Every finding on record at Aperion Care Demotte

Based on record review and interview, the facility failed to ensure residents who required assistance for activities of daily living (ADL's) received bathing/showers as scheduled for 3 of 3 residents who required assistance for ADL's. (Residents B, C, and D)Findings include:1. Resident B's closed record was reviewed on 3/16/26 at 1:19 p.m. The diagnoses included, but were not limited to, fractures of the right and left lower extremities.A Care Plan, dated 12/11/25, indicated a deficit in ADL self care and was dependent on staff for bathing.An admission Minimum Data Set (MDS) assessment, dated 12/16/25, indicated he was dependent on staff for bathing.The Plan of Care indicated the resident's preference for bathing was on day shift on Wednesdays and Saturdays.The Shower Sheets and Task forms, dated 1/2026, indicated bathing had not occurred on 1/3/26. 2. Resident C's record was reviewed on 3/17/26 at 8:37 a.m. The diagnoses included, but were not limited to, seizures and bipolar.An Annual MDS assessment, dated 3/6/26, indicated moderate assistance was required for bathing.A Care Plan, revised on 3/17/26, indicated a deficit in ADL self care and required extensive assistance of one to two staff for bathing.The preferred bathing days were on day shift on Mondays, Wednesdays and Fridays. The Shower Sheets and Task forms, dated 1/2026, 2/2026, and 3/2026, indicated bathing had not occurred on January 14 and 30, February 23, and March 2 and 4, 2026.During an interview on 3/17/26 at 9:00 a.m., the Director of Nursing (DON) indicated bathing was completed three times a week due to the resident's poor hygiene. 3. Resident D's record was reviewed on 3/17/26 at 10:36 a.m. The diagnoses included, but were not limited to diabetes mellitus and below the knee amputation.A Care Plan, revised on 10/1/25, indicated a deficit in ADL self care and required assistance of one staff member for bathing.A Quarterly Minimum Data Set (MDS) assessment, dated 3/2/26, indicated the resident was dependent on staff for bathing.The preferred bathing days were on day shift on Tuesdays and Fridays.The Shower Sheets and Task forms, dated 1/2026, 2/2026 and 3/2026, indicated bathing had not been completed on January 24, February 14, 24, and 28, 2026 and March 10, 2026.During an interview on 3/17/26 at 11:37 a.m., the DON indicated she was unable to find documentation that indicated the bathing had been completed and was not able to say if the bathing had been completed.This citation relates to Intake 2707235.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)410 IAC (Indiana Administrative Code) 16.2-3.1-38(b)(2)

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for urinary incontinence care for 1 of 7 resident care plans reviewed. (Resident F)Finding includes:Resident F's record was reviewed on 3/17/26 at 12:01 p.m. The diagnoses included, but were not limited to, diabetes mellitus.An ADL Care Plan, dated 2/15/26, indicated a deficit in activities of daily living. The toilet hygiene section indicated the resident's usual performance was not documented. There was no intervention of how much care the resident required.A Care Plan, dated 2/15/26, indicated there was a potential of impairment of the the skin integrity related to incontinence. There were no interventions that indicated what care should be done for the incontinence.An admission Minimum Data Set (MDS) assessment, dated 2/18/26, indicated the resident was dependent for toileting and was frequently incontinent of the bowel and bladder.During an interview on 3/17/26 at 12:08 p.m., the MDS Coordinator indicated she needed to tighten up the Care Plans.During an interview on 3/17/26 at 12:10 p.m., the MDS Coordinator indicated there was no Care Plan for incontinence care.This citation relates to Intake 2707235.410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure medications were stored properly, with appropriate labeling and not expired, for 2 of 2 medication carts observed and in 2 resident rooms. (ACU Cart, [NAME] Hall Cart, room [ROOM NUMBER], and room [ROOM NUMBER]) Findings include:1. On [DATE] at 10:24 a.m., the following was observed on the ACU Cart with RN 2.- A Basaglar KwikPen (insulin) was opened with no open date written on the pen. During an interview, RN 2 indicated she had used the insulin pen that day. She was unsure when it was opened, and staff should have written the open date on the insulin pen. 2. On [DATE] at 10:35 a.m., the following was observed on the [NAME] Hall Cart with LPN 1.- Lantus (insulin) vial was opened with no open date written on the vial or the box. During an interview, LPN 1 indicated she was unaware when the insulin vial had been opened. The staff should have written the open date on the insulin vial. 3. During random observations on [DATE] at 11:19 a.m., [DATE] at 9:13 a.m. and [DATE] at 8:49 a.m., an open tube of Medihoney (a topical wound treatment) and a tube of diclofenac (a topical pain medication) were observed in the bathroom of Resident room [ROOM NUMBER]. One of two residents who resided in the room used the bathroom. At that time, neither resident was prescribed Medihoney or diclofenac. 4. During random observations on [DATE] at 11:00 a.m., [DATE] at 9:15 a.m. and [DATE] at 8:24 a.m., a bag filled with saline filled syringes was observed hanging from an IV pole in room [ROOM NUMBER]. On [DATE] at 8:34 a.m., LPN 2 was observed disconnecting the IV antibiotic from the resident in room [ROOM NUMBER]. She flushed the line with one of the syringes from the bag and indicated they were all pre-filled saline syringes. During an interview on [DATE] at 3:50 p.m., the Administrator indicated she would remove the medications from the residents' rooms. A policy titled, Storage of Medications, received as current from the Corporate Nurse Consultant on [DATE] at 11:00 a.m. indicated, Medications and biologicals are stored safely, securely, and properly . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated . The nurse shall place a date opened sticker on the medication and enter the date opened. 3.1-25(j)3.1-25(m)

Based on record review and interview, the facility failed to ensure food consumption logs were complete for residents with a history of weight loss for 1 of 3 residents reviewed for nutrition. (Resident 20)Finding includes:The record for Resident 20 was reviewed on 9/3/25 at 3:49 p.m. Diagnoses included, but were not limited to, heart disease, pressure ulcer of buttock, and dementia.The 8/18/25 admission Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, required maximal assistance with ADLs and transfers, and had a weight loss of 5% or more in the last month or 10% or more in last 6 months. The resident's record lacked documentation of 3 meal intakes per day on 8/13/25, 8/14/25, 8/16/25, 8/17/25, 8/18/25, 8/19/25, 8/20/25, 8/23/25, 8/25/25, 8/28/25, 8/29/25, 9/1/25, and 9/2/25.A care plan, revised 8/13/25, indicated the resident was at risk for fluctuations in weight. Interventions included monitoring and recording the resident's intake each shift.During an interview on 9/4/25 at 11:50 a.m., the MDS Coordinator indicated the resident had a weight loss of 8.6 pounds in the past 3 months (4%) and 40 pounds (16.2%) in the past 7 months, based on the Dietician's notes from the facility from where the resident transferred. During an interview on 9/8/25 at 2:38 p.m., the Nurse Consultant indicated the resident's meal consumptions should be documented three times a day, once each shift. A policy titled, Food Intake, received as current from the Corporate Nurse Consultant on 9/8/25 at 2:56 p.m. indicated, . Food intake will be recorded by assigned staff. All personnel recording intakes will receive instructions on method used, recording intake on community specific form or electronic monitoring system.3.1-46(a)(1)

Based on observation, record review and interview, the facility failed to maintain a resident's dignity related to lack of dignity bag on a urine collection bag, wearing a hospital gown during the day, and not being fully dressed for 1 of 3 residents reviewed for dignity. (Resident 74)Finding includes:During random observations on 9/2/25 at 11:41 a.m., 9/3/25 at 10:41 a.m., 9/4/25 at 7:13 a.m., and 9/5/25 at 10:51 a.m., Resident 74 was observed resting in bed. The urine collection bag from her Foley catheter (a tube that drains the bladder) was visible from the hallway. There was no dignity bag in place. On 9/3/25 at 10:42 a.m. and 9/8/25 at 10:06 a.m., the resident was observed wearing a hospital gown.On 9/5/25 at 10:51 a.m. and 11:29 a.m., the resident was observed from the hallway. She was in bed, wearing only a shirt and disposable brief. Her brief was pulled down and her bare skin was exposed. Several staff members were observed walking past the resident's room.The record for Resident 74 was reviewed on 9/4/25 at 2:13 p.m. Diagnoses included, but were not limited to, acute respiratory failure, diabetes, and dementia.The 8/15/25 Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs) and transfers, and was on hospice. A Physician's Order, dated 5/22/24, indicated to ensure the Foley catheter bag was covered and / or in a dignity bag.A Care Plan, dated 9/20/24, indicated the resident had a terminal condition, was receiving hospice services, and would suffer no loss of dignity. During an interview on 9/8/25 at 2:38 p.m., the Administrator and Nurse Consultant were informed of the findings and offered no further information.3.1-3(t)

Based on interview and record review, the facility failed to ensure a resident had the right to choose what time of day she received a shower for 1 of 1 resident reviewed for choices. (Resident 18)Finding includes:During an interview on 9/3/25 at 10:34 a.m., Resident 18 indicated she took a shower twice a week whenever the staff had time to give her one. The staff would have her take showers at nighttime. She had told them on multiple occasions that she preferred not to take a shower at night and preferred to take them in the morning. She did not like to go to bed with wet hair. Staff would tell her that was her scheduled time to take a shower but never asked her preference or when she wanted to shower. Record review for Resident 18 was completed on 9/8/25 at 1:22 p.m. Diagnoses included, but were not limited to, heart failure, hypertension, Parkinson's disease, and depression. The resident was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the resident was cognitively intact. The resident's preference was marked that it was very important to the resident to choose their bathing. The resident required partial moderate assistance with bathing. The Bathing Tasks were documented the resident preferred bathing on Wednesday and Saturday evenings. There was a lack of documentation that indicated the resident's preference for bathing was asked and not just assigned. During an interview on 9/9/25 at 9:23 a.m., the Assistant Director of Nursing (ADON) indicated she would talk with the residents and family when the residents were admitted about their bathing schedules. She would tell them what the schedule was for them and ask them if they were ok with that schedule. They did not have a process for asking residents after admission if their preferences had changed unless the resident or family expressed they preferred something different. The facility could not provide a policy related to choices and or preferences for bathing. 3.1-3(u)(1)

Based on record review and interview, the facility failed to ensure there was indication for use and interventions were attempted prior to administering a PRN (as needed) antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 90)Finding includes:Record review for Resident 90 was completed on 9/4/25 at 8:49 a.m. Diagnoses included, but were not limited to, alcohol dependence with induced psychotic disorders with delusions, dementia, and hypertension. The resident was admitted to the facility on [DATE].A Care Plan, dated 8/29/25, indicated the resident had potential for adverse side effects related to medication use of an antipsychotic. An intervention included to administer the medications per order and to observe for side effects.A Physician's Order, dated 8/28/25, indicated to administer quetiapine fumarate (antipsychotic medication) 25 mg, give 1/2 a tablet every 24 hours as needed for agitation.A Fall Initial Occurrence Note, dated 8/28/25 at 9:45 p.m., indicated the resident had a fall in his room next to his bed. The resident was brought to the nurse's station and given a snack and milk per his request.An Orders Administration Note, dated 8/28/25 at 11:14 p.m., indicated the resident was administered the PRN antipsychotic medication.There was a lack of documentation as to why the resident was administered the medication almost an hour and a half after the fall incident or if any interventions were attempted prior to the administration of the PRN antipsychotic.An Orders Administration Note, dated 8/31/25 at 8:48 p.m., indicated the resident was administered a PRN antipsychotic medication.A Nurses Note, dated 8/31/25 at 8:50 p.m., indicated the resident was standing in his room naked and walking round. He was brought to the nurse's station in his Broda chair (padded positioning wheelchair) and given his PRN medication at that time.There was a lack of documentation to indicate if any interventions were attempted prior to administering the PRN antipsychotic.During an interview on 9/5/25 at 11:20 a.m., the Nurse Consultant (NC) indicated they could not provide any documentation that prior interventions were attempted before administering the resident the PRN antipsychotic medication.A policy, titled Psychotropic Medication - Gradual Dose Reduction, received as current from the NC indicated .The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches.3.1-48(a)(4)

Based on record review and interview, the facility failed to successfully complete the Minimum Data Set (MDS) assessment in timely manner for 1 of 24 residents whose MDS assessments were reviewed. (Resident 6) Finding includes: Closed record review for Resident 6 was completed on 9/9/25 at 10:46 a.m. The resident was admitted to the facility on [DATE] and discharged on 5/14/25.A Nurses Note, dated 5/14/25 at 2:05 p.m., indicated the resident was discharged to another healthcare facility.There was a lack of documentation to indicate a discharge MDS assessment had been completed on the resident after his discharge from the facility. During an interview on 9/9/25 at 11:15 a.m., the MDS Coordinator indicated she had worked on the resident's discharge from the facility but had forgotten to complete the MDS discharge assessment.3.1-31(d)(1)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to an anticoagulant medication and insulin administered for 2 of 24 MDS assessments reviewed. (Residents 24 and 8) Findings include:1. Record review for Resident 24 was completed on 9/9/25 at 9:55 a.m. Diagnoses included, but were not limited to, anemia, hypertension, and diabetes mellitus. The Significant Change MDS assessment, dated 7/2/25, indicated the resident had received an anticoagulant medication during the assessment period. There was a lack of documentation of a Physician's Order for an anticoagulant medication or that the resident had received an anticoagulant medication during the assessment period. 2. Record review for Resident 8 was completed on 9/9/25 at 10:06 p.m. Diagnoses included, but were not limited to, heart failure, hypertension, and dementia. The Quarterly MDS assessment, dated 7/23/25, indicated the resident had received 7 days of insulin injections during the assessment period. There was a lack of documentation of a Physician's Order for insulin or that the resident had received insulin injections during the assessment period.During an interview on 9/9/25 at 11:15 a.m., the MDS Coordinator indicated there was a discrepancy with the MDS assessments and the residents had not received an anticoagulant or insulin during the assessment period. She marked them by mistake and would modify the assessments. The facility could not provide a policy related to MDS resident assessments. 3.1-31(i)

Based on observation, record review, and interview, the facility failed to assess and document a wound for 1 of 1 resident reviewed for non-pressure skin conditions. (Resident 32)Finding includes:During a random observation on 9/2/25 at 11:15 a.m., a dressing was observed on Resident 32's right leg stump. At that time, the resident indicated the surgical incision from her leg amputation had previously healed, but part had re-opened.The resident's record was reviewed on 9/4/25 at 12:11 p.m. Diagnoses included but were not limited to, bleeding stomach ulcer, stroke, and right leg amputation. The 8/14/25 Medicare-5 Day Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, required maximum assistance with activities of daily living (ADLs) and moderate assistance with transfers. An 8/29/25 Physician's Office Visit Note indicated the orthopedic doctor saw the resident in his office. He consulted infectious disease as well as wound care for the resident's right stump infection. The record lacked any wound assessments since 8/21/25.During an interview on 9/4/25 at 8:24 a.m., the resident indicated she went to the wound clinic on the previous day and was going to go back for continued treatment for her right leg stump.During an interview on 9/4/25 at 8:34 a.m., LPN 2 indicated the resident had several small open areas along her previously healed right leg amputation incision.During an interview on 9/5/25 at 2:12 p.m., the Corporate Wound Nurse indicated the resident's surgical wound was healed on 8/21/25 and opened on 8/25/25. She indicated she would check with the facility wound nurse or wound clinic for wound assessments. No further documentation was provided. A policy, titled, Skin Condition Assessment and Monitoring-Pressure and Non-Pressure, received as current from the Corporate Nurse Consultant on 9/8/25 at 2:56 p.m., indicated, . A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse.3.1-37

Based on observation, record review, and interview, the facility failed to ensure a resident's electronic smoking materials were locked up and fall precautions were in place for a resident with a history of falls for 2 of 11 residents reviewed for accidents. (Residents 58 and 82)Findings include:1. On 9/3/25 at 2:06 p.m., Resident 58 was observed lying in bed in his room. There were 2 electronic cigarette vapes observed on his bedside table. The resident's daughter was in the room and indicated his smoking vapes were supposed to be locked up. On 9/4/25 at 3:05 p.m., Resident 58 was observed propelling himself in his wheelchair out of his room. There were 2 electronic cigarette vapes observed on his bedside table. CNA 1 indicated the resident was going out to smoke and she was unsure if his smoking vapes were supposed to be locked up or not and she had not given the resident his smoking vapes. Record review for Resident 58 was completed on 9/4/25 at 2:20 p.m. Diagnoses included, but were not limited to, hypertension, diabetes mellitus, dementia, chronic obstructive pulmonary disease, and legal blindness. The Significant Change Minimum Data Set (MDS) assessment, dated 8/20/25, indicated the resident was moderately cognitively impaired. The resident required a partial moderate assistance with transfers. A Care Plan, dated 11/17/23, indicated the resident had been deemed an unsafe smoker and could no longer smoke cigarettes. The resident had refused smoking cessation and had agreed to an electronic cigarette. An intervention included the resident's smoking materials were to be in a secure location. A Smoking Safety Risk Assessment, dated 7/31/25, indicated the resident used an electronic smoking device. All smoking materials would be kept locked in facility designated area. During an interview on 9/5/25 at 11:51 a.m., the Social Services Director indicated the resident was a safe smoker for electronic cigarette vaping. He was not supposed to keep the vapes out in the open on his bedside table. A policy titled, Smoking Safety and received as current from the facility on 9/4/25, indicated, .A Smoking Safety Assessment will be completed to ensure that the resident is capable of safe storage, charging and use of the electronic cigarette or vaping device. 2. On 9/3/25 at 9:25 a.m., Resident 82 was observed lying in bed. He had sutures to his forehead and a neck brace in place. He indicated he had fallen recently and hit his head. He had gone to the hospital and now had to wear a neck brace. His wheelchair was next to his bed and there was no Dycem (non-slip mat) observed on the seat. There were no non-skid strips on the floor in his bathroom. On 9/4/25 at 10:20 a.m., Resident 82 was observed lying in bed with his eyes closed. His wheelchair was next to his bed and there was no Dycem observed on the seat. There were no non-skid strips on the floor in his bathroom. Record review for Resident 82 was completed on 9/4/25 at 9:13 a.m. Diagnoses included, but were not limited to, displaced fracture of the first cervical vertebra, type 2 diabetes mellitus, and hypertension. The Quarterly MDS assessment, dated 6/4/25, indicated the resident was moderately cognitively impaired and required a partial/moderate assist with bed mobility and transfers. A Care Plan, updated 6/18/25, indicated the resident was at risk for falls. The interventions included, Dycem to the wheelchair seat above the cushion and non-skid strips in front of the toilet. During an interview on 9/8/25 at 11:47 p.m., the Director of Nursing was made aware of the Dycem and non-skid strips not in place. No further information was provided. A current facility policy, titled Fall Prevention Program, indicated, .Safety interventions will be implemented for each resident identified at risk.Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 11 residents observed during medication pass. Two errors were observed during 26 opportunities for errors during medication administration. This resulted in a medication error rate of 7.69%. (Resident 17) Finding includes:On 9/5/25 at 3:11 p.m., RN 1 was observed preparing Resident 17's medications to be administered. The nurse popped out 1 Flomax 0.4 mg (milligrams) capsule (urinary medication) and 1 senna 8.6 mg (stimulant laxative) pill into a cup. She then proceeded to place the medications into a clear plastic bag and crushed the medications. She poured the crushed medications into a cup and put a spoonful of pudding on top of the medications and stirred. The capsule was not crushed and was flattened out but still intact. The nurse indicated she was finished and ready to administer the resident's medications. The nurse locked her medication cart and proceeded to go into the resident's room. The nurse was then asked to stop and not to administer the medication. The nurse was asked if she always crushed capsule medications. The nurse indicated yes because she did not want to open the capsule and get it all over. She was unaware capsules could not be crushed.The resident's senna 8.6 mg medication card and current Physician's Order indicated to give 2 pills every evening.The nurse indicated she had only popped out 1 senna pill to administer to the resident and had not realized the order was for 2 pills.During an interview after the observation, the Director of Nursing (DON) indicated the nurse should have opened up the Flomax capsule instead of crushing it and administered two senna pills instead of one.A policy titled, Medication Administration General Guidelines and received as current from the DON on 9/9/25, indicated, .6. Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered.8. Tablet Crushing/Capule Opening: Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed.3.1-48(c)(1)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to duplicate medications on the Medication Administration Record (MAR) for 1 of 5 residents reviewed for unnecessary medications. (Resident 10)Findings include:The record for Resident 10 was reviewed on 9/8/25 at 10:23 a.m. Diagnoses included, but were not limited to, dementia and diabetes.The 8/5/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and required supervision or touching assistance with activities of daily living (ADLs) and transfers.The September 2025 MAR indicated, . Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% [a lubricating eye drop] . Instill 1 drop in both eyes one time a day. and .Refresh Tears Solution (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes one time a day. Both entries were signed out as given each morning. During an interview on 9/8/25 at 11:03 a.m., LPN 1 indicated the resident received one drop to each eye every morning, and that the duplicate order was entered in error. She indicated she did not notice it when she administered and signed out the medications that morning, and that she would delete one of the entries.During an interview on 9/8/25 at 11:47 a.m., the Director of Nursing (DON) was informed of the finding. No additional information was received.3.1-50(a)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented related to a dirty bedside table used for wound care supplies and lack of hand hygiene with glove changes during wound care for 1 of 1 resident reviewed for pressure ulcers. (Resident 20)Finding includes:Wound care for Resident 20 was observed on 9/4/25 at 7:10 a.m. After removing the old dressing, the Wound Nurse took gauze that was placed directly on a bedside table, soaked it in Dakin's solution (a wound cleanser), and used it to cleanse the open wound on the resident's buttock. There was no barrier, and the table was visibly dirty. The Wound Care Physician assessed and measured the wound, removed his gloves, and put on gloves he got from his pocket. He debrided the wound, again removed his gloves and put on gloves from his pocket, and cleansed inside the open wound with gauze from the table. He did not perform hand hygiene after removing his gloves. During an interview on 9/4/25 at 7:40 a.m., the Wound Nurse indicated she told someone to clean the bedside table earlier, but she was not sure what happened. During an interview on 9/4/25 at 7:50 a.m., the Wound Care Physician was informed of the findings and offered no further information.A policy titled, Dressing Change (Clean / Non-Sterile), received as current from the Administrator on 9/4/25 at 1:25 p.m., indicated, . Prepare a clean, dry work area at bedside. Bring supplies into the resident's room. Individual resident supplies may be placed on the over bed table after it has been disinfected and / or a protective barrier placed on the table.A policy titled, Hand Hygiene / Handwashing, received as current from the Administrator on 9/4/25 at 1:25 p.m., indicated, . When to Perform Hand Hygiene . After glove removal.3.1-18(a)

Based interview and record review, the facility failed to ensure residents were free from misappropriation of resident property related to drug diversions of residents' narcotic pain medications (hydrocodone and oxycodone) for 3 of 3 residents reviewed for misappropriation of resident property. (Residents B, F, and G) The deficient practice was corrected on 1/3/25, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A Indiana Department of Health (IDOH) reported incident indicated on 12/27/24 at 10:01 a.m., it was reported to the Assistant Director of Nursing and the Administrator that the facility was unable to account for a Resident B's narcotic pain medication or oxycodone 15 mg (milligrams). A 5-Day Follow-up to the reported incident, dated 1/3/25, indicated a registered nurse had admitted to taking Resident B's oxycodone 15 mg. The investigation of the incident, undated and completed by the RN Nurse Consultant, indicated all residents' medications and count sheets were reviewed. There were discrepancies for the narcotic pain medications for Residents B, F, and G. Review of the resident records and investigation indicated the following: 1. Resident B's record was reviewed on 2/6/25 at 11:02 a.m. The diagnoses included, but were not limited to, peripheral neuropathy and diabetes mellitus. A Physician's Order, dated 10/12/24, indicated oxycodone 15 mg was to be administered every four hours as needed for pain rated at 5-10. The pharmacy delivery sheets indicated 30 tablets of oxycodone 15 mg were delivered on on November 5, 16, 21, 24, and 27, 2024, and December 3, 9, 18, 21, and 26, 2024, for a total of 300 tablets. The narcotic count records were unable to be located for the deliveries on November 5, 24, and 27, 2024 and December 3, 18, and 21, 2024. The Medication Administration Records (MARs), dated 11/2024 and 12/2024, indicated 12 tablets of oxycodone 15 mg were given in November and 15 tablets given in December. A total of 273 oxycodone 15 mg were unaccounted for. 2. Resident F's record was reviewed on 2/6/25 at 2/6/25 at 2 p.m. The diagnoses included, but were not limited to, diabetes mellitus and dementia. The Quarterly Minimum Data Assessment, dated 12/2/24, indicated a severely impaired cognitive status. A Physician's Order, dated 5/18/24 and discontinued on 12/23/24, indicated hydrocodone-acetaminophen 5-325 mg was to be administered as needed every six hours for breakthrough pain. The investigation indicated the hydrocodone was signed out by RN 4 on the narcotic count sheets on October 25, 27 (twice), 29, and 30 (twice), 2024, November 1, 4, 5 (twice), 9, 10, 11, 12, 21, 23 (twice), and 28, 2024, and December 2, 3, 5, and 12, 2024. The MAR, dated 11/2024 and 12/2024, indicated the medication was only signed out as administered on 10/27/24 and 11/2024. There were 22 tablets of hydrocodone 5-325 mg unaccounted for and not documented as received by the resident. 3. Resident G's record was reviewed on 2/6/25 at 2:15 p.m. The diagnoses included, but were not limited to, osteoarthritis. A Physician's Order, dated 9/9/24, indicated hydrocodone-acetaminophen 10-325 mg was to be given every 6 hours as needed for moderate pain. The pharmacy delivery sheets indicated 30 tablets of hydrocodone 10-325 mg was delivered on 11/1/24, 11/10/24, 11/20/24, 11/27/24 and 12/3/24 for a total of 150 tablets. The narcotic count records were unable to be located for the deliveries on 11/1/24, 11/20/24, 11/27/24, and 12/3/24. The MARs, dated 11/2024 and 12/2024, indicated there were 60 tables given in November and 65 tablets given in December. A total 125 tablets were signed as given. There were 25 tablets not accounted for. The investigation indicated there were a total of 440 narcotic tablets unaccounted for from November through 12/27/24. During an interview on 2/6/25 at 12:17 p.m., the ADON indicated RN 3 had voiced a concern on 12/26/24 that RN 4 had been administering several oxycodones to Resident B. On 12/26/24, Resident B had a card of 8 and a card of 30 oxycodone tablets in the medication cart. On the morning of 12/27/24, the ADON indicated the card of 8 oxycodone tablets was missing. RN 3 had indicated 1 oxycodone had been given out of the card of 8 on the evening of 12/26/24. The 7 left in the card were unaccounted for. She indicated RN 4 would volunteer to come in early to relieve the nurses on the evening shift. When the facility reviewed when she came in early, it was the days the pharmacy was delivering the narcotics that she had ordered. RN 4 would sign for the narcotics and the count sheet and the cards would be missing. RN 4 took the card with 7 of Resident B's oxycodone and the narcotic count record. RN 4 admitted to taking the card and the narcotic count record. During a telephone interview with the Corporate RN Consultant on 2/6/25 at 12:28 p.m., she indicated RN 4 had admitted to taking the 7 oxycodone tablets. RN 4 had informed the Police Officer she had been taking the medication over the course of a year. There were over 300 narcotics missing. It was determined RN 4 would order the medications then be at the facility when they were delivered and take the medications along with the narcotic count record or she would sign the medications out and not sign the MAR as given. The deficient practice was corrected by 1/3/25 after the facility implemented a systemic plan that included the following actions: law enforcement were notified and responded to the allegation with an investigation, narcotic counts were immediately performed, oriented residents were interviewed to ensure there was no pain or discomfort, and nurses were interviewed. New protocols were initiated to prevent further drug diversion, the Director of Nursing (DON) or the ADON will check the narcotic counts randomly to ensure staff are following the new protocols. When adding narcotic cards to the cart, there must be two signatures and two staff members must sign the delivered narcotic in when delivered by pharmacy. If the narcotic is discontinued, medication card is empty, or the narcotic count record is completed, the DON or ADON will remove the card and the count record. The Narcotics will be counted at the beginning and end of every shift and will be signed by two staff (nurse/QMA). Education has been provided to 12 of the 21 nurses/QMA's and agency staff will be educated when they work. The new protocols are kept in the front the narcotic count binder on each cart. A narcotic count was completed on the 4 of 4 medication carts in the facility and all narcotics were accounted for. Five nurses on day and evening shift were interviewed and were able to describe the new protocols and what to do if there was a discrepancy. They also indicated they would report if a resident was receiving more pain medications than normal. The DON indicated the audits would be continued indefinitely and the results form the audits would be discussed in Quality Assurance meetings. This citation relates to Complaint IN00450100. 3.1-28(a)

Based on record review and interview, the facility failed to ensure a 5-Day follow up to a reported incident of misappropriation to the Indiana Department of Health (IDOH) contained thorough and complete information from the facility's investigation of the incident, for 1 of 1 reported incident reviewed. Finding includes: A Indiana Department of Health (IDOH) reported incident indicated on 12/27/24 at 10:01 a.m., it was reported to the Assistant Director of Nursing and the Administrator, the facility was unable to account for a Resident B's narcotic pain medication or oxycodone 15 mg (milligrams). The Staff involved were RN 3 and RN 4. A 5-Day follow-up to the reported incident, dated 1/3/25, indicated the drug diversion was substantiated due to RN 4 admission of taking the oxycodone. Cross reference F602. The 5-day follow up lacked information from the investigation that indicated two other residents were found to have missing narcotic medication, how many narcotics were unaccounted for, and that RN 3 was not involved in the misappropriation of the medication. During an interview on 2/6/25 at 12:17 p.m., Regional [NAME] President indicated the 5-day follow up was missing information found during the investigation. This citation relates to Complaint IN00450100. 3.1-28(e)

Based on observation, interview, and record review, the facility failed to ensure a resident received necessary care and services related to no investigation for the root cause for a resident's multiple skin tears for 1 of 2 residents reviewed for quality of care and skin tears. (Resident C) Finding includes: During an observation and interviews on 2/5/25 from 8:45 a.m. to 9:42 a.m., CNA 1 and CNA 2 entered Resident C's room to provide care. The resident was observed to have two dressings on the right arm and two dressings on the back of her right hand. CNA 1 indicated the resident had skin tears on her arms. Resident C's record was reviewed on 2/5/25 at 11:46 a.m. The diagnoses included, but were not limited to, vascular dementia and diabetes mellitus. The resident was receiving hospice care. A Significant Change Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident had short and long term memory problems, was dependent for all activities of daily living, had skin tears present, and received hospice care. The Wound Report indicated a skin tears were identified on the right forearm and right hand on 1/31/25. During an interview on 2/5/25 at 2:30 p.m. the Assistant Director of Nursing (ADON) indicated there were no investigations for the causes of the skin tears. The resident would pick at her skin when she was uncomfortable and there was no care plan with interventions for picking at the skin. The Corporate RN Consultant indicated the skin tears were to be investigated to determine the cause of the tear. This citation relates to Complaint IN00451858. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure a resident's pressure ulcers were assessed thoroughly and timely, the Physician was notified timely of a decline in a pressure ulcer, and an intervention to prevent pressure ulcers was in place, for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: During an observation and interviews on 2/5/25 from 8:45 a.m. to 9:42 a.m., CNA 1 and CNA 2 entered Resident C's room to provide care. When the resident was turned to the right side, there was a large dressing on the left hip with copious amount of bloody drainage that was seeping under the dressing onto the pad underneath the resident and a foul odor was present from the dressing. There was a dressing also observed on the sacral area. At 9:24 a.m., the Assistant Director of Nursing (ADON) entered the room and indicated she was also the Wound Nurse. The ADON indicated she completed wound rounds with the Wound Nurse Practitioner (NP) weekly. Resident C was on hospice and the Wound NP did not see the resident weekly. The ADON completed the wound care and indicated the left hip had two wounds. The ADON estimated the first left hip wound as Length (L) 4 centimeters (cm) by width (W) 3 cm and the second wound was estimated at (L)7 cm by (W) 4 cm with a small area of 0.5 cm depth and slough covering the rest of the wound. The ADON indicated the areas had declined and the odor, drainage, and slough were new to the area. She was just made aware that the treatment to the left hip had been changed and was unsure when the Hospice Nurse changed the treatment orders, as it had not been communicated to her. The ADON indicated the left hip had just been covered with a dressing prior to the calcium alginate (wound treatment for wounds with drainage). A dry dressing was removed from the sacral area. There were two wounds on the sacral area. The ADON indicated both wounds were unstageable due to the necrotic tissue and the areas had declined. She did not complete skin checks and assessments on every resident. The nurses completed weekly skin assessments and were to notify her if there was a concern. Resident C's record was reviewed on 2/5/25 at 11:46 a.m. The diagnoses included, but were not limited to, vascular dementia and diabetes mellitus. The resident was receiving hospice care. A Care Plan, dated 11/7/24, indicated there was a potential for impairment of the skin. The interventions included, the treatments would be completed as ordered. A Re-admission Skin Assessment, dated 12/2/24 at 7:48 p.m., indicated the left buttock had a 3.6 cm by 2.4 cm (length and width was not specified) open area that was superficial. A Nurse's Progress Note, dated 12/2/24 at 8:22 p.m., clarified the open area was on the right buttock not the left buttock. A Physician's Order, dated 12/2/24, indicated a foam dressing was to be used on the right buttock for protection. The order was discontinued on 12/5/24. A Significant Change Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident had short and long term memory problems, was dependent for all activities of daily living, had an indwelling urinary catheter, was frequently incontinent of bowels, had no unhealed pressure ulcers, had skin tears present, and received hospice care. A Weekly Skin Assessment, dated 12/16/24 at 9:57 p.m., indicated there was a stage two (partial thickness of skin) wound on the right buttock and the coccyx had fragile skin. There were no measurements of the open area on the right buttock. A Weekly Skin Assessment, dated 12/23/24, indicated a stage two area on the right buttock, the coccyx was red, and a protective dressing was used for the right buttock area. The pressure areas were not measured or described. A Physician's Order, dated 12/28/24 and discontinued 12/31/24, indicated the sacral area was to be cleansed with soap and water, patted dry and a sacral foam dressing was to be applied for protection on Tuesdays, Thursdays, and Saturdays for skin maintenance. A Physician's Order, dated 1/2/25, indicated the sacral area was to be cleansed with soap and water, patted dry, and a sacral foam dressing was to be used for protection. The treatment was to be completed on Tuesdays, Thursdays, and Saturdays for skin maintenance. A Weekly Skin assessment, dated 1/3/25 at 5:31 p.m., indicated the right buttock area had a stage two pressure area and a treatment was in place. The coccyx (sacral) area was red and a prophylactic dressing was used for the area. There were no Weekly Skin Assessments completed from 12/23/24 to 1/3/25. The right buttock and coccyx areas were not measured or thoroughly described. A Weekly Skin Assessment, dated 1/25/25 and completed by RN 3, indicated the right buttock was unstageable (depth of the wound cannot be determined due to eschar or slough) and the sacral area was red. A hydrocolloid dressing was used for the sacral area. There were no Weekly Skin Assessments completed from 1/3/25 through 1/25/25. There were no measurements or thorough descriptions of the pressure areas on the 1/25/25 assessment. There was no documentation the Wound Nurse, Physician, and family had been notified of the decline of the right buttock pressure area. A Care Plan, dated 1/27/25 and revised on 2/5/25, indicated a pressure ulcer was present on the right buttock. The interventions included the treatment would be completed as ordered. The Care Plan did not indicate other pressure ulcers were present. A Physician's Order, dated 12/28/25 and discontinued on 1/31/25, indicated the bilateral hips were to be cleansed with soap and water, patted dry and a hydrocolloid (protective dressing) was to applied to the area for protection on every Tuesday, Thursday, and Saturday evening. There were no skin assessments of the bilateral hips that indicated there were open areas or the condition of the skin. A Hospice Nurse's Note, dated 1/10/25 at 1:15 p.m., indicated a large stage three (full thickness tissue loss) wound was present on the left hip that had declined from a stage two. The ADON was notified. The wound was cleansed and a foam dressing was applied. There was no thorough assessment of the left hip wound that indicated a size and description of the area. A Hospice Nurse's Note, dated 1/31/25 at 1:45 p.m., indicated the stage three area on the left hip was observed. There was odorous drainage on the old dressing and no warmth to the area. The facility staff were notified and informed the dressing needed to be changed daily. There had been no documentation of changes in the left hip status from 1/10/25 to 1/31/25. The area had not been assessed by the facility. A Physician's Order, dated 1/31/25, indicated on 2/1/25, the bilateral hips were to be cleansed with soap and water, patted dry, calcium alginate was to be applied and then covered with a foam dressing daily. There were no thorough assessments of the pressure area on the left hip that indicated the size or description. A Weekly Skin Assessment, dated 2/4/25 and completed by RN 3, indicated the sacral area was red and a hydrocolloid dressing was used for protection. The right buttock remained unstageable and a treatment was in place. There were no measurement or thorough description of the pressure areas on the assessment. There was no assessment of the left hip. During an interview on 2/5/25 at 10 a.m., the ADON indicated the Weekly Skin Assessments were to be completed by the nurses and the nurses would either contact her by writing/alert charting or orally about the concerns. The nurses were responsible for obtaining treatment orders. The nurses were not responsible for assessments/staging and measurements. The ADON looked at the wound areas on Thursdays or sooner, if I can get to them, for the initial assessment. She did rounds with the Wound NP on Thursdays and pictures were taken along with the measurements. She did not assess a pressure area unless the area was open. The ADON indicated no one had notified her the resident's left hip area had opened. The Wound NP did not consult on/assess Resident C. She had just seen the calcium alginate order for the left hip this morning. During an telephone interview on 2/5/25 at 11 a.m., the Hospice Nurse, indicated she would inform the nurse taking care of the resident of any changes and updates. The pressure areas were unavoidable due to the resident's decline in status and nutrition. During an interview on 2/5/25 at 2:30 p.m., the ADON indicated the bilateral hips were not being assessed on the weekly skin assessment. There was no area of concern on the right hip and the order should state the treatment was for the left hip. She indicated there had been no assessments or measurements of the left hip and sacral area completed. The care plan was not correct for the pressure area on the right buttock and the information was taken from the weekly skin assessments. During an interview on 2/5/25 at 2:40 p.m., the ADON indicated there was no open area on the right buttock and the treatment to right buttock had been discontinued 12/5/24 During an observation on 2/5/25 at 2:52 p.m., the resident was lying in bed, the low air loss mattress was not turned on nor plugged in. The ADON indicated at the time of the observation, she was unsure how long the air flow on the bed had been turned off. There was no pressure area located on the right buttock. The ADON indicated she was unsure why staff were documenting there was an area on the right buttock. During a telephone interview on 2/6/25 at 1:28 a.m., RN 3 indicated he had marked the wrong area and there was not an unstageable area on the right buttock. The unstageable area was on the sacral area and was necrotic. The ADON had not been notified, as it was assumed she had already known about the area. A facility skin condition assessment policy, dated 6/8/18 and received from the ADON as current, indicated pressure ulcers would be assessed and measured at least weekly by a licensed nurse and documented in the resident's record. The nurse was to observe the wound daily or with dressing changes. Any drainage, redness, pain will be documented in the Nurses' Progress Notes. A pressure ulcer policy, dated 1/17/18 and received from the Corporate RN Consultant as current, indicated a wound assessment was to be initiated and documented in the resident's record when a pressure ulcer was identified. Changes in the resident's skin was to be reported to the nurse and the nurse was to perform a detailed assessment. At the earliest sign of a pressure area, the resident, legal representative and the attending physician was to be notified. The initial observation was to be described in the the Nurses' Progress Notes. Pressure area were to be measured at least weekly and recorded in centimeters in the clinical record. The wound assessment was to be completed and to include the site/location, size in length, width, and depth, the stage of the pressure ulcer, odor, drainage, and description. This citation relates to Complaint IN00451858. 3.1-40(a)(2) 3.1-40(a)(3)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to a resident (Resident C) who was in Enhanced Barrier Precautions (EBP), for two random observations for infection control. Finding includes: During an observation on 2/5/25 at 8:45 a.m., CNA 1 and CNA 2 entered Resident C's room to provide care. There was a sign on the resident's door which indicated the resident required EBP and there was PPE stored in a container in the hallway. An indwelling urinary catheter was present and CNA 1 indicated the resident had skin tears and pressure ulcers. CNA 1 and CNA 2 wore gloves and no gowns. They were stopped prior to starting care. CNA 1 and CNA 2 indicated they should have a gown on while providing care. During an observation on 2/5/25 at 11:49 a.m., CNA 2 and LPN 5 were at Resident C's bedside and was repositioning the resident in bed. They wore gloves. They were not wearing a gown. LPN 5 indicated EBP PPE should have been worn during care. Cross reference F684. A EPB facility policy, dated 5/7/24 and received from the Corporate RN Consultant as current, indicated EBP was to be utilized for residents with chronic wounds and/or indwelling catheters. 3.1-18(b)

Based on observation and interview, the facility failed to ensure medications were properly stored for 2 of 4 medication carts observed. (ACU Cart, and [NAME] 1 Cart) Findings include: 1. On 9/20/24 at 2:33 p.m., the ACU Medication Cart was observed with Agency QMA 1. There were multiple pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The QMA indicated that was the first day she had worked on the cart. 2. On 9/20/24 at 2:47 p.m., the [NAME] 1 Medication Cart was observed with RN 2. There were multiple pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The RN indicated that nursing was responsible to clean the carts. During an interview on 9/20/24 at 2:45 p.m., the Assistant Director of Nursing indicated the Director of Nursing was usually responsible to make sure the carts were cleaned. 3.1-25(j) 3.1-25(o)

Based on record review and interview, the facility failed to ensure residents maintained an acceptable parameter of nutritional status, related to weights not obtained as ordered by a Physician and interventions for documented weight loss not initiated timely resulting in a significant weight loss. (Resident D) The facility also failed to document all meal intakes, the percentage of dietary supplements consumed as weight loss interventions, initiate interventions of weight loss timely, and to notify the Physician and Responsible Party in a timely manner of weight loss for 3 of 3 residents reviewed for weight loss. (Residents D, G, and F) Findings include: 1. Resident D's record was reviewed on 6/8/23 at 9:10 a.m. The diagnoses included, but were not limited to, dementia. An Admission Minimum Data Set assessment, dated 2/25/23, indicated a moderately impaired cognitive status, able to feed herself with set up, weighed 111 pounds, had no significant weight loss or gain, and was on a therapeutic diet. A Care Plan, dated 2/27/23, indicated a history of weight loss. The interventions included the weight would be obtained and monitored per facility protocol, the dietary intakes would be monitored and recorded with each meal, and the Registered Dietician (RD) would evaluate and make diet change recommendations as needed. A Physician's Order, dated 2/22/23, indicated a no added salt diet. A Physician's Order, dated 2/27/23, indicated a weekly weight was to be obtained for four weeks. The weekly weights indicated on 2/27/23 the weight was 112 pounds and on 3/2/23 the weight was 112 pounds. The weights were not obtained and an NA (not applicable) was marked for the weekly weights of 3/13/23 and 3/20/23. The weight on 4/6/23 (next weight after the 3/2/23 weight) was 101.5 pounds, which was a 9.37% weight loss in a month. There was no documentation the Physician and Responsible Party had been notified of the significant weight loss on 4/6/23. No weight loss interventions were initiated at the time of the significant weight loss. No re-weigh was obtained after the weight of 4/6/23 to ensure accuracy. A Registered Dietician (RD) Progress Note, dated 4/13/23, indicated the weight was 101.5 pounds, a 9.4% weight loss in 30 days. The body mass index (BMI) was 18.6, which indicated underweight, and she had consumed 50-100% of most meals. A house supplement twice a day to help with calories and protein was recommended. A Physician's Order was received on 4/13/23 for the house supplement to be given twice a day. Another weight was obtained on 5/4/23 and was 101 pounds. A Physician's Order, dated 5/5/23, indicated Ensure pudding was to be given three times a day and mirtazapine (antidepressant, used as appetite stimulant) 7.5 mg (milligrams) was to be given at bed time. The order for the pudding was discontinued on 5/17/23. The Nurses' Progress Notes, dated 5/5/23 at 8:36 p.m., 5/6/23 at 12:15 p.m., 5/6/23 at 3:20 p.m., and 5/7/23 at 6:52 p.m., indicated the Ensure pudding had been unavailable and had not been given as ordered. An RD Progress Note, dated 5/17/23, indicated the resident was underweight, mirtazapine was ordered on 5/5/23 to enhance her appetite and the house supplement was administered three times a day. A Physician's Order, dated 6/7/23, indicated the house supplement was to be given three times a day and the mirtazpine was increased to 15 mg at bed time. The Medication Administration Record, dated 4/2023 and 5/2023, indicated the house supplements had been given to the resident, the amount consumed had not been documented. The diet intake records for the past 30 days (May 12 to June 7), indicated meals were not monitored for breakfast on May 12, 27, 28, 29, 30, 2023 and June 1, 5, and 7, 2023, for lunch on May 27, 28, 29, 30, 2023 and June 1, 2, 5, and 7, 2023, and for supper on June 6, 2023. On 6/8/23 at 12:00 p.m., the Director of Nursing (DON) and Administrator were informed of the weights not obtained as ordered, a significant weight loss was present when the weight was obtained and interventions had not been initiated for seven days after the significant weight loss. They were also informed the Physician and Responsible Party had not been notified timely. No further information was received at the time. During an interview on 6/8/23 at 1:40 p.m., the DON indicated the Ensure pudding had been discontinued due to the inability to get it. She was unsure why fortified pudding or other nutritional supplements available at the facility were not given. 2. Resident G's record was reviewed on 6/8/23 at 2:20 p.m. The diagnoses included, but were not limited to, dementia. A Quarterly MDS assessment, dated 2/22/23, indicated a moderately impaired cognitive status, able to feed herself with set up, weighed 100 pounds, had a significant weight loss, was on a prescribed weight loss regimen, and was on a mechanically altered diet. A Care Plan, dated 11/20/22, indicated she left 25% or more of her food uneaten for most meals and refuses/failure to eat. The interventions included, provide dietary supplements as ordered and monitor and record intake every shift. The monthly weights were: On 11/7/23 - 113 pounds. On 12/4/22 - 109.5 pounds. On 1/3/23 - 101 pounds. On 2/9/23 - 100 pounds. On 3/2/23 - 99 pounds. On 4/4/23 - 91 pounds. On 5/4/23 - 97 pounds a 14.15% weight loss in 6 months The Physician's Orders, indicated a mechanical soft diet on 11/7/22, mirtazpine 15 mg at bed time on 11/9/22, and health shakes with meals were ordered on 1/3/23. A Physician's Order, dated 5/18/23, two weeks after the significant weight loss, indicated house nutritional supplement twice a day. The Nurses' Progress Notes lacked documentation that the Responsible Party and Physician had been notified of the significant weight loss on 5/4/23. A re-weight had not been obtained. An RD Progress Note, dated 5/17/23, indicated a nutritional risk due to an unplanned weight loss of 14.2% in six months. She consumed 50-75% of meals and had a house nutritional supplement twice a day. The plan of care was appropriate to meet the estimated nutrition needs at this time. The MAR, dated 5/2023, indicated the house supplement was provided. The amount consumed had not been documented. The Dietary intake forms for the past 30 days, dated 5/12/23 through 6/8/23, indicated there had been no dietary intake for breakfast and lunch on 5/12/23, lunch on 5/15/23, breakfast and lunch on 5/21/23, lunch on 5/24/23, breakfast and lunch on 5/26/23, supper on 6/1/23, lunch and supper on 6/2/23, breakfast, lunch and supper on 6/3/23, breakfast and lunch on 6/4/23, breakfast and lunch on 6/6/23, and breakfast, lunch, and supper on 6/7/23. On 6/8/23 at 4 p.m., the Administrator indicated the planned weight loss on the MDS assessment was incorrect. 3. Resident F's record was reviewed on 6/8/23 at 12:49 p.m. The diagnoses included, but were not limited to, Parkinson's disease. A Quarterly MDS assessment, dated 3/7/23, indicated a moderately impaired cognitive status, required limited assistance with meals, weight was 123 pounds, had a significant weight loss, and was on a therapeutic diet. A Care Plan, dated 11/16/21 and revised on 6/6/23, indicated she was on a therapeutic diet. The interventions included encouragement to consume the diet ordered. The Care Plan had not been updated with the significant weight loss. The monthly weights were: On 11/8/22 - 140 pounds. On 12/14/23 - 132.5 pounds. On 1/4/23 - 131 pounds. On 2/14/23 - 130.5 pounds. On 3/2/23 - 122.5 pounds, a 6.13% weight loss from the previous month. On 4/6/23 - 120.5 pounds. On 5/8/23 - 123.5 pounds, a 11.8% weight loss in 6 months. There was no documentation that indicated the Physician and Responsible Party had been notified of the 6.13% weight loss on 3/2/23 and on 5/8/23. The had been no re-weight completed. The Physician's Orders indicated a 120 milliliters of a house supplement was administered from 12/19/22 to 3/6/23, 120 milliliters of health shake was administered from 3/7/23 to 5/17/23, a no added salt diet was ordered on 4/14/23, and a house supplement was to be given three times a day starting on 5/18/23. The MAR, dated 5/2023 and 6/2023, indicated the supplements had been given, the amount consumed had not been documented. A RD's Progress Note, dated 5/17/23, indicated the resident was a nutritional risk related to an unplanned weight loss at 11.8% in 6 months, which could be related to the Parkinson's disease. She consumed 50-100% of most meals and the house nutritional supplement three times a day had been clarified. The nutritional approach was adequate to meet the nutritional needs with intervention clarified. The Dietary intake forms for the past 30 days, dated 5/12/23 through 6/8/23 indicated there had been no dietary intake for lunch on 5/12/23, breakfast and lunch on 5/27/23, 5/28/23, 5/29/23, 5/30/23, Lunch on 6/1/23, breakfast and lunch on 6/5/23 and 6/7/23. A facility policy on weights, dated 11/14/23 and received from the DON as current, indicated residents identified at a nutritional risk may be weighed weekly or bi-weekly. A re-weight should be obtained if there is a difference of five pounds or greater (loss or gain) since the previous recorded weight. The re-weight should be taken as soon as possible, usually within 72 hours, prior to calling the Physician. Undesired weights of gains/losses of 5% in 30 days, 7.5% in three months, or 10% in six months were to be reported to the Physician, the RD and/or the Dietary Manager. A House Nutritional Supplement policy, received as current from the Dietary Manager on 6/8/23 at 1:05 p.m., indicated residents identified as needing additional nutrition interventions related to unplanned weight loss may consist of pudding, ice cream, health shakes, chocolate milk, Med Pass, a super donut, cookies and fortified cookies, a Magic Cup, name brand supplements if available, and yogurt/frozen yogurt. A facility policy for Physician and family notification, dated 11/13/18, indicated the Physician and family would be notified with a significant change in status or a need to alter treatment. This Federal tag relates to Complaint IN00408033. 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure interventions were in place for a resident with a history of falls, which resulted in a fractured clavicle sustained during another fall for 1 of 5 residents reviewed for accidents. (Resident B) Finding includes: Resident B's record was reviewed on 11/3/22 at 9:20 a.m. The resident was admitted on [DATE]. Diagnoses included, but was not limited to, dementia. A Significant Change Minimum Data Set assessment, dated 9/27/22, indicated the resident had significant cognitive impairment, and required extensive two person assistance for bed mobility. A Fall Care Plan, dated 8/18/22, indicated the resident was at high risk for falls due to generalized weakness and impaired cognition. Interventions included anticipate resident need, bed height where feet are flat on the floor, proper foot wear and encourage call light use. A Progress Note, dated 8/27/22, indicated the resident had been found on the floor next to her bed. She was complaining of pain and had decreased range of motion. She was sent to the emergency room (ER) for evaluation and returned to the facility with no major injury noted. Actions indicated an intervention of a floor mat was to be added. An Interdisciplinary Team Note, dated 8/29/22, indicated interventions and care plan were updated. The Fall Care Plan had no updates at that time. A Progress Note, dated 9/20/22, indicated the resident had again been found on the floor next to her bed. The resident was noted to have an injury to the left side of her head, so was sent to the ER for evaluation. The resident returned to the facility later that day with a diagnosis of a left clavicle fracture. Interview with the Director of Nursing (DON) on 11/4/22, indicated the intervention of a floor mat had not been implemented and the care plan had not been updated after the first fall on 8/27/22. The current policy, Fall Prevention Program, was provided by the DON on 11/3/22, indicated, .Accident/ Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions This Federal tag relates to Complaint IN00388875. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure residents received necessary treatment and services to promote healing of pressure ulcers, related to not thoroughly assessing pressure ulcers, not accurately completing weekly skin observations, orders for treatments not obtained timely, and treatments and interventions were not completed as ordered, which resulted in a resident's pressure ulcers becoming stage 3 and unstageable, for 2 of 3 residents reviewed for pressure ulcers. (Residents G and C) Findings include: 1. During an observation on 2/20/19 at 9:11 a.m., resident G was lying in bed. His bilateral feet were elevated on a pillow. There were no heel protectors on the feet. During an observation on 2/21/19 at 10:35 a.m. with LPN 1, there was a wound dressing on the left heel dated 2/19/19 and no dressing on the left lateral foot. The resident's feet were resting directly on the mattress with no heel protectors. LPN 1 turned the resident to the left side and there was a loose dressing located on the right hip, dated 2/17/19. LPN 1 removed the dressing from the right hip and there was no open area under the dressing. LPN 1 indicated it looked like the dressing had shifted from another area. LPN was unable to turn the resident completely on his side and the RN Nurse Consultant then entered the room to assist. Once the resident was turned completely onto the left side, there was no dressing on the open area on the coccyx/left buttock open area. There was a moderate amount of blood tinged drainage located on the incontinent pad underneath the resident. The RN Nurse Consultant indicated to LPN 1 the CNA had informed her (LPN 1) earlier that morning the dressing was off of the coccyx/left buttock area. LPN 1 indicated no one had informed her the dressing was off of the coccyx/left buttock area and the CNA's would have informed LPN 2. During an interview on 2/21/19 at 10:42 a.m., LPN 2 indicated no one had informed her the dressing was off the coccyx/left buttock area and if she would have known, she would have replaced it immediately. During an interview on 2/21/19 at 10:45 a.m., CNA 1 indicated the resident was on her assignment and she last checked him at 8 a.m. and CNA 2 assisted her with the care. During the care at 8 a.m., there was a dressing on the coccyx/left buttock area. She indicated she had not paid attention to the date on the dressing. During an interview on 2/21/19 at 10:50 a.m., CNA 2 indicated she had assisted CNA 1 with care for the resident and she did not remember if the dressing was on the coccyx/left buttock. Resident G's record was reviewed on 2/20/19 at 4:28 p.m. The [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, dated 1/1/19, indicated a moderately impaired cognition status, no behaviors, required extensive assistance of two for bed mobility and dependent on two for transfers, required extensive assistance for dressing and personal hygiene, dependent for bathing, had a urinary catheter, was always incontinent of bowel, and had no unhealed pressure ulcers. The care plans indicated: 10/24/18 - Activities of Daily Living (ADL) deficit. Interventions included, turn and reposition, shifting weight to enhance circulation every 2-3 hours. 12/26/18 - potential for further pressure ulcers. The interventions included, cushion when in the wheelchair, pressure reducing mattress, encourage to change position frequently, and notify the Physician for red or open areas. (undated) - bowel incontinence. The interventions included, monitor skin and report any areas of breakdown. 2/19/19 - pressure ulcer to the right and left lateral feet and left buttock. The resident refuses to turn/reposition. The interventions included, off load heels with pillow in bed, supplements as ordered, treatments as ordered, and turn and reposition every two hours and as needed. A Skin-Pressure/Diabetic/Venous/Arterial Wound Report, dated 2/3/19, indicated there were new wounds on the left dorsal outer foot, acquired in-house, and was a pressure injury which measured 1.5 inches in diameter. The pressure injury had not been staged or assessed for tissue status. It was documented the Physician and family were notified on 2/3/19 and under List Any New Orders, was documented ADON (Assistant Director of Nursing), Wound Nurse would evaluate for orders. A Weekly Skin assessment, dated 2/4/19, indicated the skin was intact, no skin concerns on the feet and no skin condition concerns. A Skin-Pressure/Diabetic/Venous/Arterial Wound Report, dated 2/5/19, indicated there were new wounds: - Wound #1 was located on the left lateral foot, was acquired, a pressure injury, and was unstageable (full thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed due to slough or eschar). The wound was measured at 3.8 centimeters (cm) by 3 cm, and was first observed on 2/5/19. The tissue was 100% necrotic/eschar and the treatment was to apply [MEDICATION NAME] daily. - Wound #2 was located on the right lateral foot, was an acquired in house pressure injury and was a deep tissue injury (DTI) (pressure related injury to the tissue under intact skin). Measured 0.3 cm x 0.2 cm, first observed 2/5/19 with 100% necrotic/eschar tissue. The treatment was to apply [MEDICATION NAME] daily. The Wound Physician assessed the resident on 2/5/19, and documented the following: - The area on the left buttock was healed - The left lateral foot was unstageable at 3.8 cm x 3.0 cm and had 100% eschar. The treatment was to apply [MEDICATION NAME] every three days. - The right lateral foot was unstageable at 0.3 cm x 0.2 cm and had 100% eschar. The treatment was to apply [MEDICATION NAME] every three days. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The MAR, dated 2/2019, indicated a weekly skin assessment was completed on 2/11/19. There were no findings documented. The Wound Physician assessed the resident on 2/13/19 and documented the following: - Left lateral foot wound measured 2.8 cm x 2.5 cm with 100% eschar. The treatment ordered was to apply [MEDICATION NAME] daily. - Left heel measured 1 cm x 1 cm x 0.3 cm with 100% granulated tissue. The treatment ordered was alginate (absorbing wound dressing) dressing every three days and heel protector was to be worn. - Left buttocks (reopened) measured 9 cm x 4 cm x 0.1 cm with 50% slough. The treatment ordered was Santyl ([MEDICATION NAME] agent) every day after cleansing and cover with a dry dressing. - There was no assessment of the right lateral foot. A physician's orders [REDACTED]. The MAR, dated 2/2019, indicated the treatment to the left and right lateral feet, sacrum/coccyx, and left heel started on 2/15/19. The Wound Physician assessed the resident on 2/19/19 and documented the following: - Left lateral foot, unstageable, and measured 3.5 cm x 3 cm, declined in condition and to use [MEDICATION NAME] every day. - Left heel, stage 3 (full thickness skin loss), measured 4.2 cm by 4.6 cm and 0.1 cm depth. The status declined. Alginate was to be used every three days after cleansing and specialized foam dressing was to be used and a heel protector. - Left buttock, unstageable, declined, 8 cm x 6.2 cm and 0.1 cm depth. There was no dressing in place and the area was 50% slough and 25% eschar. The treatment was to be a nickel thick layer of Santyl after cleansing and cover with moist gauze every day. - There was no assessment of the right lateral foot. The MAR, dated 2/2019, indicated the left heel treatment had been completed on 2/19/19. there were no initials to indicated the treatment had been completed on 2/20/19. The MAR, dated 2/2019, indicated by a lack of initials, the treatment of [REDACTED]. During an interview on 2/21/19 at 11:54 a.m. with the RN Consultant and the DON (Director of Nursing), the RN Consultant indicated the left dorsal foot area was not thoroughly assessed until 2/5/19. The skin assessment on 2/4/19 did not indicate there were any skin condition concerns. The RN Consultant had completed rounds with the Wound Physician on 2/5/19 and the [MEDICATION NAME] was ordered every day. She had written the order for [MEDICATION NAME] to be applied to the bilateral heels on 2/7/19 and clarified it on 2/14/19 that it should have been applied to the right and left lateral feet. She was unsure about the status of the right lateral foot since there had not been further assessments since 2/5/19. She indicated the left heel treatment and the left buttock treatment had not been started until 2/15/19. During an observation on 2/21/19 at 12:17 p.m. with the RN Consultant, there was an orange discoloration of [MEDICATION NAME] located on the right lateral foot. The RN Consultant indicated the area had healed. She indicated if the area was healed, the treatment should have been discontinued after the Physician was notified. She was unsure how long the right foot had been healed. 2. Resident C's record was reviewed on 2/19/19 at 9:54 a.m. The [DIAGNOSES REDACTED]. An Admission MDS assessment, dated 1/21/19, indicated a severely impaired cognitive status, no behaviors, extensive assistance of two for bed mobility,transfer, dressing, eating, toileting, and hygiene. The resident was always incontinent of bowel, had a urinary catheter, had unhealed pressure sores of one stage 1 (skin intact, red and nonblanchable), one stage 2 (partial thickness skin loss), one stage 3 (full thickness of skin loss), and one unstageable area upon admission, no pressure reducing device for the chair or bed, no turn or repositioning program, no nutrition or hydration interventions for the skin problems, no pressure ulcer/injury care, and no ointments or medications for the pressure areas. The Nurse's Admission Assessment, dated 1/14/19, indicated the coccyx was red and there was a dressing to the left heel, which the resident refused to allow the nurse to take off for a full assessment and became agitated when an assessment was attempted. The admission orders [REDACTED]. An Allevyn (foam) dressing was to be applied to the bilateral buttocks every Tuesday and Friday. There was a lack of documentation to indicate the orders from the transferring facility were transcribed and started. The care plan indicated: 1/18/19 - potential of impairment to skin integrity. The interventions included, medications as ordered, encourage good nutrition and hydration in order to promote healthier skin, minimize pressure over bony prominence, diet as ordered, monitor nutritional status and dietary needs, and treatment per orders. 2/6/19 - pressure ulcer to sacrum/coccyx, and left heel related to immobility. The interventions included, medication as ordered, treatments as ordered and monitor for effectiveness. A Physician's Progress Note, dated 1/15/19 at 5:59 p.m., indicated the right heel measured 1 cm x 1 cm, was a stage 1, and was covered by a protective foam dressing. The left heel was wrapped in gauze and had an approximate 6 cm x 4 cm unstageable pressure ulcer with eschar present. A physician's orders [REDACTED]. The MAR, dated 1/2019, indicated the skin prep to the heels was started on 1/17/19 on night shift. The resident's heel areas were not treated from 1/14/19 to 1/17/19. A Nurse's Progress Note, dated 1/18/19 at 9:57 a.m., indicated the left heel was a deep tissue injury, measured 5.5 cm x 4 cm and had black necrotic tissue. The right heel measured 1 cm x 1 cm and was red and blanchable. The Nurse Practitioner was in the facility and ordered skin prep to the heels every shift. A Nurse's Progress Note, dated 1/22/19 at 1:25 p.m., indicated the Wound Physician assessed the resident and new orders for [MEDICATION NAME] to the left heel and leave open to air, and a right heel foam dressing was to be applied to the right heel every three days. A foam dressing was to be applied every three days to the left and right buttocks. A Wound physician progress notes [REDACTED]. - Left heel had an unstageable pressure injury, which measured 4.6 cm by 4 cm, with 100% eschar. The treatment ordered was breadline every three days. - Right heel had an intact reddened area which was unblanchable and measured 1 cm x 1 cm. The treatment was a foam dressing. - Right buttock was a stage 3, measured 3 cm by 1.5 cm by 0.1 cm with 40% slough. The treatment was a foam dressing. - Left buttock, was a stage 2 and measured 6 cm by 1 cm by 0.1 cm. The treatment was foam dressing. The physician's orders [REDACTED]. - [MEDICATION NAME] swab to the left heel every three days. - Foam dressing pad to buttocks every three days and as needed after cleansing the left and right buttocks. - Foam dressing circular border pad to right heel every three days after cleansing for [MEDICATION NAME]. The area on the buttocks had not been treated from 1/14/19 to 1/22/19 The Registered Dietician assessed the resident on 2/7/19 due to the pressure sores and recommended a Magic Cup (nutritional supplement) twice a day and Prostat (protein supplement) three times a day for wound healing and weight gain. The physician's orders [REDACTED]. During an interview on 2/20/19 at 10:40 a.m. , the Dietary Manager indicated the Registered Dietician evaluated all new admissions and any resident with a wound. During an interview on 2/20/19 at 11:06 a.m., the Registered Dietician indicated she had been in the building on 1/17/19 and had not been notified the resident had wounds. If she would have been notified, an assessment would have been completed at that time instead of waiting until 2/7/19. During an interview on 2/20/19 at 1:46 p.m., the RN Consultant indicated the protocol has been the nurses can measure and describe the wound, but cannot stage the wound. The Wound Nurse or designee was to see the resident within 24 hours to assess and stage the area. A facility policy, dated 1/15/18, titled, Pressure Ulcer Prevention, received from the RN Consultant as current, indicated, .Inspect the skin several times daily during bathing, hygiene, and repositioning measures Turn dependent resident approximately every two hours or as needed . A facility policy, dated 6/8/18, titled, Skin condition Assessment & Monitoring - Pressure and Non-Pressure, received as current from the Director of Nursing, indicated, .Pressure and other ulcers .will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record .A skin condition assessment .will be completed at the time of admission/readmission .A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by license nurse. Each resident will be observed for skin breakdown daily during care .A wound assessment for each identified wound .will be completed and will include: a. site location b. size .c. stage of wound .f. description .Dressings which are applies to pressure ulcers .shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness . An undated facility policy, titled, Nutrition Referral for the Dietician, received from the Dietary Manager on 2/20/19 as current, indicated, Residents with possible nutritional problems with be (sic) referred to the regional dietitian consultant .Nursing staff will use the referral form to notify the dietitian of residents at nutritional risk .new or worsening pressure ulcers .The regional dietician consultant will communicate nutritional interventions to the community . This Federal Tag relates to Complaint IN 500. 3.1- 40(a)(2)

Based on record review and interview, the facility failed to identify and implement plans of action to correct quality deficiencies related to falls and grievances for 3 of 3 residents with falls (Residents #J, #L , and #K) and 2 of 3 residents with grievances (Residents #C and #J) in a total sample of 11. Findings include: 1. Resident #J's record was reviewed on 10/28/15 at 1:55 p.m. The resident's [DIAGNOSES REDACTED]. The Resident's Record indicated the resident had fallen on 08/13/15 at 10:09 a.m. and 10/17/15 at 3:02 p.m. During an interview on 10/28/15 at 2:37 p.m., the Director of Nursing (DoN) indicated she had not documented the resident's interview. The DoN indicated she had not interviewed the CNA. During an interview on 10/28/15 at 8:40 a.m., Resident #J indicated she has had missing items. She indicated she had a ring missing and the ring was never found. She indicated she was unsure when the ring went missing. She indicated the facility had offered to replace it but she could not find one like the missing ring. Review of the Resident Council Minutes, indicated the Resident had voiced a grievance of two sweaters being missing during the 06/24/15, 07/28/15, 08/26/15, and 09/30/15 meetings. The resident also voiced the grievance of a diamond ring being missing during the 09/30/15 meeting. During an interview on 10/29/15 at 8:56 a.m., the Administrator indicated the Activity Director conducted the Resident Council Meetings and gave the concerns to Laundry. The Administrator indicated the A Resident Council Concern/Recommendation form had not been given to her. The Administrator indicated she could not remember if the missing diamond ring had been reported to her. She indicated there had been no follow-up on the missing items. 2. Resident #K's record was reviewed on 10/29/15 at 9:30 a.m. The resident's [DIAGNOSES REDACTED]. The Resident's Record indicated the resident had a fall on 08/16/15 at 6:50 p.m. During an interview on 10/29/15 at 9:02 a.m., the DoN indicated the resident's fall had not been investigated. 3. The record for Resident #L was reviewed on 10/29/15 at 10:39 a.m. The resident's [DIAGNOSES REDACTED]. The Resident's Record indicated the resident had fallen on 08/31/15 at 2:13 p.m. During an interview on 10/29/15 at 11:50 a.m., the Director of Nursing indicated an investigation was initiated on 9/1/15. The Director of Nursing indicated a Falls Investigation Worksheet was to be completed by Nursing staff at the time of a fall and this was not done related to the above fall with injuries. 4. Resident #C's record was reviewed on 10/28/15 at 2:51 p.m. The resident's [DIAGNOSES REDACTED]. A Grievance/Concern Form, dated 03/13/15, completed by the Social Service Director, indicated the concern was voiced by the past Director of Nursing (DoN). The Grievance/Concern Form indicated the DoN reported to the Social Service Director the resident was missing a gold wedding band. The Investigation/Follow-up indicated the Social Service Director spoke to the POA to get a description of the ring and the Social Service Director informed the Housekeeping Department and the Administrator to start the investigation. The form indicated the Administrator signed the and dated the form on 03/13/15 and the resolution indicated the POA was not able to give a description of the ring and the resolution was pending. A Social Service Progress Note, dated 05/18/15 at 10:44 a.m., indicated the Social Service Director notified the POA and left a message in regards to the resident's ring and was waiting for a return call. There were no further Progress Notes in the resident's record after 05/18/15. A typed letter, written by the Administrator, dated 08/14/15, and sent to the POA's Husband, indicated a good faith monetary amount was offered to the POA. There was no further follow-up on the missing ring. During an interview on 10/28/15 at 1:09 p.m., the Administrator indicated the Social Service Director was not in the facility. The Administrator indicated an investigation had not been completed on the missing ring. The Administrator indicated no one had followed-up with the POA until May. During an interview on 10/29/15 at 3:18 p.m., the Administrator indicated she was the Quality Assurance (QA) Coordinator. She indicated the committee meets monthly and the Supervisors meet daily. She indicated falls and grievances were discussed in the QA meetings. The Administrator indicated the committee discuss fall investigations. She indicated she was unaware the fall investigations were not completed and this should have been found during the QA process. She indicated the grievances should have been discussed in the morning meetings but had not been and she had not realized there had been a break in the system. This Federal Tag relates to Complaint IN 011. 3.1-52(b)(2)

Based on record review and interview, the facility failed to ensure residents' were free from accident hazards and received adequate assistance devices to prevent accidents related to transferring residents with a mechanical lift with 1 person assistance, and the residents fell or were lowered to the floor, which caused 1 resident to receive a fracture of the upper humerus bone (arm), and failed to thoroughly investigate the reason for the fall, for 3 of 3 residents reviewed for falls, in a total sample of 11. (Residents #J, #K, and #L) Findings include: 1. Resident #J's record was reviewed on 10/28/15 at 1:55 p.m. The resident's [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment, dated 06/05/15, indicated the resident's cognition was intact, required extensive assistance of two staff for bed mobility and transfers, and had impairment in movement of one of the upper and lower extremities. A care plan, initiated on 03/09/11, indicated the resident was a risk for falls. The interventions included utilize a sit to stand mechanical lift for transfers, initiated on 11/03/11. A Fall Assessment, dated 08/13/15, indicated the resident was a high risk for falls. A Nurses' Progress Note, dated 08/13/15 at 10:09 a.m., indicated the Nurse was called to the shower room to assist a CNA with the resident and upon entering the room the resident was holding onto the lift with her knees on the floor. The note indicated the resident complained of discomfort, rated a seven out of ten, to her right knee and the resident's Physician was notified. A Nurses' Progress Note, dated 08/14/15 at 2:32 a.m., indicated the resident complained of pain of the right leg and knee, rated a 10 out of 10, the right knee had an abrasion and redness of the right lower leg. A Nurses' Progress Note, dated 08/14/15 at 2:57 a.m., indicated the resident continued to complain of right knee, foot, and buttock pain. A Fall IDT (Interdisciplinary Team) Note, dated 08/17/15 at 10:46 a.m., indicated the resident was using the sit to stand lift. Her foot was not in the correct position and the staff member attempted to fix her foot and the resident would not let her. The note indicated when the staff member began to raise the lift, the resident's foot began to slip off the lift and the staff was unable to get the resident's feet back onto the lift so three staff members lowered the resident to the ground. The Root Cause of the fall was listed as improper foot placement and transfer technique and the staff was in-serviced about proper lift usage and foot placement. A Fall IDT Note, dated 08/17/15 at 10:58 a.m., indicated, Root cause of fall: Resident has previously been deemed by therapy as unsafe to use the sit to stand lift because of weakness and foot placement. Family and resident were previously educated about this and her risk for injury, but they still will not use anything but the sit to stand lift. It was recommended that she use the hoyer lift but refused to use it . A Physician's Progress Note, dated 08/21/15 at 1:01 p.m., indicated the resident had pain to the right leg from the hip to the ankle since the fall. The right side was flaccid post CVA (stroke), and the resident had not wanted an x-ray. A Nurses' Progress Note, dated 08/23/15 at 3:04 p.m., indicated the resident approved an x-ray and an order was received to x-ray the right knee, lower leg, ankle and foot. A Nurses' Progress Note, dated 08/23/15 at 7:22 p.m., indicated there were no fractures. During a telephone interview, on 10/28/15 at 3:02 p.m., with the Administrator present, CNA #7 indicated she had used the sit to stand lift without assistance from another staff member. She indicated she had tried to reposition the resident's feet and the resident said she was ok so she lifted the resident and pulled the lift out and the resident's foot started to slip, and the resident was lowered to the floor. CNA #7 indicated she did not know she was not suppose to use the mechanical lift by herself. An in-service form, dated 08/17/15, indicated, All lift transfers hoyer and sit to stand are to be done with two people. This is what the (Company Name) policy is . During an interview on 10/28/15 at 8:40 a.m., Resident #J indicated she had fallen from the sit to stand lift. She indicated there had been one CNA assisting with her transfer with the lift, and the CNA had her standing and attempted to sit her in the chair and she was not back far enough, so the CNA raised her up and attempted to place her in the chair again, and she still was not placed far enough back. Resident #J indicated the CNA had lifted her up again and then she had lost her grip on the hand hold of the lift and fell backwards to the floor. The resident indicated there was no sling being used. The resident indicated there were usually two staff who assist with the lift transfer but this time only one CNA had assisted her. A CNA Care Card, dated 10/01/15, indicated Resident #J was a two person assist with the sit to stand lift. A Nurses' Progress Note, dated 10/17/15 at 3:02 p.m., indicated, resident in sit to stand. affected arm slipped and resident was lowered to floor by nurses aid (sic) .resident complaining that right shoulder hurts and right knee hurts .ambulance called. A Nurses' Note, dated 10/17/15 at 7 p.m., indicated the resident had returned from the hospital and complained of pain of 10 on a scale of 1-10 to the right shoulder. A Fall Investigation Worksheet, dated 10/19/15, indicated the time of the fall on 10/17/15 was 1:40 p.m., the resident was up in the sit to stand lift and the affected arm (right) slipped and resident was lowered to the floor. The investigation indicated CNA #8 had been transferring the resident with one assistance and the resident was unable to use her right upper and lower extremity due to hemiparesis. The Indiana State Department of Health reportable incident report, dated 10/19/15, indicated the resident was diagnosed with [REDACTED]. A Physician's Progress Note, dated 10/21/15 at 1:29 p.m., indicated, .Pt (patient) reports that she fell .diagnosed with [REDACTED]. Pt returned to facility with sling to right arm. Pt. reports severe pain if someone touches her right hand . During an interview on 10/28/15 at 2:37 p.m., the Director of Nursing (DoN) the resident had never said there had been no sling used with the sit to stand transfer. The DoN indicated the resident had told her during the investigation she had fallen to the floor not lowered to the floor, after the CNA had moved the lift up and down 2-3 times during the transfer. The DoN indicated she had not documented the resident's interview. The DoN indicated she had not interviewed the CNA. During an interview on 10/28/15 at 3:30 p.m., CNA #9 indicated she had assisted the resident off the floor and the sit to stand lift was in the corner of the bathroom and the sling was attached to the lift. 2. Resident #K's record was reviewed on 10/29/15 at 9:30 a.m. The resident's [DIAGNOSES REDACTED]. A Quarterly MDS assessment, dated 06/06/15, indicated the resident's cognition was intact, had one sided upper and lower extremity impairments, and required extensive assistance of two for bed mobility and transfers. A care plan, initiated on 03/02/11, indicated the resident was a fall risk and the staff were to use a sit to stand life for all transfers (intervention added on 12/29/13). A care plan, dated 01/16/15, indicated the resident had impaired range of motion of the left upper and lower extremity due to hemiparesis and required passive range of motion to the left extremities. A Quarterly Clinical Summary, dated 06/11/15, at 1:25 a.m., indicated the resident was unable to bear weight, had impaired balance and weakness. A Nurses' Note, dated 08/16/15 at 11:02 p.m., indicated at 6:50 p.m., the resident was found on the floor on his back with the sit to stand lift upright next to the resident. The note indicated the sling was around the resident and the CNA said the lift had fallen over with the resident when the resident was being transferred to bed. The resident was assessed with [REDACTED]. The IDT Note, dated 08/17/15 at 11:17 a.m., indicated the resident was being transferred with the sit to stand lift and when the lift was close to the bed the staff closed the legs of the lift to get the lift under the bed frame and the lift started to tip to the side and the staff lowered the lift and resident down to the floor slowly. During an interview on 10/29/15 at 9:02 a.m., the DoN indicated the resident's fall had not been investigated and had not been reported due to there had been no injury. She indicated one CNA had attempted the transfer with the sit to stand lift. During an interview on 10/29/15 at 10:06 a.m., Resident #K Indicated there had been only one CNA using the lift the night of his fall. He indicated he had fallen over in the lift to the floor. He indicated his back hurt, but once he was in bed he didn't have any further pain. The CNA Performance Checklist, received from the Administrator on 10/29/15 at 2 p.m., titled, Using Mechanical Lift, indicated, .Assemble equipment and request help from co-workers . The Manufacturer's Instructions for the stand up lift, received from the DoN on 11/29/15 at 11:02 a.m., indicated, .The stand up lift may be operated by one healthcare professional for all lifting preparation, transferring from and transferring to procedures with a cooperative, partial weight -bearing patient. However, since medical conditions vary, healthcare professional evaluate the need for assistance and determine whether more than one assistant is appropriate in each case to safely perform the transfer .Individuals that use the standing patient sling must be able to support the majority of their own weight, otherwise injury may occur . 3. The record for Resident #L was reviewed on 10/29/15 at 10:39 a.m. The resident's [DIAGNOSES REDACTED]. Review of the 8/21/15 Minimum Data Set (MDS) Significant Change assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (0). A score of (0) indicated the resident's cognitive patterns were severely impaired. The assessment also indicated the resident had no behaviors. The assessment also indicated the resident required limited assistance of two staff members for bed mobility, dressing, eating, and personal hygiene. A Fall Risk assessment completed on 8/31/15 indicated the resident's score was (18). A score of (18) indicated the resident was at risk for falls. The resident's current Care Plans were reviewed. A Care Plan initiated on 10/9/14 indicated the resident had the potential for falls related to a history of falls and decreased mobility. The Care Plan was last reviewed on 8/27/15. Care Plan interventions included, but were not limited to, bed pad alarm, alarming seat belt to the wheel chair, anti tippers to the the front of the wheel chair, and keep her frequently used items in reach. The 8/2015 Nurses' Notes were reviewed. A late entry was entered on 8/31/15 at 2:25 p.m. The entry indicated at 2:13 p.m. the resident fell out of her wheel chair onto the floor. Injuries were noted and neurological checks were initiated. There was no documentation of the resident's Physician being notified of the fall at this time. Further entries on 8/31/15 indicated there was no documentation of the Physician being notified on 8/31/15 of the resident's fall and injuries. The 8/31/15 Witnessed Fall report was reviewed. The report indicated the resident was noted to have fallen forward from there wheel chair. The resident had a bloody nose and bruising starting to appear around her left eye. Neurological checks were initiated and the resident refused to leave cold compresses in place to her face. A small linear laceration was also noted to the bridge of the resident's nose. The laceration measured 2.5 cm in length. A Skin Condition report was initiated on 9/1/15 at 1:20 a.m. The report indicated the resident fell on [DATE] and bruising was noted to the resident's face. Bruising to the left eye lid measured 3.5 cm(centimeters) wide x 2 cm high and the left inner canthis to the cheek measured 3 cm x 0.5 cm. Bruising the right inner nose/eye area measured 2.5 cm x 0.5 cm. A CT scan of the facial bones was completed on 9/1/15 at 6:50 p.m. The CT scan results indicated there a medial angulations of the bridge of the left nasal bone suggestive of a fracture. The final impression indicated the finding could be acute but the exact onset was difficult to determine. When interviewed on 10/29/15 at 11:50 a.m. the Director of Nursing indicated the resident fell on [DATE] at 2:13 p.m. The Director of Nursing indicated she worked as a floor Nurse on the day shift on 9/1/15 and was assigned to care for Resident #L . The Director of Nursing indicated the night shift Nurse reported to her the resident had bruising which progressed through the night and the Physician had been faxed. The Director of Nursing indicated when she then assessed the black bruising was noted to the both her eye areas. Continued interview with the Director of Nursing indicated an investigation was initiated on 9/1/15. The Director of Nursing indicated a Falls Investigation Worksheet was to be completed by Nursing staff at the time of a fall and this was not done related to the above fall with injuries. Review of a Fall Investigation Worksheet form indicated staff were to complete information on the resident's current medications, behaviors past falls, assistive devices in place, medical changes in condition, a physical assessment of the resident, and the environmental factors. The form also Staff were to note interventions put into place at the time of the fall. The facility policy titled Fall Evaluation and Investigation was reviewed on 10/29/15 at 2:50 p.m. The policy had a revised date of 8/2013. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated when a resident fall occurred Licensed Nurses were to initiate an investigation at the time. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident had the needed supplies in the facility to care for a drainage catheter ([MEDICATION NAME]) placed in the pleural space (lung) to drain fluid accumulation in the pleural space, which caused a resident to exhibit signs of increased shortness of breath and increased anxiety, and the resident had to be transferred to the emergency room for drainage of the catheter, in which the hospital drained 700 milliliters of fluid and the resident's symptoms of increased shortness of breath and increased anxiety had resolved after the fluid had been drained. The facility also failed to assess the resident before the resident was transferred to the emergency room and failed to assess the resident's respiratory status before and after nebulizer treatments had been administered, for 1 of 3 residents reviewed for nebulizer treatments. (Resident # B) Finding includes: Resident #B's record was reviewed on 10/27/15 at 9:32 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted into the facility from an acute care hospital on [DATE]. The Admission/5-Day Minimum Data Set assessment, dated 09/18/15, indicated the resident's cognition was intact. A care plan, dated 09/23/15, indicated, the resident received steroids (anti-[MEDICAL CONDITION]) for pneumonia. The interventions included, administer nebulizer medications as ordered, assess for shortness of breath, assess vitals and lung sounds. The physician's orders [REDACTED]. The Nurses' Progress Notes indicated: 09/14/15 at 9:30 a.m.-Nebulizer was administered due to the resident complaining of shortness of breath and the oxygen saturation (O2 SAT) was 98% (normal 90-100%). 09/14/15 at 10:22 a.m.-writer made aware by floor nurse that pt (patient) [MEDICATION NAME] tube scheduled to be changed today. drainage (sic) kit ordered on [DATE] but has not arrived. medical records (sic) called supplier who stated it was enroute from Los Angeles , and would most likely arrive Wednesday 09/16/15. pt was complaining of sob per nurse who administered ned (sic) (nebulizer) tx (treatment) . 09/14/15 at 11:34 a.m. late entry for 9:45 a.m.-Res (resident) transferred from bed to gurney without incident . The Transfer Form, dated 09/14/15 at 10 a.m., indicated the resident was transferred to an acute care hospital for evaluation. No assessment was completed on the resident at the time of the transfer. The Ambulance report, dated 09/14/15 at 10:08 a.m., indicated the resident's complaint was respiratory distress, respirations were 26, and the O2 SAT was 98% on oxygen at three liters. The report indicated, .having difficulty breathing with 'fluid on the lungs that needs drained' .Last draining was this past Friday .Pt. presents in moderate distress .Breathing obviously labored. Noted minor wheezing at both upper lobes and decreased sounds at the bases .Pt. is oddment (sic) that he will be fine once the fluid is drained and is very upset at the nursing home delay . The Emergency Department Notes, dated 09/14/15, indicated a [DIAGNOSES REDACTED]. The notes indicated the resident was resting comfortably and in no acute distress after having the catheter drained. The resident indicated complete resolution of all of his symptoms after the drainage. The Emergency Department Physician's Note, dated 09/14/15, indicated, the resident's [MEDICATION NAME] had been drained three days ago, was scheduled to be drained today, and the facility was unable to drain the catheter because they had not received the equipment. The note indicated the resident had a breathing treatment hoping for some relief but the treatment had not helped. The Treatment Administration Record, dated 09/15, indicated the catheter was drained on Mondays, Wednesdays, and Fridays at the facility as ordered, after the Hospital drained the catheter on 09/14/15, and was also drained on 09/17/15 (Thursday), 09/19/15 (Saturday), and 09/201/5 (Sunday), with drainage being from 150 to 650 milliliters. During an interview on 10/27/15 at 11:52 a.m., the Medical Records Nurse (orders supplies), indicated the Admission Coordinator informed her about the resident's pleural catheter. She indicated she called and ordered the catheter and it should have come in on Friday. An order invoice, dated 09/10/15 (Thursday) at 11:39 a.m. Pacific Time, the one case (10 in a case) of [MEDICATION NAME] drainage kits had been ordered with overnight priority. An order tracking number had also been included on the invoice. During an interview on 10/27/15 at 12 p.m., with the Admission Coordinator and the Director of Nursing (DoN), the Admission Coordinator indicated she had been informed a day or two before the resident was to be admitted into the facility about the pleural drainage tube and had informed the DoN, the Assistant Director of Nursing (ADoN), and the Medical Records Nurse. The DoN indicated the catheter was ordered to be changed/drained on Thursday (09/10/15). The DoN indicated the orders for the drainage tube was on Monday, Wednesday, and Friday, and the facility thought they would get the drainage tube on time. She indicated they had received a drainage tube from another facility, after the resident had been sent to the emergency room . During an interview on 10/27/15 at 12:11 p.m., the Medical Records Nurse indicated she was unsure if she was in the facility on 09/11/15 when the supplies came in. She was unsure if she had checked the supplies to see if the catheter had arrived. She indicated she did not know the catheter had not arrived. During an interview on 10/27/15 at 12:20 p.m., the DoN indicated on 09/14/15 everything happened quickly. She indicated the resident started yelling and was insistent about wanting to go to the hospital. During an interview on 10/27/15 at 1:21 p.m., LPN #10 indicated on 09/14/15, the resident all of a sudden had shortness of breath and then she realized there were no supplies to drain his pleural catheter. During an interview on 10/28/15 at 10:12 a.m., the Medical Records Nurse indicated she was not working on Friday 09/11/15 and the staff put the supplies away. The Medication Administration Record, [REDACTED] 09/13/15 at 3:39 p.m. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/14/15 at 9:30 a.m. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/18/15 at 3:43 p.m. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/19/15 at 3:32 p.m. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/20/15 at 4:36 A.M. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/22/15 at 9:56 a.m. and no breath sounds were assessed during or after the treatment. No pulse and respirations were obtained after the treatment. 09/23/15 at 7:31 a.m. and 11:53 a.m. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/24/15 at 4:31 p.m. and 9 p.m. and no breath sounds were assessed during or after the treatment. No pulse and respirations were obtained after the treatment. 09/25/15 at 4:55 a.m., 2:44 p.m., and 8 p.m. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/26/15 at 12 a.m. and 4:29 a.m. and no breath sounds were assessed before/during/ or after the treatment. No pulse and respirations were obtained after the treatment. 09/26/15 at 10:26 a.m. and no breath sounds were assessed during or after the treatment. No pulse and respirations were obtained after the treatment. During an interview on 10/27/15 at 11:52 a.m., the DoN acknowledged the breathing assessments were not completed when the nebulizer treatment was administered. A facility policy, dated 08/14, received by the DoN as current, titled, Nebulizer Therapy, indicated, .Obtain pulse and respirations prior to beginning treatment and after treatment has been completed. Monitor breath sounds and cough after the treatment . This Federal Tag relates to Complaint IN 824. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a registered dietician's recommendations were followed in a timely manner for a resident with a significant weight loss, which resulted in continued weight loss, for 1 of 3 residents reviewed for weight loss in a total sample of 5. (Resident #B) Findings include: Resident #B's record was reviewed on 12/11/14 at 8:45 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted into the facility from an acute care hospital on [DATE]. The Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident required supervision for meals, had a weight of 157 with no significant weight loss (5% in 30 days or 10% in 180 days) in the past 30 or 90 days. The care plan, dated 07/08/14, indicated the resident was at risk for weight loss due to leaving 25% or more of food on the plate at some of the meals. The interventions included, diet as ordered, monitor weights, monitor intake. The resident's weights were as follows: 06/28/14- 157 07/07/14- 148.6 (5.35% weight loss in nine days) 07/10/14- 138 (12.10 % weight loss in 12 days) 07/18/14- 139 07/23/14- 137.4 (12.48% weight loss in 25 days) 07/28/14- 136 (13.40% weight loss in 30 days) 08/01/14- 140 A Dietary-Nutritional Risk Assessment, completed by the Registered Dietician, dated 07/02/14 at 11:07, indicated, "...Admission nutrition score of 6 indicates malnourished due to decreased meal intake recently...Weight 157# (pounds) 6/28/14. Weights in 2013 were 150-160#'s...Recently he ate less than 50% of two meals on 7/1/14...Resident with inadequate intake r/t (related to) recent surgery as evidenced by meal intake < (less than) 50% recently. Suggest health shakes BID (twice a day). There was a lack of documentation to indicate the Registered Dietician's recommendation was followed up. There were no Physician's orders for the health shakes twice a day. The dietary intake records did not indicate the resident received the health shakes as recommended. A Dietary-Nutritional at Risk note, written by the Dietary Manager, dated 07/09/14 at 12:54 p.m., indicated, "...Weekly weight 148...triggered a loss of 5.4% since 6/28/14...Supplements: (left blank)...Recommendation: continue nutritional at risk." There continued to be no follow up on the Registered Dietician's recommendation from 07/02/14 and the resident continued to loose weight (07/10/14-138 pounds). A Weight Change Note, written by the Dietary Manager, dated 07/10/14 at 3:36 p.m., indicated, "...138...-5.0% change...Will continue with weekly weights his weight is at low end of BMI (Body Mass Index) will recommend a health shake at supper meal to better meet nutritional needs." There continued to be no follow up on the Registered Dietician's recommendation from 07/02/14 and the resident continued to loose weight (07/10/14-138 pounds). A Physician's Order, dated 07/14/14, indicated a health shake was to be provided at each evening meal. A Physician's Order, dated 07/15/14, indicated a health shake was to be provided twice a day. (This was 13 days after the Registered Dietician recommended this and the resident continued to loose weight from 157 to 138 pounds) A Physician's Order, dated 07/16/14, indicated to provide health shakes at all meals. A Physician's Order, dated 07/14/14, indicated an order for [REDACTED]. The Dietary Intake Record, dated 07/14, indicated the resident received the first health shake on 07/15/14 at 5 p.m. and consumed 100%. The record indicated the health shake was offered on 07/16/14 at 5 p.m., and the resident did not consume any of the shake. The record indicated the health shake was then given to the resident with each meal, starting on 07/17/14 and the resident consumed 25-100% of the health shake. The Registered Dietician's Note, dated 07/15/14 at 9:45 a.m., indicated, "...Weight down to 148.6# 7/7/14 and 138# 7/10/14. Loss of 19# in 12 days...No reports of [MEDICAL CONDITION] found that could affect weights...Current weight represents 8.8% loss...Healthshakes and two cal (calorie)/Hi Cal ordered...Resident with inadequate intake r/t appetite...Recommend CMP (electrolyte panel) labs, continue supplements, continue weekly weights." A Physician's Order, dated 07/31/14, indicated to obtain a CMP one time only. This was 16 days after the Registered Dietician recommendation was made. The CMP was completed on 08/01/14. The resident's protein was low at 6.1 (normal 6.4-8.3) and the [MEDICATION NAME] was low at 3.1 (normal 3.4-5.2). The Registered Dietician's note, dated 08/28/14 at 11:29 a.m., indicated, "...receives Healthshakes with meals, often takes 100% of these. He also receives Two Cal/Hi Cal, increased to TID (three times a day) as recommended, he takes 60 cc of that as ordered. He eats 51-100% of Regular diet and takes 50-100% of super cereal at breakfast. Weight 138# this week, he has maintained in 4# range for the past 7 weeks...Supplements should promote repletion of alb ([MEDICATION NAME])..." During an interview on 12/11/14 at 9:45 a.m., with the RN Nursing Consultant, Dietary Manager, Director of Nursing, and Administrator present, the RN Nursing Consultant indicated there had been no follow up or supplements provided prior to 07/14/14. She indicated the CMP recommendation had not been completed until 07/31/14. The Dietary Manager indicated when the Registered Dietician makes recommendations, she (Dietary Manager) passes the information on to nursing and to the Assistant Director of Nursing and Director of Nursing and then she checks to make sure the recommendations are followed up. The Director of Nursing indicated the Physician should be notified with in 24 hours. The RN Nursing Consultant then indicated the facility usually has five days for follow up on recommendations. A facility policy, dated 03/12, titled, "Weights", and received from the Director of Nursing as current, indicated, "...The physician will be notified of significant weight changes by nursing...Dietary recommendations will be acted upon in a timely manner..." This Federal Tag relates to complaint IN 799. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to prevent, assess, and treat a resident for pressure ulcers resulting in a linear open area becoming a Stage III (full thickness of skin loss) pressure area; a Stage III pressure area between the scrotum and anus; a Stage III pressure area on the left lower buttock, and a Stage II area (partial thickness of skin loss), which is now classified as a Stage III on the right gluteal fold area of the buttock, without the staff being aware of the pressure areas for 1 of 3 residents reviewed for pressure areas in a sample of 9. (Resident #13) Findings include: Resident #13's record was reviewed on 12/17/10 at 10:40 a.m. The resident's [DIAGNOSES REDACTED]. A Bowel and Bladder assessment, dated 03/05/10 indicated the resident had short term memory loss, showed a urinary continence patten of greater than two hours, had, "functional (decreased mental awareness/decreased or loss of mobility or personal unwillingness)" incontinency, and was on a check and change program. The, "Analysis and Summary of Assessment Data", indicated, "resident is incontinent of bladder & bowel unable to participate on scheduled toileting due (sic) loss of mobility & personal unwillingness..." An updated, "Bowel and Bladder Quarterly Review", dated 11/24/10 indicated there had been no change in the resident's status and the resident was to continue on a check and change program. A, "Braden Scale" (predicts pressure sore risk), dated 11/24/10, indicated the resident's score was 15. The form indicated the resident had a mild risk for pressure sores with a score of 15. The resident's significant change, "Minimum Data Set" (MDS) assessment, dated 12/09/10, indicated a mental status score of six (severely impaired), the resident had difficulty communicating some words and may miss some part of the message,required extensive assistance of one person for bed mobility, dependent on staff for transfers, required extensive assistance for toilet use, and was dependent on staff for personal hygiene and bathing. The MDS indicated the resident had an indwelling catheter and was always incontinent of bowel. A care plan, dated 07/26/10 and revised 08/30/10, indicated the resident had an open area to the coccyx. The interventions included, "1. Treatment as ordered...6. Encourage resident to reposition every 2 hours and prn (as needed) while in bed and assist as needed...9. If resident is incontinent...provide peri-care as needed...cushions to prevent pressure. 13. non-compliant c/ (with) laying down." During an interview on 12/20/10 at 8 a.m., the Wound Nurse indicated the care plan should have been updated on 11/30/10. A care plan, dated 11/01/10, revised 12/15/10, indicated the resident required two people to assist with activities of daily living (ADL's). The interventions included, "...provide assistance with ADL's as needed...provide peri care at least every shift and after each incontinent episode..." A weekly skin assessment, dated 11/23/10, indicated the resident had a coccyx wound, which was being treated. A non-pressure ulcer skin condition record, dated 11/23/10 indicated the resident had a linear open area caused by moisture, which was 0.5 centimeters (cm) by 0.5 cm and 0.1 cm in depth and the wound bed was pink. A shower sheet, dated 11/25/10, indicated a bed bath was given and the resident had an old open area to the coccyx. The shower sheet indicated the resident had no other concerns about skin issues. A CNA, ADL sheet, dated 11/10, indicated peri care had been completed on the resident every shift November 28, 29, and 30, 2010. A physician's orders [REDACTED]. The "Medication Administration Record", (MAR), dated 11/10, indicated, " 09/24/10 Sensi-care Protective Ointment apply topically to buttocks & coccyx every shift & as needed for soiling". The MAR indicated [REDACTED]. A Nurses' Note, dated 11/30/10, indicated, "Res (resident) has o/a (open area) to R (right) gluteal fold stage II 5.0 x (by) 1.4 x 0.2 (in centimeters) red, (L) (left) buttock mid stage one 1.0 x 3.0 x <0.1 (cm) red nonblanchable, (l) buttock lower...3.0 x 2.0 x > 0.1 (cm) purple, between scrotum et (and) anus 4.0 x 3.0 x >0.3 (cm) , red/yellow slough..." The, "Pressure Ulcer Progress Reports", indicated: 1) The coccyx pressure ulcer progress report of 11/30/10 indicated the area measured in cm was 2 x 0.5 x 0.2, the color was red/yellow slough, was a Stage III and had serosanguineous (bloody) drainage. 2) 11/30/10, the right gluteal fold, measured in cm, 5.0 x 1.4 x 0.2, the color was red, was a Stage II, and had serosanguineous drainage. 3) 11/30/10, the left lower buttock, measured in cm, 3.0 x 2.0 x 0.1, the color was purple and was a suspected deep tissue injury. 4) 11/30/10, the area between the scrotum and anus was measured in cm, 4.0 x 3.0 x 0.3, the color was red/yellow/tan slough, and was a Stage III. A physician's orders [REDACTED]. A physician's orders [REDACTED]. (every day). 3) Santyl to necrotic area between scrotum and anus...." A pre-[MEDICATION NAME] (protein) result, dated 12/13/10, was 16.9 (normal 13.0-38.0). A facility investigation for the wounds, dated 11/30/10, and received from the Wound Nurse, indicated, "...What is the detailed suspected cause of the wound?...pressure/moisture...when was the resident last shower? 11/18/10. Did the CNA identify any new areas of concern on the shower sheet? no...concerns noted: res did not receive shower on 11/29/10 as scheduled, up too long in chair... Conclusions from the investigation and action plan if needed: res found to have wounds from being up (arrow) to (sic) long, showers not being done. Staff inserviced on peri care, lay down..." During an interview on 12/17/10 at 11:10 a.m., the Wound Nurse indicated she was informed about the gluteal fold area and then found the other areas when she was wiping the Sensicare from the resident's buttocks. During an interview on 12/17/10 at 11:30 a.m., the Wound Nurse indicated the nurses should have seen the areas when they were applying the Sensicream every shift. During an interview on 12/17/10 at 11:40 a.m., the ADoN (Assistant Director of Nursing), indicated the area between the scrotum and anus was a hard area to see. She indicated the CNA's should see the area with pericare and showers. During an interview with CNA #1 (CNA assigned to resident's hallway 11/29/10), on 12/17/10 at 12:20 p.m., she indicated she worked the hallway with another CNA. She indicated the other CNA was supposed to give the resident his shower. She indicated the facility did not assign rooms. During a telephone interview with CNA #2 on 12/17/10 at 12:25 p.m., she indicated the resident was supposed to get a shower. She indicated she was working the hallway with CNA #1 and CNA #1 was assigned the resident and should have given the resident his shower. She indicated she assisted CNA #1 with laying the resident down into bed. She indicated the resident does not mind being laid down and sometimes prefers not to get up in a chair. She indicated she could not remember if she looked at the resident's skin when she assisted CNA #1. A, "Daily Staffing" form, received from LPN #3, dated 11/29/10, indicated CNA #1 was assigned to Resident #13's room. During an interview on 12/17/10 at 1:15 p.m., the Wound Nurse indicated the resident had not received a shower as scheduled. She indicated the resident had not been laying down between meals prior to finding the pressure areas and the resident was probably in a chair too long. She indicated the incontinent residents were to be checked and changed every two hours and as needed. She indicated the resident would need to be laid down to change his wet brief. She indicated the areas should have been seen when the staff were doing peri care. During an interview on 12/17/10 at 1:25 p.m., CNA #1 indicated the resident was changed after every meal. She indicated the resident was laid down on 11/29/10 after breakfast and he did not have any red or open areas at all on his buttocks. The resident's pressure ulcers were observed with the facility's Wound Nurse on 12/20/10 at 9:45 a.m. The Wound Nurse indicated the following description of the pressure ulcers: 1) Coccyx- 1cm x 0.7cm x 0.2 cm, Stage III, red around the periwound and pink in the middle with small amount of serosanguineous drainage. 2) Left lower buttock-1 cm x 1.8 cm x 0.2 cm, between a Stage II and Stage III. The area was pink in the middle and the peri wound was pink, no drainage. There is a scab between 9 and 3 o'clock. 3) Scrotal/anal area- (which was visible upon the spreading of the resident's buttocks), 2 cm x 0.5 cm x 0.3 cm, Stage III. The area is pink without slough, no drainage with granulation tissue. 4) Gluteal fold- 1 cm x 0.5 cm, superficial, Stage II. The area is pink with granulation. The Wound Nurse indicated during the observation, she would notify the resident's physician to change the treatment for [REDACTED]. During an interview on 12/20/10 at 9:45 a.m., the resident indicated he did not mind laying down in bed after meals. He indicated he was very comfortable laying down. 3.1-40(a)(1) 3.1-40(a)(2)