no pain. Pt. was crying, stated 'I'm sorry I'm so sorry, please don't be mad at me.' Reassured pt. everything was okay nobody is mad. She stated, 'Is the girl mad at me? Tell her I'm sorry. Please don't be mad.' While staying by pt. side, this writer completed assessment and noted her left hip had an abnormal body alignment. Second nurse left room to obtain dynamap (a device to measure the resident's blood pressure and pulse), and assigned nurse <sic>. When nurses returned to room obtained vitals (vital signs). Log rolled pt. onto a sheet, made as comfortable as possible." A subsequent nurses notation on 12-14-11 at 2:45 p.m. indicated the following:"Was called to res. room at 2:20 p.m. by nursing staff. Found res. on floor. Res. a & o (alert and oriented) times 3. Neuro (neurological checks) WNL (within normal limits) Res. stated 'I shifted my wt. (weight) and slid out of the bed. I'm sorry.' Res. c/o (complained of) left hip and right shoulder pain. Left leg externally rotated no discoloration or open areas noted. Res. cried out in pain to touch. Made comfortable on floor r/t (related to) resident request to not be moved. Res. state she hit her head on the trash can next to bedside. Examined head. No note <sic> s/s (signs of symptoms) of injury/discoloration." A nurses progress note dated 12-15-11 at 10:00 a.m. indicated the nurse "call <sic> hospital to obain <sic> status of res. Nurse reported "B" (circled - bilateral) pelvis fx. (fracture) with multiple fx." During interview on 12-27-11 at 2:20 p.m., Licensed Practical Nurse Employee #3 indicated, "I was at the desk at the nurses station, charting, when the aide (in reference to Certified Nurses Aide employee #11) asked if someone could do a dressing change. The nurse assigned to (resident) was not available. I checked the orders and the I heard her (CNA employee #11) scream 'Oh my God she's on the floor.' (Name of Licensed Practical Nurse employee #6) was also at the nurses station. We went into the room. she (in reference to the resident) was on the floor under the register. I had to let the bed out all the way because I couldn't get to her, the bed was really close to the wall - she fell out the side by the windows. The height of the bed was about 3 feet from the floor. The top siderails were up and she was laying on the right side on the floor. Her left hip was in funny alignment and her leg was across her body. I didn't move her. We tilted her a little bit and put a sheet under her. When she slid out of bed her pillow went with her and it was partially under her head." During interview on 12-28-11 at 9:30 a.m., Licensed Practical Nurse employee #6 indicated "I was at the desk and so was (name of Licensed Practical Nurse employee #3) when the CNA came to the door and said she needed a nurse to change the dressing. The next thing she yelled 'Oh my God, she's on the floor.' (Name of resident) fell off the bed. I went to the room, and I couldn't believe the little space between the wall and the bed and she was between the little space on the floor, and her legs were in a weird position." The nurse demonstrated a space between the bed and the wall of approximately 1 foot. During interview on 12-29-11 at 9:10 a.m., Licensed Practical Nurse employee #5 (wound care nurse) indicated "(Name of resident) is flaccid on the left side. When I did the dressing change I usually placed her on the right side so she couldn't move. It was safer. If she was laying in bed on her back, it looked like her legs went straight down, until her knees where they seemed to go out away from the center and then her ankles were contracted." During interview on 12-29-11 at 9:20 a.m. Licensed Practical Nurse employee #10 indicated, "I changed her urostomy that day and she was saturated with urine. I told the CNA (employee #11) she need to be cleaned up. I know if she (in reference to the resident) was holding onto the side rail she couldn't do it for very long because she could spontaneously let go and not realize it. She might be able to reposition her shoulders but not her legs. When she was on the floor I put another pillow under her head. There was already a sheet under her when I got to the room and I put a sheet over her because she was exposed. When I first went into the room I thought she was dead." Interview on 12-29-11 at 10:10 a.m. with the Physical Therapist employee #8, who was identified by the Director of Nursing services as the therapist who worked with the resident, indicated the following: "She couldn't be positioned on her side safely. The only thing she could really move is her neck. She was usually positioned on her back." During interview on 12-27-11 at 10:00 a.m., the Executive Director indicated she spoke with the resident who indicated to her that the CNA positioned her too close to the edge of the bed, "so close that her nose touched the side rail. She left the resident unattended and the resident fell from the bed onto the floor." During an observation on 12-27-11 at 3:00 p.m., with the Executive Director in attendance, the resident's room, bed placement and the register were observed. The register spanned the entire length of the wall. Review of the Hospital "Radiology Result," dated 12-14-11 indicated, "fell out of bed at rehabilitation center." "Impression: 1. Acute nondisplaced obliquely oriented fracture through the proximal diaphysis of the left femur, 2. Acute fracture through the left superior pubic ramus. An acute fracture of the right acetabulum and probable acute nondisplaced fracture of the right inferior pubic ramus, 3. Acute comminuted fracture through the proximal diaphysis of the right femur, 4. Acute nondisplaced fracture through the distal diaphysis of the left femur, 5. Age interminate buckle fracture through the distal right femoral metaphysis." Review of facility policy on 12-28-11 at 9:50 a.m., titled "Care of a Patient with Possible Injury", and dated 04-28-11, indicated the following:"Rationale: A patient involved in an incident where injury can be reasonable suspected is assessed and emergency care given as needed.""Procedure: 1.) Call for assistance. a.) Do not move the patients. b.) Do not place anything under the head. 2.) The record for Resident "A" was reviewed on 12-27-11 at 11:50 a.m. [DIAGNOSES REDACTED]. The record also indicated the resident was blind. These [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set assessment, dated 11-16-11 indicated the resident required set up and supervision of one staff member for eating. The record indicated the resident received a regular no added salt diet and ate all three meals in the assist dining room. Review of the resident's current plan of care, dated 11-15-11, indicated "feed resident meals." A "Medical Nutrition Therapy Review" notation, dated 08-24-11 indicated the resident "must be fed." On 12-28-11 at 1:10 p.m., the resident was observed sitting up in bed, eating the noon meal without supervision. During an interview, a CNA indicated the resident didn't want to get out of bed "all day so we gave (resident) the tray in room." 3.) The record for Resident "C" was reviewed on 12-28-11 at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. During an interview on 12-28-11 at 11:00 a.m., the resident indicated recent hospitalization and (pointing to the left side of head), craniotomy. During the interview, the resident struggled to speak, but the resident was able to indicate the lack of peripheral vision with the right eye. The resident continued to explain, the peripheral vision with the left eye remained intact, but had increased difficulty with the right eye. The resident indicated he left the blinds to the window in his room, "up," because he had hoped something, a movement, might "catch" his eye, and the peripheral vision would return. Review of the resident progress notes, dated 12-12-12 at 4:00 p.m., indicated "Res. (resident) states unable to see out of the 'sides of eyes together' when focusing on an object. Able to see peripherally when one eye covered." Although the record contained information in the progress notes related to the resident's lack of peripheral vision, the facility failed to provide supervision or assistive devices to aide the resident or prevent the potential of an accident. This Federal deficiency relates to Complaint IN 278. 3.1-45(a)(2)

A. Based on record review and interview, the facility failed to thoroughly investigate an allegation of sexual abuse by 1 resident and ensure residents were protected from future abuse for 1 of 3 allegations of abuse reviewed. This deficient practice resulted in immediate jeopardy. Resident B. The Immediate Jeopardy was identified on 4/06/11 and began on 3/24/11. The Administrator, Director of Social Services, and the District Director of Clinical Operations were notified of the immediate jeopardy on 4/06/11. The Immediate Jeopardy was removed on 4/10/11, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was continuing inservicing, educating, and monitoring of employees for knowledge and compliance with building and visitation policies and policies and procedures related to investigating and reporting injuries of unknown injury and allegations of abuse. B. Based on record review and interview, the facility failed to re-investigate and report to the state agencies a fracture of unknown origin for 1 of 3 residents reviewed for injuries of unknown origin in a sample of 5. Resident C. Findings include: A 1. The record of Resident B was reviewed on 4/06/11 at 11:00 a.m. [DIAGNOSES REDACTED]. Resident B's admission Minimum Data Set (M.D.S.) assessment, dated 2/24/2011, indicated she did not experience hallucinations or [MEDICAL CONDITION]. Resident B's record did not contain any documentation of Resident B having a guardian or an appointed power of attorney. A Recapitulation of physician's orders [REDACTED]." A "Facility Incident Reporting Form" provided by the Director of Nursing Services (D.N.S.) on 4/06/11 at 10:00 a.m., and completed by him indicated: "Incident Date: 3/24/2011... Resident Name: (Resident B)... Brief Description of Incident: Resident reported to the Unit manager and the sosial (sic) service Director, that allegation of rape. (sic) when asked when it happened, resident stated it happened last night. resident unable to describe what happened when asked. asked if resident knew who did it, he (sic) said his name was "rock" and he does not work here. asked if she could describe him, all she said was, he is dark skin and has good grade hair. resident she (sic) gas already told her husband and her daughter and that they will be picking her up after work. resident continue to repeat the same statement over and over. she was unable to give any further information and description when asked. when questioned if she screemed (sic) she said yes, staff came in but the man has already left." The "Facility Incident Reporting Form" quoted above did not document the date or time the report was completed, or the time Resident B made the allegation of rape. A Nursing Progress Note, dated 3/25/11 at 11:00 a.m., indicated "Reported to this writer et (and) Social Service Director that resident made an allegation of rape-Spoke to resident-stated 'I was raped'...asked if she knew when it happened stated 'Yes it happened last night'...." A facility "Resident Event Report Worksheet" received from the D.N.S. on 4/07/11 at 5:00 p.m., indicated the Administrator had been advised of Resident B's allegation of rape on 3/25/11 at 11:30 a.m. During an interview on 4/08/11 at 9:55 a.m. the Administrator confirmed he had not participated in any way in the investigation of Resident B's allegation of rape. Resident B was interviewed on 4/07/11 at 4:00 p.m., in private in her room. She was pleasant and cooperative. When asked about her allegation of rape, she refused to discuss it and ended the interview. During an interview with the Social Services Worker on 4/07/11 at 5:00 p.m., with the D.N.S. and Administrator present she provided copies of two resident interviews, dated 3/25/11, she indicated she did following Resident B's allegation of rape. The D.N.S. and Administrator had no explanation for why this documentation was not included in documentation provided earlier. A Social Services Progress Note, dated 3/25/11 at 1:30 p.m., indicated "This writer (symbol for "and") UM (unit manager) went to speak to (name of resident) to follow up with investigation. This writer asked (name of resident) if she heard anything last night R/T (related to) neighbors on hall. (Name of resident) stated No (symbol for "and") that she slept all night heard nothing." A Social Services Progress Note, dated 3/25/11 at 1:35 p.m., indicated "This writer went to speak with (name of resident) in regards to investigation. (Name of resident) stated he did not hear anything last noc (night) it was pretty quiet..." During interviews on 4/06/2011 at 10:30 a.m. and again at 4:30 p.m., the D.N.S. indicated he had not interviewed any residents or staff following Resident B's allegation of rape, and had not done any other investigation or instituted any interventions to assure resident safety. An Immediate Jeopardy was identified on 4/06/11 at 4:30 p.m. The Immediate Jeopardy began on 3/24/11 when a resident alleges she was sexually assaulted. The Administrator, Director of Social Services, and the District Director of Clinical Operations were notified of the immediate jeopardy related to the facility's failure to protect residents from potential abuse on 4/06/11 at 5:15 p.m. The Immediate Jeopardy was removed on 4/10/11, when through observations, interviews, and record reviews it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility performed multiple interviews with residents to uncover any information related to the allegations, to assess for any harm including psycho-social, discover any concerns the residents had, and responded to those concerns. The facility notified the local police agency, and the police investigated on 3 visits to the facility during the survey. At the time of exit all investigations were noted as unfounded. The facility also began interviewing all involved staff members, and began conducting inservice training on new building security policies, visitation policies, policies and procedures related to investigating and reporting injuries of unknown origin and allegations of abuse. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. B. 1. The Clinical Record of Resident C was reviewed on 04/08/11, at 11:50 a.m. [DIAGNOSES REDACTED]. An Annual Minimum Data Sheet (MDS) assessment, dated 02/21/11, triggered Resident C as moderately impaired in cognition. The MDS assessment indicated Resident C required extensive assistance with one staff person when transferred. A current Recapitulation, dated 04/1/11 thru 04/30/11, with an original order date of 11/19/10, indicated Resident C "...DX" {diagnosis}[MEDICAL CONDITION]." A Care Plan titled, "Cognition," with the most recent update of 02/21/11, indicated, "Res. {resident} has impaired cognition & (sic) decision-making abilities (needs cues/reorientation); poor s/t {short term} memory; cannot recall three items after five minutes, such as "clock, table, penny...." A Care Plan titled, "Communication," with the most recent update of 02/21/11, indicated..."Resident has potential for misscommunication (sic) due to: Dementia, HOH {hard of hearing}...." A Nurses Note, dated 03/18/11, at 1030 (10:30 a.m.), indicated Resident C had "...black discoloration on front of R (right) ankle. 3cm x 2cm. res. (resident) does not know how it happened. staff (sic) not aware of how it happened. MD office in facility notified. POA (power of attorney) notified...wound nurse also aware...." A Resident Event Report Worksheet, dated 03/18/11, at 10:30 a.m., indicated six staff had been interviewed relative to the injury. Staff indicated they were unaware of the origin of the injury. Resident C indicated in report ..."possibly when transferred or propelling-not sure...." The box "Injury of unknown cause" was marked, and the box "Circumstances Unknown" was marked. The report indicated the Director of Nursing Services (DNS) and the Administrator notifications were not applicable as indicated by a mark in the box "N/A." A Nurses Note, dated 03/20/11, at 1830 (6:30 p.m.), indicated Resident C had [MEDICAL CONDITION] to the right lower leg. The leg was warm to touch and tender when moved. Resident C's attending physician's answering service was called and a doppler study was suggested. The note also indicated the weekend supervisor was notified. A Nurses Note, dated 03/21/11, at 0800 (8:00 a.m.), indicated..."Resident cries out in pain {with} attempt to elevate legs...." The nurse indicated she called the Nurse Practitioner (NP) and the resident's power of attorney. A physician's orders [REDACTED]. A preliminary report for "Lower Extremity Venous Duplex," dated 03/21/11, indicated negative for [MEDICAL CONDITION] ([MEDICAL CONDITION] of the right leg. A radiology report which examined the right knee and right tibia and fibula, dated 03/21/11, indicated ..."there is no indication of fracture... A radiology report which examined the right pelvis, hip and femur, dated 03/24/11, indicated..."No recent fracture...." A Nurses Note, on 03/25/11, at 1100 (11:00 a.m), indicated, "Bruising cont {continued} to R (right) leg-...." A Nurses Note, on 03/28/11, at 0830 (8:30 a.m.), indicated..."Rt {right} leg {with} bruising...Resident offered pain med {medication}." A Nurses Note, on 03/31/11, at 11:00 a.m., indicated Resident C was assessed by the NP. The bruising is noted in the nurses note as ...."purple in color to inner side of Rt {right} thigh - yellowish bruising to outer leg - ...." A physician's orders [REDACTED]." A radiology report, dated 04/01/11, at 12:33 p.m., which examined the right knee indicated, ..."Impression: 1. Nondisplaced [MEDICATION NAME] tibial metaphysis...." A physician's orders [REDACTED]. ..."He is aware pt. (patient) is coming." A Nurses Note, on 04/01/11, at an illegible time, indicated, " Resident returned from ...ER with a Plaster (sic) cast or Splint (sic) to R {right} Leg (sic)...." In an interview on 04/07/11, at 2:20 p.m., the NP indicated the resident was at risk for [MEDICAL CONDITION] due to her age and weight and non weight-bearing status. She indicated the resident was not receiving calcium supplements. NP indicated she is unaware of the cause of the fracture. NP indicated Resident C needs assist to transfer to a wheel chair. During the end of day conference on 04/07/11, at 5:00 p.m., the DNS indicated he did not report the fracture to the state because Resident C was not considered totally dependent according to the MDS assessment of the resident. The DNS was asked to provide any further information on investigation or reporting from the time it was discovered Resident C had a tibia fracture. In the morning conference on 04/08/11, at 9:15 a.m., the DNS did not provide any further documentation of an investigation related to the tibia fracture of Resident C. He indicated he believed the injury was related to the resident's [DIAGNOSES REDACTED]. The Administrator did not provide any further documentation concerning the tibia fracture of Resident C. On 04/08/11, at 10:30 a.m., the DNS provided A Resident Event Report Worksheet. The report indicated the event date and time was 04/01/11 at 6:00 p.m. The event was listed as a right leg fracture. The "Circumstances Unknown" box is marked. Also listed in the report is a history of [MEDICAL CONDITION]. The worksheet indicated the physician, family, Administrator and DNS were notified on 04/01/11 at 6:00 p.m. The box "Reported to State" was marked "no." In an interview on 04/08/11, at 11:30 a.m., the Brookshire Unit Manager indicated Resident C had an initial investigation of the original bruise done on 03/18/11. "I did not know I had to do another one for the fracture." This Federal tag relates to complaint IN 559. 3.1-28(c)

A. Based on record review and interview, the facility failed to thoroughly investigate an allegation of sexual abuse by 1 resident and ensure residents were protected from future abuse as indicated by facility policy for 1 of 3 allegations of abuse reviewed. This deficient practice resulted in immediate jeopardy. Resident B. The Immediate Jeopardy was identified on 4/06/11 and began on 3/24/11. The Administrator, Director of Social Services, and the District Director of Clinical Operations were notified of the immediate jeopardy on 4/06/11. The Immediate Jeopardy was removed on 4/10/11, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was continuing inservicing, educating, and monitoring of employees for knowledge and compliance with building and visitation policies and policies and procedures related to investigating and reporting injuries of unknown injury and allegations of abuse. B. Based on record review and interview, the facility failed to re-investigate and report to the state agencies a fracture of unknown origin as indicated by facility policy for 1 of 3 residents reviewed for injuries of unknown origin in a sample of 5. A.1. A facility policy titled "Abuse," dated 10/31/09, received from the Administrator on 4/06/11 at 4:45 p.m. indicated: "Policy: Verbal, sexual, physical, and mental abuse...are strictly prohibited. Compliance guidelines: 14. Results of an alleged abuse investigation are reported to the Executive Director (Administrator) or their designee and to other officials in accordance with state law..." A facility policy titled "Conducting an Investigation," dated 7/22/10 and received from the Administrator on 4/06/11 at 4:45 p.m., indicated: "Rationale: Federal regulation requires a center have evidence that all allegations of abuse...are thoroughly investigated. In addition, the center must tale action to prevent further potential abuse while the investigation is in progress. Procedure... 9. Interview staff members, visitors, and/or residents who may have knowledge of alleged incident being investigated. Interviews may include: a. Staff that cared for the resident(s) at the time of the alleged incident. b. Staff on other shifts... c. Residents in the same room, or residents in the immediate vicinity d. Visitors who may have witnessed the incident 12. Identify the cognitive status of the victim(s) and resident(s) who are witnesses... 16. Describe any action(s) taken by the center to protect the resident(s) and to prevent a possible reoccurrence... 20. If the allegation involves sexual abuse, document if the alleged victim was examined, and if so, obtain a copy...of the examination or statement from the examiner... 27. Upon conclusion of the investigation, prepare a summary report of the findings and conclusions. The summary report must include sufficient detail of the investigation; any actions taken by the center...and a summary of the findings. A 2. The record of Resident B was reviewed on 4/06/11 at 11:00 a.m. [DIAGNOSES REDACTED]. Resident B's admission Minimum Data Set (M.D.S.) assessment, dated 2/24/2011, indicated she did not experience hallucinations or [MEDICAL CONDITION]. Resident B's record did not contain any documentation of Resident B having a guardian or an appointed power of attorney. A Recapitulation of physician's orders [REDACTED]." A "Facility Incident Reporting Form" provided by the Director of Nursing Services (D.N.S.) on 4/06/11 at 10:00 a.m., and completed by him indicated: "Incident Date: 3/24/2011... Resident Name: (Resident B)... Brief Description of Incident: Resident reported to the Unit manager and the sosial (sic) service Director, that allegation of rape. (sic) when asked when it happened, resident stated it happened last night. resident unable to describe what happened when asked. asked if resident knew who did it, he (sic) said his name was "rock" and he does not work here. asked if she could describe him, all she said was, he is dark skin and has good grade hair. resident she (sic) gas already told her husband and her daughter and that they will be picking her up after work. resident continue to repeat the same statement over and over. she was unable to give any further information and description when asked. when questioned if she screemed (sic) she said yes, staff came in but the man has already left." The "Facility Incident Reporting Form" quoted above did not document the date or time the report was completed, or the time Resident B made the allegation of rape. A Nursing Progress Note, dated 3/25/11 at 11:00 a.m., indicated "Reported to this writer et (and) Social Service Director that resident made an allegation of rape-Spoke to resident-stated 'I was raped'...asked if she knew when it happened stated 'Yes it happened last night'...." A facility "Resident Event Report Worksheet" received from the D.N.S. on 4/07/11 at 5:00 p.m., indicated the Administrator had been advised of Resident B's allegation of rape on 3/25/11 at 11:30 a.m. During an interview on 4/08/11 at 9:55 a.m., the Administrator confirmed he had not participated in any way in the investigation of Resident B's allegation of rape. Resident B was interviewed on 4/07/11 at 4:00 p.m., in private in her room. She was pleasant and cooperative. When asked about her allegation of rape, she refused to discuss it and ended the interview. During an interview with the Social Services worker on 4/07/11 at 5:00 p.m., with the D.N.S. and Administrator present she provided copies of two resident interviews, dated 3/25/11, she indicated she did following Resident B's allegation of rape. The D.N.S. and Administrator had no explanation for why this documentation was not included in documentation provided earlier. A Social Services Progress Note, dated 3/25/11 at 1:30 p.m., indicated "This writer (symbol for "and") UM (unit manager) went to speak to (name of resident) to follow up with investigation. This writer asked (name of resident) if she heard anything last night R/T (related to) neighbors on hall. (Name of resident) stated No (symbol for "and") that she slept all night heard nothing." A Social Services Progress Note, dated 3/25/11 at 1:35 p.m., indicated "This writer went to speak with (name of resident) in regards to investigation. (Name of resident) stated he did not hear anything last noc (night) it was pretty quiet..." During interviews on 4/06/2011 at 10:30 a.m., and again at 4:30 p.m., the D.N.S. indicated he had not interviewed any residents, staff, or visitors following Resident B's allegation of rape, and had not done any other investigation or instituted any interventions to assure resident safety. B. 1. The Clinical Record of Resident C was reviewed on 04/08/11 at 11:50 a.m. [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS) assessment, dated 02/21/11, triggered Resident C as moderately impaired in cognition. The MDS assessment indicated Resident C required extensive assistance with one staff person when transferred. A current Recapitulation, dated 04/1/11 thru 04/30/11, with an original order date of 11/19/10, indicated Resident C "...DX" {diagnosis}[MEDICAL CONDITION]." A Care Plan titled, "Cognition," with the most recent update of 02/21/11, indicated, "Res. {resident} has impaired cognition & (sic) decision-making abilities (needs cues/reorientation); poor s/t (short term) memory; cannot recall three items after five minutes, such as "clock, table, penny...." A Care Plan titled, "Communication," with the most recent update of 02/21/11, indicated..."Resident has potential for misscommunication (sic) due to: Dementia, HOH (hard of hearing)...." A Nurses Note, dated 03/18/11, at 1030 (10:30 a.m.), indicated Resident C had "...black discoloration on front of R (right) ankle. 3cm x 2cm. res. (resident) does not know how it happened. staff (sic) not aware of how it happened. MD office in facility notified. POA {power of attorney} notified...wound nurse also aware...." A Resident Event Report Worksheet, dated 03/18/11, at 10:30 a.m., indicated six staff had been interviewed relative to the injury. Staff indicated they were unaware of the origin of the injury. Resident C indicated in report ..."possibly when transferred or propelling-not sure...." The box "Injury of unknown cause" was marked, and the box "Circumstances Unknown" was marked. The report indicated the Director of Nursing Services (DNS) and the Administrator notifications were not applicable as indicated by a mark in the box "N/A." A Nurses Note, dated 03/20/11, at 1830 (6:30 p.m.), indicated Resident C had [MEDICAL CONDITION] to the right lower leg. The leg was warm to touch and tender when moved. Resident C's attending physician's answering service was called and a doppler study was suggested. The note also indicated the weekend supervisor was notified. A Nurses Note, dated 03/21/11, at 0800 (8:00 a.m.), indicated..."Resident cries out in pain (with) attempt to elevate legs...." The nurse indicated she called the Nurse Practitioner (NP) and the resident's power of attorney. A physician's orders [REDACTED]. A preliminary report for "Lower Extremity Venous Duplex," dated 03/21/11, indicated negative for [MEDICAL CONDITION] ([MEDICAL CONDITION] of the right leg. A radiology report which examined the right knee and right tibia and fibula, dated 03/21/11, indicated ..."there is no indication of fracture... A radiology report which examined the right pelvis, hip and femur, dated 03/24/11, indicated..."No recent fracture...." A Nurses Note, on 03/25/11, at 1100 (11:00 a.m), indicated, "Bruising cont (continued) to R (right) leg-...." A Nurses Note, on 03/28/11, at 0830 (8:30 a.m.), indicated..."Rt (right) leg (with) bruising...Resident offered pain med {medication}." A Nurses Note, on 03/31/11, at 11:00 a.m., indicated Resident C was assessed by the NP. The bruising is noted in the nurses note as ...."purple in color to inner side of Rt (right) thigh - yellowish bruising to outer leg - ...." A physician's orders [REDACTED]." A radiology report, dated 04/01/11, at 12:33 p.m., which examined the right knee indicated, ..."Impression: 1. Nondisplaced [MEDICATION NAME] tibial metaphysis...." A physician's orders [REDACTED]. ..."He is aware pt. {patient} is coming." A Nurses Note, on 04/01/11, at an illegible time, indicated, " Resident returned from ...ER with a Plaster (sic) cast or Splint (sic) to R (right) Leg (sic)...." In an interview on 04/07/11, at 2:20 p.m., the NP indicated the resident was at risk for [MEDICAL CONDITION] due to her age and weight and non weight-bearing status. She indicated the resident was not receiving calcium supplements. NP indicated she is unaware of the cause of the fracture. NP indicated Resident C needs assist to transfer to a wheel chair. During the end of day conference on 04/07/11, at 5:00 p.m., the DNS indicated he did not report the fracture to the state because Resident C was not considered totally dependent according to the MDS assessment of the resident. The DNS was asked to provide any further information on investigation or reporting from the time it was discovered Resident C had a tibia fracture. In the morning conference on 04/08/11, at 9:15 a.m., the DNS did not provide any further documentation of an investigation related to the tibia fracture of Resident C. He indicated he believed the injury was related to the resident's [DIAGNOSES REDACTED]. The Administrator did not provide any further documentation concerning the tibia fracture of Resident C. On 04/08/11, at 10:30 a.m., the DNS provided A Resident Event Report Worksheet. The report indicated the event date and time was 04/01/11 at 6:00 p.m. The event was listed as a right leg fracture. The "Circumstances Unknown" box is marked. Also listed in the report is a history of [MEDICAL CONDITION]. The worksheet indicated the physician, family, Administrator and DNS were notified on 04/01/11 at 6:00 p.m. The box "Reported to State" was marked "no." This Federal tag relates to complaint IN 559. 3.1-28(a)