Every finding on record at Aperion Care Kokomo

Based on interview and record review, the facility failed to ensure a resident's representative was notified when a resident was transferred to the hospital for 1 of 3 residents reviewed for notification. (Resident D) Findings include:During a telephone interview, on 8/11/26 at 11:50 a.m., Resident D's son indicated the facility did not notify him when Resident D was transferred to the hospital.The clinical record for Resident D was reviewed on 8/11/26 at 11:40 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting the left non-dominant side, cerebrovascular disease, cerebrovascular infarction, and type 2 diabetes mellitus. A progress note, dated 7/15/26 at 8:33 p.m., indicated Resident D was convulsing, 911 was phoned, and the resident was transported to the emergency room. Resident D's son, emergency contact #1, was phoned and a message was left to call the facility. A progress note, dated 7/16/26 at 5:03 a.m., indicated Resident D was returned to the facility by Emergency Medical Services.The clinical record for Resident D had two emergency contacts, contact #1 was his son and contact #2 was his daughter.There was no documentation in the clinical record to indicate the family was notified of the transfer to the hospital.During an interview, on 8/11/26 at 12:20 p.m., the Assistant Director of Nursing (ADON) indicated the resident had a second emergency contact listed as his daughter. The ADON indicated there had been no attempt to notify his second emergency contact. There was no documentation either of his emergency contacts were notified and there should have been.During an interview, on 8/11/26 at 1:18 p.m., LPN 2 indicated there was a list of emergency contacts, in numerical order, for the residents in their clinical record. LPN 2 indicated the emergency contacts are all to be attempted, until one was notified, when a resident was transferred to the hospital. The attempts and notification should be documented in the progress notes of the clinical record. A current facility policy, titled PHYSICIAN/FAMILY/RESPONSIBLE PARTY NOTIFICATION, revised on 10/2015 and received from the ADON on 8/11/26 at 1:10 p.m., indicated .To ensure medical care problems are communicated to the attending physician and family/responsible party in a timely, efficient and effective manner .A significant change in the resident's physical, mental or psychosocial status .A decision to transfer or discharge the resident from the facility This citation relates to Intake 3096987.410 IAC (Indiana Administrative Code) 3.1-5(a)(2)410 IAC (Indiana Administrative Code) 3.1-5(a)(4)

Based on interview and record review, the facility failed to ensure vital signs related to the physician's ordered parameters were obtained, neurological checks were completed after an unwitnessed fall, and a daily weight was obtained as ordered for 3 of 3 residents reviewed for quality of care. (Resident 1, C, and 40)Findings include:1. The clinical record for Resident 1 was reviewed on 7/8/26 at 10:03 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, coronary artery disease, and chronic pain.A physician's order, dated 2/13/26, indicated to administer metoprolol succinate (a medication used to treat high blood pressure and manage heart failure) 100 milligrams (mg) once a day and to hold the medication if the systolic blood pressure was less than 110 and/or the heart rate less than 60.A medication administration record (MAR), dated 6/2026, indicated Resident 1's heart rate was not obtained and documented with the administration of the metoprolol succinate.During an interview, on 7/10/26 at 9:31 a.m., LPN 3 indicated if a medication had administration parameters for the blood pressure and heart rate, both should be checked before administration. The vital signs for a medication would be charted on the MAR and/or a note placed to show the medication was held due to being outside of the parameters. During an interview, on 7/10/26 at 9:39 a.m., the Director of Nursing indicated both the blood pressure and pulse should be checked and charted on the MAR or in the vital sign record. When an order was entered into the electronic system, a parameter for the blood pressure or pulse could be checked. It would show up on the MAR and would be documented when the medication was administered.2. The clinical record for Resident C was reviewed on 7/9/26 at 11:19 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, chronic obstructive pulmonary disease, dementia, congestive heart failure, dependence on supplemental oxygen, anxiety, and depression.A facility fall occurrence note, dated 6/15/26 at 4:00 a.m., indicated Resident C had an unwitnessed fall and was found on the floor. Neurological checks were initiated. The neurological checks for Resident C were documented as completed on 6/15/26 at 4:01 a.m. and 4:31 a.m.There were no other neurological checks documented in the clinical record. During an interview, on 7/10/26 at 12:00 p.m., the Director of Nursing (DON) indicated Resident C was sent to the hospital on 6/15/26 at 11:38 a.m. Neurological checks should have been completed and documented between 4:31 a.m. and the time of transfer.3. The clinical record for Resident 40 was reviewed on 7/10/26 at 11:41 a.m. The diagnoses included, but were not limited to, congestive heart failure, atrial fibrillation, chronic respiratory failure, anxiety, chronic kidney disease, and high blood pressure. a. A facility fall occurrence note, dated 5/25/26 at 2:00 a.m., indicated Resident 40 had an unwitnessed fall and was observed lying on the floor. Neurological checks were initiated. The neurological checks for Resident 40 were documented as completed on 5/25/26 at 2:00 a.m., 2:15 a.m., 2:30 a.m., 2:47 a.m., and 5:47 p.m., and then on 5/26/26 at 12:50 a.m. and 4:53 a.m. There were no other neurological checks documented in the clinical record. During an interview, on 7/10/26 at 12:21 p.m., LPN 12 indicated when a resident fell, a fall report was opened, and neurological checks were automatically triggered for an unwitnessed fall. The neurological checks were to be completed every 15 minutes for 4 times, then every 30 minutes for 4 times, then every hour for 4 hours, and then every shift for 72 hours. b. A care plan, dated 3/18/26, indicated Resident 40 was at risk for decreased cardiac output related to heart failure. Interventions included, but were not limited to, to observe for edema, monitor lab, and report to the physician. A care plan, dated 3/18/26, indicated Resident 40 was on diuretic therapy related to edema. Interventions included, but were not limited to, administer diuretic medication as ordered and monitor for side effects and effectiveness. A physician's order, dated 3/25/26, indicated to obtain a daily weight for Resident 40 related to congestive heart failure and notify the physician if the resident had a weight gain of 3 pounds in a day or 5 pounds in a week. The medication administration record, dated May 2026, indicated there were six (6) days a weight was not obtained and there was no documentation related to a reason for the omission.The medication administration record, dated June 2026, indicated there were six (6) days a weight was not obtained and there was no documentation related to a reason for the omission.During an interview, on 7/10/26 at 9:41 a.m., the Director of Nursing (DON) indicated daily weights were to be obtained before breakfast, when possible. Daily weights were obtained on the day shift unless otherwise ordered. A CNA usually obtained the weight and reported back to the nurse. The nurse would then enter the result on the electronic record.A current facility policy, titled Medication Administration General Guidelines, undated and received from the Administrator in Training on 7/10/26 at 9:18 a.m., indicated .medications are administered in accordance with written orders of the prescriber.A current facility policy, titled Neurological Assessment, dated as revised on 8/1/24 and received from the DON on 7/10/26 at 11:47 a.m., indicated .residents will have a neurological assessment completed.unless otherwise ordered by physician, neuro checks will be completed at the time of.change in condition and every 4 hours for 24 hours.A current facility policy, titled Weights, dated as revised 10/17/19 and received from the DON on 7/10/26 at 11:30 a.m., indicated .each resident shall be weighed.in accordance with physicians orders or plan of care.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer and a wound assessment was completed when the wound was discovered for 1 of 3 residents reviewed for pressure ulcers. (Resident C) This deficient practice resulted in Resident C developing a pressure ulcer which was not discovered until it was a stage III (a serious full-thickness skin injury appearing as a deep, crater-like wound which exposes subcutaneous fat) The deficient practice was corrected on 12/2/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an observation, on 2/3/26 at 9:52 a.m., Resident C was lying in his bed. His coccyx dressing was dated 2/3/26. He indicated the dressing was changed a few minutes ago.During an interview, on 2/4/26 at 1:25 p.m., Resident C indicated the staff found the sore on his coccyx area when they bathed him. He had complained to staff it was very sore back there prior to them finding the wound.The clinical record for Resident C was reviewed on 2/4/26 at 1:45 p.m. The diagnoses included, but were not limited to, Parkinson's disease, history of falling, incontinence, abnormalities with gait and mobility, muscle weakness, and diarrhea.The Electronic Treatment Administration Record (ETAR), dated November 2025, indicated:a. On 11/1/25 to 11/15/25, hydrocolloid dressing was placed on the resident's coccyx area every other day for a preventative reason.b. On 11/27/25, hydrocolloid dressing was applied to the tailbone after cleansing the wound with soap and water.c. There was no physician order or documentation a preventative dressing was placed on Resident C's coccyx to prevent the stage III pressure ulcer from developing for the dates of 11/15/25 until 11/26/25.A nursing progress note, dated 11/28/25 at 10:25 a.m., indicated Resident C refused to get out of bed. He would not give the facility staff a reason why he refused to get out of bed. The resident was educated on the importance of offloading pressure areas. He voiced understanding, but when the staff attempted to turn and reposition him, he swatted at the staff and stated NO.A facility document, titled Pressure Injury, dated 11/28/25 at 4:00 p.m., indicated the staff reported to LPN 12 (the previous wound nurse) Resident C had a new area on his coccyx. The document indicated Resident C was unaware of the area. The resident was assessed on this date and new treatment orders were obtained. The Nurse Practitioner, DON, and resident's representative were notified of the new area, on 11/27/25.There was no documentation in the clinical record, on 11/27/25, to indicate who found the wound, the time the wound was found, the measurements of the wound, or observations of the wound.The area on his coccyx was not documented as assessed until 11/28/25.A wound summary, dated 11/28/25 at 4:38 p.m., indicated Resident C had a Stage III facility acquired pressure ulcer. The tissue type was 20% non-adherent slough (devitalized, non-viable necrotic tissue, usually yellow or white which sat loosely on the wound bed) and 80% pink or red non-granulating tissue. There was a light amount of serous drainage (clear, thin, watery fluid which leaks from wounds during the initial inflammatory phase of healing) draining from the pressure ulcer. There were no signs or symptoms of infection. The wound measured 6.8 centimeters (cm) in length by 5.6 cm in width by 0.20 cm in depth. The resident's wound was found on 11/26/25 at 10:30 p.m.A nursing progress note, dated 11/29/25 at 10:21 a.m., indicated a weekly skin observation was completed. Resident C had a stage III pressure ulcer on his coccyx and to see wound round notes for the wound information.A hospital document, titled Consult Orders, dated 12/3/25 at 1:03 p.m., indicated Resident C was admitted to the hospital from the nursing facility with a pressure injury to his sacrum (coccyx) which was an unstageable pressure ulcer measuring 5.5 cm by 3.8 cm. The wound bed was 30% granulation, 40% slough tissue and 30% eschar tissue (thick, dry, leathery layer of black, brown, or tan dead tissue). The tissue bed description was pink, red, yellow and brown with a scant amount of serosanguinous drainage. The peri wound (skin immediately surrounding the wound) was macerated (softened and whitening skin often caused by prolonged exposure to excessive moisture).A document, titled Initial Wound Evaluation & Management Summary, dated 12/11/25, indicated the wound physician completed an initial wound evaluation on Resident C's coccyx pressure ulcer. Resident C's pressure ulcer was stage III. The wound measured 2.2 cm by 3.0 cm by 0.2 cm. There was no drainage from the wound. The wound bed was 20% slough and 80% granulation tissue. The cause of the wound was pressure.A typed facility statement signed by LPN 12 (the previous wound nurse), undated and provided by the DON on 2/5/26 at 10:10 a.m., indicated on November 26, 2025, he was notified by a night shift nurse Resident C had developed an open area to his coccyx.During an interview, on 2/3/26 at 9:15 a.m., the Director of Nursing (DON) indicated the wound nurse quit approximately two weeks ago, so she and the ADON were sharing responsibility until they could hire another full-time wound nurse.During an interview, on 2/4/26 at 3:25 p.m., the DON indicated the nurse had found the stage III pressure wound on Resident C's coccyx and notified the wound nurse.A current facility policy, titled Skin Condition Assessment & Monitoring-Pressure and Non-Pressure, dated as revised on 6/8/18 and provided by the Executive Director on 2/3/26 at 10:58 a.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. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment.Care givers are responsible for promptly notifying the charge nurse of skin breakdown.The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.A disposable measuring device (one time use) will be used to measure dimensions, and if necessary, a clean cotton tipped applicator to measure wound depth/tunneling/undermining.The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative of any suspected wound infection.The deficient practice was corrected by 12/2/25 after the facility implemented a systemic plan that included the following actions: the facility completed resident skin sweeps and assessments, and interventions and care plans were updated accordingly. All nursing staff were educated on the risk for skin breakdown, turning and repositioning, rounding and documentation. Facility rounds were completed to ensure residents were getting up and preventative measures were implemented. The medical director was notified of the incident and reviewed the facility's immediate action plan.This citation relates to Intake 2684665 and 2731672.3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure equipment settings for prescribed oxygen flow rates were include in the clinical record for 4 of 5 residents reviewed for respiratory care. (Resident 52, 40, 34 and 36)Findings include: 1. During an observation, on 8/10/25 at 1:22 p.m., Resident 52 had oxygen per nasal cannula set at a flow rate of 3 and 1/2 liters per minute (L). During an observation, on 8/11/25 at 9:28 a.m., Resident 52 had oxygen per nasal cannula set at a flow rate of 4L. During an observation, on 8/12/25 at 10:12 a.m., Resident 52 had oxygen per nasal cannula set at a flow rate of 4L. During an observation, on 8/14/25 at 10:26 a.m., Resident 52 had oxygen per nasal cannula set at a flow rate of 5L. The clinical record for Resident 52 was reviewed on 8/12/25 at 10:32 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, emphysema, osteoarthritis, dementia without behavioral psychotic disturbance, mood disturbance, and anxiety. A care plan, dated 1/17/22, indicated Resident 52 was at risk for altered respiratory status. An intervention, last updated on 2/1/25, indicated the oxygen settings were oxygen via nasal cannula per the physician's order. There was no physician order which included the equipment settings for the prescribed oxygen flow rate for Resident 52. 2. During an observation, on 8/10/25 at 1:58 p.m., Resident 40 had oxygen per nasal cannula set at a flow rate of 2 and 1/2 liters per minute (L). During an observation, on 8/11/25 at 12:12 p.m., Resident 40 had oxygen per nasal cannula set at a flow rate of 2 and 1/2L. During an observation, on 8/15/25 at 9:02 a.m., Resident 40 had oxygen per nasal cannula set at a flow rate of 4L. The clinical record for Resident 40 was reviewed on 8/12/25 at 11:47 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, chronic obstructive pulmonary disorder, anxiety disorder, atrial fibrillation, and major depressive disorder. There was no physician order which included the equipment settings for the prescribed oxygen flow rate for Resident 40. 3. During an observation, on 8/10/25 at 11:45 a.m., Resident 34 had oxygen per nasal cannula set at a flow rate of 2L. During an observation, on 8/11/25 at 9:30 a.m., Resident 34 had oxygen per nasal cannula set at a flow rate of 2L. During an observation, on 8/12/25 at 9:26 a.m., Resident 34 had oxygen per nasal cannula set at a flow rate of 2L. During an observation, on 8/13/25 at 1:39 p.m., Resident 34 had oxygen per nasal cannula set at a flow rate of 2L. The clinical record for Resident 34 was reviewed on 8/12/25 at 10:36 a.m. The diagnoses included, but were not limited to, bipolar disorder, intermittent explosive disorder, insomnia, anxiety, high blood pressure, hyperlipidemia, borderline personality disorder, persistent mood disorder, iron deficiency anemia, history of liver cancer, and mild intellectual disabilities. There was no physician order which included the equipment settings for the prescribed oxygen flow rate for Resident 34. 4. During an observation, on 8/11/25 at 9:36 a.m., Resident 36 had oxygen per nasal cannula set at a flow rate of 3L. During an observation, on 8/12/25 at 9:27 a.m., Resident 36 had oxygen per nasal cannula set at a flow rate of 3L. During an observation, on 8/13/25 at 11:26 a.m., Resident 36 had oxygen per nasal cannula set at a flow rate of 3L. During an observation, on 8/14/25 at 10:37 a.m., Resident 36 had oxygen per nasal cannula set at a flow rate of 3L. The clinical record for Resident 36 was reviewed on 8/12/25 at 11:59 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting the left side, high blood pressure, diabetes mellitus, morbid obesity, anxiety, chronic obstructive pulmonary disorder, schizoaffective disorder, dysphagia, heart failure, and atrial fibrillation. There was no physician order which included the equipment settings for the prescribed oxygen flow rate for Resident 36. During an interview, on 8/12/25 at 2:39 p.m., the Regional Nurse Consultant indicated a nurse could start oxygen at a flow rate of 2L and titrate as a nursing measure. During an interview, on 8/14/25 at 12:06 p.m., the Director of Nursing (DON) indicated the facility did not have a specific policy for oxygen administration. The medication administration policy was followed. During an interview, on 8/14/2025 at 1:43 p.m., Registered Nurse (RN) 2 indicated a physician's order with liter flow would be needed to indicate where to set a resident's oxygen flow rate. If a liter flow rate was not found, the physician should be notified. A specific liter flow rate should be ordered when administering oxygen to a resident. During an interview, on 8/14/25 at 2:29 p.m., LPN 4 indicated a resident on oxygen should have an order with a specific liter flow rate and parameters to titrate. A current facility policy, titled Medication Administration General Guidelines, undated and received from the DON on 8/14/25 at 2:00 p.m., indicated .FIVE RIGHTS .right dose .are applied for each medication being administered. A triple check of these 5 rights is recommended 31-47(a)(6)

Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed related to hypertension, heart failure, and anticoagulation therapy for 1 of 20 residents reviewed for care plans. (Resident 52)Findings include:The clinical record for Resident 50 was reviewed on 8/12/25 at 10:32 a.m. The diagnoses included, but were not limited to, atrial fibrillation, cardiomyopathy, chronic systolic congestive heart failure, hypertension, acute embolism and thrombosis of deep veins, and history of pulmonary embolism. A physician's order, dated 7/8/25, indicated to administer apixaban (an anticoagulant medication) 5 milligrams (mg) by mouth one time daily.The care plans for Resident 50 did not include a care plan for hypertension, heart failure, or the use of anticoagulant medication. During an interview, on 8/13/25 at 1:22 p.m., the Director of Nursing (DON) indicated there were no care plans for hypertension, heart failure, or the use of anticoagulant medication. There should have been care plans in place.A current facility policy, titled Comprehensive Care Plan, dated as last revised 11/17/17 and received from the DON on 8/15/25 at 9:32 a.m., indicated .The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.3.1-35(a)

Based on interview and record review, the facility failed to ensure a physician's order was followed according to the ordered parameters for 1 of 5 residents reviewed for quality of care. (Resident 50)Findings include: The clinical record for Resident 50 was reviewed on 8/12/25 at 10:32 a.m. The diagnoses included, but were not limited to, atrial fibrillation, cardiomyopathy, chronic systolic congestive heart failure, hypertension, acute embolism and thrombosis of the deep veins, and a history of pulmonary embolism. A physician's order, dated 7/8/25, indicated give metoprolol tartrate (used to treat high blood pressure) by mouth two times a day for hypertension and to hold the medication for a systolic blood pressure of less than 120 or a heart rate of less than 60.A medication administration record (MAR), dated 7/1/25 through 7/31/25, indicated metoprolol was administered outside of the ordered parameters on:a. the morning of 7/25/25 with a systolic blood pressure of 109.b. the evening of 7/11/25 with a systolic blood pressure of 111.c. the evening of 7/14/25 with a systolic blood pressure of 111.d. the evening of 7/15/25 with a systolic blood pressure of 104.e. the evening of 7/18/25 with a systolic blood pressure of 108.f. the evening of 7/23/25 with a systolic blood pressure of 119. A MAR, dated 8/1/25 through 8/31/25, indicated metoprolol was administered outside of the ordered parameters on:a. the evening of 8/6/25 with a systolic blood pressure of 116.A care plan for hypertension or the use of a medication to treat high blood pressure was not located in the clinical record.During an interview, on 8/13/25 at 11:57 a.m., Qualified Medication Aide (QMA) 2 indicated if a resident's vital signs were outside the parameters for a medication, the medication would be held, and the supervising nurse would be informed. QMA 2 indicated a check mark in the box with initials next to the time on the medication administration record indicated the medication was given. A number in the box would mean the medication was held.During an interview, on 8/13/25 at 3:47 p.m., the Director of Nursing (DON) indicated medications should not be given if a resident's vital signs were outside the physician's ordered parameters.A current facility policy, titled Medication Administration General Guidelines, undated and received from the DON on 8/14/25 at 2:00 p.m., indicated .Medications are administered in accordance with written orders of the prescriber.3.1-37(a)

Based on interview and record review, the facility failed to ensure the resident or resident's representative received notification in writing of the facility's bed hold policy and the reason for the resident's transfer and discharge to the hospital for 1 of 2 residents reviewed for hospitalization. (Resident 36)Findings include:The clinical record for Resident 36 was reviewed on 8/12/25 at 11:59 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting the left side, hypertension, diabetes mellitus, bipolar disorder, morbid obesity, anxiety, insomnia, chronic obstructive pulmonary disease, schizoaffective disorder, dysphagia, heart failure, atrial fibrillation, a history of urinary tract infection, and kidney stones. A nursing progress note, dated 7/14/25 at 12:13 p.m., indicated Resident 36 had an altered level of consciousness and was sent to the emergency room via ambulance.A nursing progress note, dated 7/21/25 at 4:45 p.m., indicated Resident 36 was transported back to the facility from the hospital via ambulance.The clinical record did not include documentation the bed hold policy or the transfer and discharge summary was provided to Resident 36 or the resident's representative. During an interview, on 8/14/25 at 10:30 a.m., the Director of Nursing (DON) indicated there was no documentation the bed hold policy or the transfer and discharge summary was provided to Resident 36 or the resident's representative. A current facility policy, titled Bed Hold Policy Notice, dated 7/14/25 (the resident's transfer date) and received from the DON on 8/13/25 at 2:00 p.m., indicated Resident 36 was unable to sign at time of transfer and no copy was mailed to the representative. 3.1-12(a)(6)(A)(i)3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure staff completed an accurate admission assessment of a resident's pressure ulcer by a licensed nurse qualified to assess pressure wounds according to their policy and procedure for 1 of 1 new admission reviewed for a pressure ulcer. (Resident B) Finding includes: During a phone interview, on 12/2/24 at 12:31 p.m., a confidential interviewee indicated Resident B had a pressure ulcer which was almost healed when he arrived at this facility, on 7/12/24, but when he left the facility to be hospitalized on [DATE], the pressure ulcer on his coccyx was a Stage 4. The clinical record for Resident B was reviewed on 12/2/24 at 1:19 p.m. The diagnoses included, but were not limited to, flaccid neuropathic bladder, complete paraplegia, and muscle wasting and atrophy. A rehabilitation hospital document, titled Wound Care Note, dated 6/21/24, from Resident B's admission prior to his admission to the facility indicated on admission to the hospital he presented with a sacral (coccyx) Deep Tissue Injury (DTI) (intact skin with localized area of persistent non-blanchable deep red, maroon, and purple discoloration due to damage of underlying soft tissue) which evolved to an unstageable pressure wound. The physical exam of the coccyx wound, dated 7/8/24 at 9:00 p.m., indicated Resident B's pressure injury wound measurements were 9 cm (centimeters) wide, 5.5 cm long and 0.2 cm deep and the wound tissue had 20% slough attached to it (non-viable yellow, tan, gray, green or brown tissue; usually moist, could be soft, stringy and mucinous in texture) and/or eschar (dead or devitalized tissue that was hard or soft in texture; usually black, brown, or tan in color, and might appear scab-like). The stage was unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). A facility document for Resident B's admission, titled Admission/Re-Admission Observation dated 7/12/24 at 11:00 a.m., indicated Resident B had a sacrum pressure area, which measured approximately 2.5 cm in diameter with a yellowish and white wound bed with a pink center. The documentation of the pressure ulcer did not include the stage of the pressure ulcer and if there was any drainage observed. A facility document, titled Weekly Skin Observation, dated 7/16/24 at 8:30 a.m., indicated Resident B had a pressure wound to his coccyx area and his right buttock. The comment section area indicated no new areas were noted. The dressing and treatment were completed following his shower. The coccyx and right buttock pressure wounds lacked documentation of size (length x width x depth), stage of pressure ulcer, odor, drainage and description. A facility document, titled Initial Wound Evaluation & Management Summary, dated 7/23/24, indicated Resident B had an unstageable pressure wound to his coccyx. The wound measured 5 cm x 4.2 cm x 1.0 cm. There was a moderate amount of serosanguineous drainage. There was 100% necrotic tissue (necrotic tissue and eschar were usually firmly adherent to the base of the wound and often the sides/ edges of the wound). A hospital document, titled Inpatient Consult to Wound Care, dated 7/30/24, indicated Resident B had a pressure wound to his sacrum (coccyx). The wound was a deep, foul smelling open wound. The wound was open. The wound was present on admission. The stage 4 wound measured 5 cm x 4 cm x 3.5 cm, there was 90% slough and 10% bone was seen. The wound bed was black. The exposure was bone exposed with necrosis. There was scant amount of drainage from the wound with an odor coming from wound. During an interview, on 12/3/24 at 3:45 p.m., the Director of Nursing (DON) indicated the previous Assistant Director of Nursing (ADON) quit her position in July 2024 around the time the resident was admitted . The previous ADON was responsible for assessing and managing the wounds in the facility. A current policy, titled Pressure Injury and Skin Condition Assessment, dated 1/17/18 and provided by the Executive Director on 12/3/24 at 11:30 a.m., indicated .Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse, and documented in the resident's clinical record .A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse .Pressure injuries and other ulcers .will be measured at least weekly and recorded in centimeters in the resident's clinical record. 11. A wound assessment for each identified open area will be completed and will include: a. Site location b. Size (length x width x depth) c. Stage of Pressure ulcer d. Odor e. Drainage f. Description g. Date and initials of individual performing the assessment 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident's specialized wheelchair was treated with respect when the wheelchair was unable to be located after his discharge from the facility for 1 of 3 residents reviewed for personal property. (Resident B) Finding includes: A document, titled Intake Information, dated 11/22/24, indicated an anonymous person notified the Indiana Department of Health Resident B was loaned a Quickie QRI blue wheelchair from a specialized wheelchair company, when he was discharged from the rehabilitation hospital on 7/12/24. After he was admitted to the facility, he was placed in bed, and he never saw the loaner wheelchair again. He was transferred to the hospital on 7/30/24, and never returned to the facility. The facility was unable to find the loaner specialty wheelchair the resident was admitted to the facility in and his insurance company was being charged for the loaner chair. During an interview, on 12/2/24 at 12:05 p.m., the Executive Director (ED) indicated Resident B was transported to the facility from the hospital on 7/12/24, on a stretcher by ambulance to his room. She knew how he was transported because she was in her office when he was wheeled by on the stretcher. There was no specialty wheelchair in his room. She was notified sometime in October 2024, by his mother that he had been transported to the facility on the day of admission by a van in his wheelchair and she wanted the wheelchair back. The ED indicated she looked for a specialty wheelchair and could not find one anywhere in the facility. She told the resident's mother to give her a description of the wheelchair, so she knew exactly what she was looking for and the mother never gave her a description. She thought they were looking for a high-back wheelchair and they never found one of those in the facility. During a phone interview, on 12/2/24 at 12:31 p.m., a confidential interviewee indicated an ambulance company van brought Resident B in a specialty loaner wheelchair to the facility to use until he came home, then he would get a wheelchair custom made for him when he got home. He had to return the loaner prior to getting the custom build wheelchair. The confidential interviewee provided a description of the wheelchair with the serial number. The clinical record for Resident B was reviewed on 12/2/24 at 1:19 p.m. The diagnoses included, but were not limited to, flaccid neuropathic bladder, complete paraplegia, and muscle wasting and atrophy. A facility document, titled Admission-Admission Observation, dated 7/12/24 at 2:08 p.m., indicated the admission details for Resident B included, but were not limited to, arrival via ambulatory, stretcher or wheelchair (neither one of these options were selected as a way the resident arrived at the facility). The vitals area indicated at 2:40 p.m., the resident weighed 168 pounds using a wheelchair to weigh him. During an interview, on 12/2/24 at 4:45 p.m., Resident B indicated he was transported to the admitting facility on 7/12/24, via a van in the loaner wheelchair he was given at the hospital prior to discharge. When he arrived at the facility, he was taken out of his wheelchair, placed in bed, and his wheelchair was removed from his room. He never saw the loaner wheelchair again. During an interview, on 12/3/24 at 9:34 a.m., the Executive Director (ED) indicated if a resident was admitted with a wheelchair, the wheelchair should stay with the resident their entire stay at the facility. During an interview, on 12/3/24 at 10:35 a.m., the Assistant Director of Nursing (ADON) indicated the day Resident B was admitted , he turned his call light on shortly after he was admitted , and she answered the call light. He wanted to get up out of bed, so she got a wheelchair from therapy, but it was not comfortable for him, so she had physical therapy complete a wheelchair evaluation on him. During a phone interview, on 12/3/24 at 10:48 a.m., National Seating and Mobility in Indianapolis was called and Staff member 7 indicated a loaner Quickie QRI wheelchair was delivered to the Rehabilitation Hospital of Indiana (RHI) on 7/8/24, to Resident B, who was being discharged to Aperion Care Kokomo on 7/11/24. During a phone interview, on 12/3/24 at 11:50 a.m., Team Lead staff member for Health Information Management 8 called back from RHI indicating an ambulance company transported Resident B in an ambulance van via his loaner wheelchair to the facility. An outside entity company came to their facility to measure the resident, then provided the resident with a loaner wheelchair until his was built. During an interview, on 12/3/24 at 12:10 p.m., the Regional [NAME] President of Operations and LPN 12 was in attendance. LPN 12 indicated she was the nurse who admitted Resident B to the facility on [DATE]. He was pushed into his room in a wheelchair. He sat up in the wheelchair for a while after being admitted , then he was placed in bed to finish his admission assessment. She had no idea what happened to the wheelchair he was transported to the facility in after he was placed in bed. A current facility policy, titled Resident Rights, dated 1/4/19 and provided by the Executive Director on 12/2/24 at 1:19 p.m., indicated .These rights include the resident's right to .Retain and use personal possessions to the maximum extent that space and safety permit This citation relates to Complaint IN00447825. 3.1-9(a) 3.1-9(b) 3.1-9(c)

Based on interview and record review, the facility failed to ensure staff anchored an indwelling catheter with proper placement into a resident's bladder for 1 of 1 resident reviewed for an indwelling catheter. (Resident B) Finding includes: During a phone interview, on 12/2/24 at 12:31 p.m., a confidential interviewee indicated prior to Resident B being admitted to the hospital on 7/30/24, two nurses placed indwelling catheters in the wrong place and caused trauma to his urinary tube. The first nurse put too large of a tube in, and it had to be removed because of the blood in the catheter, then the second nurse put too large of a catheter in as well and it was inserted in the wrong place. The clinical record for Resident B was reviewed on 12/2/24 at 1:19 p.m. The diagnoses included, but were not limited to, flaccid neuropathic bladder, complete paraplegia, and muscle wasting and atrophy. A nursing progress note, dated 7/29/24 at 10:50 a.m., indicated an indwelling catheter size 16 French/10 cubic centimeter (cc) balloon was inserted into Resident B's bladder without difficulty for a diagnosis of neurogenic bladder. This progress note did not indicate if there was a urine return, or the color of the urine return when the indwelling catheter was anchored. A nursing progress note, dated 7/29/24 at 11:12 a.m., indicated the nurse who anchored the indwelling catheter on Resident B was called to his room by a CNA due to complaints of blood in his catheter. Upon entering the resident's room, there was a dark red fluid in the resident's catheter. The catheter was removed without difficulty. The nurse covered the urethral meatus and applied pressure after removing the catheter. After the resident was cleaned up, there was no bleeding noted to the opening of the urethra. A PRN (as needed) pain medication was given to the resident as requested. A nursing progress note, dated as a late entry on 7/29/24 at 3:20 p.m., indicated a 12 French indwelling urethral catheter with a six-cc balloon was anchored without difficulty. A large amount of bloody urine with blood clots drained into the catheter drainage bag and from around the catheter at the meatus. A hospital document, titled ED [Emergency Department] Progress Notes, dated 7/30/24 at 4:48 a.m., indicated the resident had an indwelling catheter, which was reportedly placed by the facility staff last night and it resulted in penile bleeding and hematuria (blood in the urine.) The abdomen and pelvis IV (intravenous) contrast CAT Scan completed on 7/30/24 at 6:43 a.m., indicated the indwelling catheter was malpositioned (not correctly placed) with the balloon blown up within the penile urethra. Urology was consulted for the malposition indwelling catheter. During an interview, on 12/3/24 at 11:11 a.m., the Regional [NAME] President of Operations indicated he did not have any further information to provide for the catheter anchored on 7/29/24, at the facility prior to the resident's hospitalization on [DATE]. The nurse should have documented if she got a urine return or not. A current policy, titled FOLEY CATHERIZATION AND REMOVAL, undated and provided by the Executive Director on 12/3/24 at 10:17 a.m., indicated .INSERTION PROCEDURE: Follow approved sterile technique for catheter insertion. (Same as straight catheter technique for male or female) Inflate balloon to the capacity with sterile water to test for balloon patency. Deflate for insertion, then re-inflate. 6. Pull catheter gently to be sure it is secured in the bladder .Document pertinent observations on nursing record 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident was able to receive personal funds when requested for 1 of 1 resident reviewed for personal funds. (Resident 36) Finding includes: During an interview, on 9/16/24 at 11:17 a.m., Resident 36 indicated she asked several times to get money from her account and she was not able to get money out of her account. An email, dated 9/17/24, from the Corporate Business Office Manager indicated she had deposited the resident's check into the AR side instead of her RFMS (Resident Fund Management Service) account. During an interview, on 9/23/24 at 9:27 a.m., the Administrator indicated the facility did not have a business office manager. The Corporate Business Office Manager was covering multiple facilities. During an interview, on 9/23/24 at 10:00 a.m., the Administrator indicated when the resident was discharged to another facility they cancelled Resident 36's funds. When the resident was readmitted , her funds were messed up. The resident's funds could take more than 30 days to get resolved. During an interview, on 9/23/24 at 12:07 p.m., the Corporate Business Office Manager indicated the RFMS (Resident Fund Management Service) rejected her funds. The resident's social security check was deposited into her account, and it was rejected. The facility had to reapply for her, and it took a while. They received a check for $333.00, and the Corporate Business Office Manager had deposited all the check into her facility patient liability billing account and did not deposit $50 to her personal account. During an interview, on 9/23/24 at 3:02 p.m., the Administrator indicated if the resident wanted the funds today, she would take the money out of the Administrator's personal funds to give to the resident. The Administrator's funds would be reimbursed from the corporate office. A current policy, titled Resident Funds, dated as revised 4/29/19 and received from the Administrator on 9/23/24 at 2:00 p.m., indicated .This facility manages the personal funds of residents when such request is made by the resident .The resident may choose to have the facility hold, safeguard, and manage his/her personal funds .Resident funds are deposited into an interest bearing resident trust fund account .Residents should have access to petty cash on an ongoing basis and be able to arrange for access for larger funds .Resident requests for access to their funds should be honored by facility staff as soon as possible but no later than .Three banking days for amounts of $100.00 ($50.00 for Medicaid residents) A current policy, titled Resident Rights, dated 8/23/17 and received from the Administrator on 9/23/24 at 9:00 p.m., indicated .To promote the exercise of rights for each resident .These rights include the resident's right to: Exercise his or her rights .If he or she wishes, have the facility manage his personal funds 3.1-6(e) 3.1-6(f)(1)

Based on observation, interview and record review, the facility failed to ensure a care plan was reviewed and revised as appropriate for 1 of 4 residents reviewed for accidents. (Resident 23) Finding includes: During daily observations, on 9/16/24, 9/17/24, 9/18/24, 9/19/24 and 9/20/24, a mattress was noted on the floor on the right side of Resident 23's bed with the left side of the bed positioned against the half wall in the room. The clinical record for Resident 23 was reviewed on 9/17/24 at 3:22 p.m. The diagnoses included, but were not limited to, seizures, schizoaffective disorder, depression, pseudobulbar affect, dementia- moderate with behavioral disturbance, cerebellar ataxia, bipolar disorder, chronic kidney disease-stage 3, intellectual disabilities, and atrial flutter. A Minimum Data Set (MDS) assessment, dated 3/26/24, indicated Resident 23 was discharged to an inpatient psychiatric facility and was expected to return to the facility. The resident was readmitted to the facility on [DATE]. A care plan, dated 6/10/24, indicated interventions included, but were not limited to, the resident was to be 1:1 with staff member at all times and Mattress against wall between wall and bed for resident safety. Both interventions were initiated on 3/22/24 with no revision date. The resident was not observed to be on 1:1 with a staff member or to have a mattress between the resident's bed and the wall. During an interview, on 9/20/24, the Director of Nursing (DON) indicated the care plan had not been updated to indicate the resident no longer needed to be 1:1 with a staff member and no longer needed a mattress against the wall beside her bed, following the resident's stay at an inpatient psychiatric facility. A current policy, titled Comprehensive Care Plan, dated as revised 11/17/17, indicated .A comprehensive care plan must be .reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments .The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to administer oxygen at the correct flow rate as ordered by the physician for 2 of 3 residents reviewed for respiratory care. (Residents 32 and 43) Findings include: 1. During an observation, on 9/16/24 at 4:03 p.m., Resident 32 was receiving oxygen at a flow rate of 2 liters per minute (LPM) via a nasal canula. During an observation, on 9/17/24 at 9:15 a.m., Resident 32 was receiving oxygen at a flow rate of 2 LPM via a nasal canula. During an observation, on 9/18/24 at 11:35 a.m., the resident was receiving oxygen at a flow rate of 2 LPM via a nasal canula. During an observation, on 9/19/24 at 1:29 p.m., Resident 32 was receiving oxygen at a flow rate of 2 LPM via a nasal canula. The clinical record for Resident 32 was reviewed on 9/19/24 at 12:35 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (not enough oxygen in the body), asthma, atrial fibrillation, dependence on supplemental oxygen, and anxiety disorder. A current care plan, dated as initiated and revised on 11/27/23, indicated to use oxygen therapy for altered respiratory status related to COPD, anxiety disorder, respiratory failure with hypoxia, and asthma. Interventions included, but were not limited to, administering oxygen via nasal canula according to the physician's order. A physician's order, dated 2/2/24, indicated to administer oxygen at 3 LPM via nasal canula continuously every day and night shift for COPD. A physician's progress note, dated 9/16/24, indicated the resident was dependent on 3 LPM of oxygen with a plan to continue the supplemental oxygen at 3 LPM continuously for the resident's COPD, asthma, and respiratory failure with hypoxia. A Medication Administration Record (MAR), dated 9/1/24 through 9/30/24, indicated the resident was administered 3 LPM of oxygen continuously. During an observation and interview, on 9/19/24 at 1:40 p.m., the Assistant Director of Nursing (ADON) indicated the resident was on 2 LPM of oxygen rather than the ordered 3 LPM. The ADON indicated the oxygen should be at the rate ordered by the physician. 46961 2. During an observation, on 9/17/24 at 11:29 a.m., Resident 43 was receiving oxygen at a flow rate of 4 LPM via a nasal canula. During an observation, on 9/19/24 at 2:38 p.m., the resident was receiving oxygen at a flow rate of 4 LPM via a nasal canula. During an observation, on 9/23/24 at 11:28 a.m., the resident was receiving oxygen at a flow rate between 3 and 3.5 LPM via a nasal canula. The clinical record for Resident 43 was reviewed on 9/17/24 at 4:24 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), anxiety, chronic kidney disease (CKD), and arteriosclerotic heart disease. A care plan, dated 6/20/23, indicated the resident was at risk for altered respiratory status/difficulty breathing related to morbid obesity, COPD, congestive heart failure (CHF), and a history of embolism and thrombosis. Approaches included, but were not limited to, O2 via NC (nasal cannula) per MD order. A physician's order, dated 6/20/24, indicated O2 at 3 LPM every day and night shift. A MAR, dated 9/1/24 to 9/30/24, indicated the resident received O2 at 3 LPM every day and night shift. During an interview, on 9/23/24 at 10:20 a.m., LPN 6 indicated the oxygen should have been at 3 LPM per the physician's order. A current policy, titled Oxygen Safety, undated and received from the Director of Nursing on 9/20/24 at 3:24 p.m., indicated .Oxygen is a prescribed drug and must have a Physician's order which outlines .liter flow .All changes in an order (liter flow .) must be verified by physician BEFORE changes are made. 31-47(a)(6)

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was in the facility at least 8 consecutive hours a day, 7 days a week for 5 of the days reviewed during the third quarter for RN coverage. (8/10, 8/11, 8/31, 9/1 and 9/14/24) Finding includes: A Payroll-Based Journal (PBJ) staffing report, for the third quarter of 2024, indicated the facility had failed to have licensed nursing coverage for 24 hour/day. During a record review, on 9/23/24 at 11:20 a.m., the actual worked staffing schedule indicated there was no RN coverage for 8/10, 8/11, 8/31, 9/1 and 9/14/24. During an interview, on 9/19/24 at 11:18 a.m., the Director of Nursing (DON) indicated RN 2 was on call for 8/10, 8/11, 8/31, 9/1 and 9/14/24. The nurse was not in the building on those days. During an interview, on 9/23/24 at 2:20 p.m., the Scheduler indicated other than management staff, the facility had one RN who worked every other weekend. The facility followed the state regulations and guidelines and did not have a policy for staffing. 3.1-17(b)(3)

Based on record review and interview, the facility failed to ensure medications were available and a resident received her scheduled medication as ordered for 1 of 1 resident reviewed for pharmacy services. (Resident 4) Finding includes: During an interview, on 9/16/24 at 11:42 a.m., Resident 4 indicated she had missed 2 days of her Oxybutynin (used for overactive bladder) and she had several incontinent episodes. She was told by staff the pharmacy was slow and had not delivered the medication. During an interview, on 9/18/24 at 11:29 a.m., Resident 4 indicated she did not receive her morning dose of Oxybutynin. The staff told her the pharmacy had not delivered it yet. The resident indicated she had not received her Oxybutynin for 3 days and had increased incontinence episodes. The clinical record for Resident 4 was reviewed on 9/18/24 at 8:49 a.m. The diagnoses included, but were not limited to, overactive bladder, rheumatoid arthritis, emphysema, and hypertension. A care plan, dated 12/24/22, indicated Resident 4 had an alteration in urinary elimination. Interventions included, but were not limited to, bladder assessments completed upon admission, quarterly and when needed and to monitor for incontinence and change as needed. A care plan, dated 12/24/22, indicated Resident 4 was incontinent of bowel and bladder. Interventions included, but were not limited to, monitor any possible causes of bladder incontinence. A physician's order, dated 6/20/24, indicated to give 1 tablet of Oxybutynin Chloride ER (Extended Release) 10 mg (milligrams) daily. A pharmacy signed delivery invoice indicated the resident received 14 tablets of Oxybutynin 10 mg ER tablets from the pharmacy on 8/24/24, and did not receive additional tablets until 9/18/24. During an interview, on 9/18/24 at 11:32 a.m., QMA 3 indicated the resident did not have the Oxybutynin 10 mg tablets in the drawer with the rest of her other pills. The medication was not available in the Emergency Drug Kit (EDK). QMA 3 looked in the bottom of the medication cart and found a card of Oxybutynin 10 mg ER containing 14 tabs which were received on 9/18/24. During an interview, on 9/19/24 at 1:24 p.m., the Director of Nursing (DON) indicated the pharmacy documentation indicated the resident went 7 days without her medication. The staff should have documented the medication was unavailable and contacted the pharmacy. During an interview, on 9/19/24 at 2:20 p.m., the resident indicated she received her medication, on 9/18/24 and 9/19/24, and her incontinent episodes were a lot less. A current policy, titled Medication Administration General Guidelines, undated and received from the DON on 9/18/24 at 4:27 p.m., indicated .If a medication with a current active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the emergency kit .If a dose of regularly scheduled medication is .not available .the space provided on the front of the MAR for that dosage administration is initialed and circled. 3.1-25(a) 3.1-25(g)(3)

Based on observation and record review, the facility failed to ensure eye drops were dated when opened and medication drawers were free of loose unidentified medications for 1 of 2 medication carts reviewed for medication storage. (walnut hall) Findings include: During an observation, on 9/23/24 at 3:04 p.m., 2 bottles of eye drops for Resident 49 were opened and in the top drawer of the medication cart. No open dates were on the bottle or plastic bag containing the bottles. The second drawer of the medication cart had 6 loose medications: 1 large green, 2 round white, 2 oval white and 1 small round yellow pill. A physician's order, dated 9/19/24, indicated to administer 1 drop of prednisolone acetate ophthalmic suspension to Resident 49 in both eyes. During an interview, on 9/23/24 at 3:07 p.m., QMA 3 indicated the eye drops should have had open dates on the package or bottle and the loose medications should have been removed and destroyed. A current policy, titled Storage of Medications, not dated and received from the Administrator on 9/23/24 at 1:57 p.m., indicated .certain medications or package types, such as I.V. solutions, multiple dose, injectable vials, ophthalmic, nitroglycerin tablets, once opened, required an expiration date shorter that the manufacturer's expiration date to insure medication and potency .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(m) 3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure food was served at the proper temperature, menus were followed, or residents were offered a substitution of nutritional value of their choice, and to ensure puree recipes were followed to ensure residents received nutritional adequacy for 1 of 1 resident and 2 of 2 cooks reviewed for food and diet. (Resident 32, [NAME] 4 and [NAME] 5) Findings include: 1. During an interview, on 9/17/24 at 10:07 a.m., Resident 32 indicated the food tasted terrible because they kept decreasing the budget and the food was often served cold. During an interview, on 9/18/24 at 12:05 p.m., Resident 32 indicated the fish was served very cold last evening, he was not sure if it was cooked all the way because it still seemed a little frozen in the middle, and the coleslaw was served at room temperature. During an interview, on 9/20/24 at 10:07 a.m., Resident 32 indicated according to the menu last evening he was to be served a bacon, lettuce, tomato (BLT) wrap with a salad but instead he received a grilled cheese sandwich with mashed potatoes and gravy. Resident 32 indicated this menu substitution happened routinely without them ever asking him what he would like as a substitute for his selection when they ran out of the menu items or had to serve something different because they did not have the correct ingredients. During an observation, on 9/20/24 at 12:36 p.m., the room tray cart with the 300 hall room trays were being passed out and a test tray was received at 12:51 p.m. During an observation and interview, on 9/20/24 at 12:51 p.m., the Dietary Manager (DM) tested the temperature of the items on the food tray. The temperature of the fish was 118.9. She indicated the temperature for the fish should be 145 degrees. The clinical record for Resident 32 was reviewed on 9/19/24 at 12:35 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, other asthma, bipolar disorder current episode hypomanic, recurrent major depressive disorder, atrial fibrillation, and anxiety disorder. A Minimum Data Set (MDS) assessment, dated 6/9/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. A current care plan, dated as initiated and revised on 11/27/23, included the problem of having the potential for a nutritional problem. 44598 2. During an observation, on 9/17/24 at 11:12 a.m., the facility menu indicated garlic bread was to be served for lunch. [NAME] 4 indicated the facility had one resident on a puree diet. The cook retrieved two slices of garlic bread from a metal pan and placed the garlic bread in the robot coupe (blender). She then added two Tablespoons of melted butter. The cook then added two and half cups of milk and started the blender. She looked inside the blender and stated the bread was too runny. The cook then added two slices of white bread. The Dietary Manager (DM) asked [NAME] 4 if she followed the recipe and had noticed [NAME] 4 used a four-cup measuring cup instead of a one cup measuring cup to measure the milk. The DM told [NAME] 4 the recipe called for 3/4 cup of milk, and she measured two and half cups instead. The extra milk made the bread too runny. 3. During an observation, on 9/17/24 at 11:05 a.m., [NAME] 5 placed a bowl of unmeasured cake into the robot coupe. She then took a gallon of milk and poured an unmeasured amount of milk into the blender. She blended the cake and milk and indicated it was still too thick. [NAME] 5 then added another unmeasured amount of milk and poured it into the robot coupe. She blended the mixer and scrapped the edges of the inside of the robot coupe. She indicated it was still too thick and added more milk. [NAME] 5 indicated she should have measured the ingredients and followed the recipe. During an interview, on 9/17/24 at 11:35 a.m., the DM indicated [NAME] 4 and [NAME] 5 were supposed to follow the recipes and they did not. A current policy, titled Pureed Food Preparation, dated 2020 and received from the DM on 9/17/24 at 1:35 p.m., indicated .Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value .Standardized recipes will be used to prepare all pureed foods .Serve with appropriate scoop number or divide equally to provide an equal number of portions. All of the pureed food must be used in order to deliver correct nutrient density to each resident .Review altered pureed recipes with the facility Registered Dietitian. Pureed foods will be the consistency of applesauce or smooth, mashed potatoes .Staff will be in-serviced on proper preparation of pureed foods 3.1-21(a)(1) 3.1-21(a)(2) 3.1-21(a)(3) 3.1-21(a)(4)

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity from a staff member for 4 of 8 residents reviewed respect and dignity. (Residents F, D, E and B) Findings include: 1. A facility document, titled Concern/Compliment Form, dated 10/23/23, indicated, on 10/23/23, Resident F asked her roommate to turn on the call button for her at approximately 8:00 p.m. LPN 2 went into her room to ask what she wanted. The resident indicated she wanted a pain pill and LPN 2 responded with I don't have time for that right now. The summary of pertinent findings indicated the resident received her pain medication, at 8:00 p.m., as routinely scheduled. 2. A facility document, titled Concern/Compliment Form, dated 12/11/23, indicated, on 12/8/23, Resident D asked to go to the Harmony unit to take her shower. The CNA went to check for a shower chair. The resident waited at the Harmony nurses' station. LPN 2 indicated I don't know why people can't stay on their own F***ing hallway. The resident went back to her room and took her shower on 12/9/23 instead. The summary of pertinent findings indicated the incident was partially substantiated. LPN 2 was spoken to and told this behavior was unacceptable and was not going to be tolerated. LPN 2 indicated she told Resident D she needed to take a shower on her hallway. She indicated to the resident the Harmony hallway had a lot of COVID residents on it at that time, so she should go back down to the Walnut hallway and request her shower be done there. The corrective actions taken indicated LPN 2 had to do customer service training on the computer and she was given a verbal warning, with the next step being a written warning. During an interview, on 1/24/24 at 2:45 p.m., Resident D indicated, on 12/8/23 at approximately 9 p.m., she asked her CNA if she could use the Harmony shower room to take a shower. She and the CNA went to the Harmony unit. The CNA went to get the shower chair and shower room ready, while the resident waited at the nurses' station. LPN 2 was standing at the medication cart in front of the nurses' station. LPN 2 indicated I don't know why people can't stay on their own f***ing hallway. Then, LPN 2 started telling Resident D, she should not be on the Harmony hallway due to there was a lot of residents with COVID-19, she needed to go back to her own hallway, and request her shower on her hall. The walnut hallway did not have a shower room on it. The resident went back to her room and took her shower the next day. Resident D indicated she was disrespected by LPN 2 by the way she was spoken to. 3. A facility document, titled Concern/Compliment Form, dated 12/15/23, indicated, on 12/14/23, Resident E woke up at 7:00 p.m., and had not received a room tray, so she went to the kitchen door to notify them. LPN 2 saw her at the kitchen door and yelled at her with an attitude indicating to her she could not be in that hallway. The resident indicated to the nurse, no one had been to her room, and she had not gotten dinner. LPN 2 indicated no one was supposed to be on that hallway (it was the COVID hallway at that time.) The summary of pertinent findings indicated the incident was partially substantiated. LPN 2 was spoken to regarding this incident, and she admitted to telling the resident she was not to be on the hallway because it was the COVID hallway. She denied yelling and being aggressive and indicated she spoke loudly. An unidentified kitchen worker had written a statement, dated 12/15/23, which indicated while she was attempting to get what Resident E wanted to eat for dinner at the kitchen door, on 12/14/23, LPN 2 came around the corner and started going off asking the resident if she wanted COVID-19 again. LPN 2 told her if all the red signs and trash bags were not enough for her to see she was on the COVID hallway, then she was going to end up with COVID-19 again. 4. A document, titled Indiana State Department of Health Survey Report System, dated 1/8/24, indicated Resident B reported LPN 2 used profanity while speaking to him. After the investigation, LPN 2 was terminated for violating company policy. a. A facility document, titled Concern/Compliment Form, dated 11/8/23, indicated, on the evening of 11/7/23, Resident B asked LPN 2 to get him up into his wheelchair. She indicated you're staying in bed. The resident indicated to the nurse he would call the police and the nurse indicated Don't threaten me. The summary of pertinent findings indicated the incident was unsubstantiated. The corrective actions indicated LPN 2 was instructed to assist the resident up when the CNAs finished his personal care. b. A facility document, titled Concern/Compliment Form, dated 1/9/24, indicated, on 1/8/24, Resident B turned on his call light for assistance at approximately 7:30 p.m. LPN 2 came into his room at approximately 9:45 p.m. He indicated he wanted to go outside to smoke. LPN 2 indicated to him You need to Quit hitting that F***ing button. I have things to do. What do you want? The summary of pertinent findings indicated the incident was substantiated. LPN 2 used profanity towards the resident. LPN 2 already had multiple complaints alleged against her regarding her verbal aggression in the recent past. The corrective actions taken indicated she was terminated for misconduct. A facility document, titled Human Resources Notice of Corrective Action, dated 12/22/23 and provided by the Executive Director (ED) on 1/24/24 at 2:55 p.m., indicated LPN 2 was given a final written warning due to at that time, she had multiple grievances regarding her yelling or speaking rudely to residents. Those residents were not comfortable with asking her for help. A typed statement by the Executive Director (ED), dated 1/12/24, indicated a phone conversation occurred between the ED and LPN 2. LPN 2 was notified she was terminated because she had several complaints regarding how she spoke and treated residents, in addition to the concern with Resident B. The ED indicated the Director of Nursing (DON) and the Human Resources Director (HRD) was in attendance during the phone call to LPN 2. A facility document, titled Human Resources Notice of Corrective Action, dated 1/12/24 and provided by the Executive Director (ED) on 1/24/24 at 2:55 p.m., indicated LPN 2 was terminated due to a resident complained she used profanity and was yelling at him because he used his call light. She was on a final written warning and had been told not to get any other resident complaints against her regarding speaking negatively or yelling at them. She was terminated due to misconduct towards a resident. During a phone interview, on 1/24/24 at 1:19 p.m., LPN 2 indicated from 12/5/23 until the end of 12/2023, Resident B complained about all the nursing staff daily. She wrote progress notes regarding his behavior and threats to get someone in trouble if he did not get to go smoke when it was below the allowed temperature for the residents to go outside and smoke. Resident D came towards the end of her hall, which had COVID-19 residents on it. She indicated to the resident she was not allowed to shower on the COVID-19 hallway. The resident reported her for telling her to get off the F***ing hallway. Resident E was walking in the COVID-19 hallway when she asked the resident to come and talk with her a minute. LPN 2 told the resident she could not be on the COVID-19 hallway, and she reported LPN 2 for yelling at her. She was terminated due to the tone of my voice. A current policy, titled Resident Rights, dated 1/4/19 and provided by the DON on 1/24/24 at 3:40 p.m., indicated .Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to Exercise his or her rights .Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement A current facility handbook policy, dated 01/2023 and provided by the ED on 1/24/24 at 1:45 p.m., indicated .Employee Conduct .it is important that you maintain the highest standards of conduct, courtesy and respect for the dignity of others at all times .Any concerns regarding employee conduct will be addressed through the Corrective Action process .each employee's conduct and performance will conform with the highest standards of professionalism and ethical practice, the requirements of their job .and applicable federal, state and local laws, rules and regulations .Violations of Aperion's standards of conduct may lead to corrective action, up to and including immediate termination. Violations of Conduct Standards That Constitute Grounds for Immediate Dismissal .Engaging in abusive, discourteous, profane, indecent or unprofessional language or conduct while on duty or on Aperion property .Threatening, intimidating or coercing patients .Violating any federal, state or local laws, rules or regulations applicable to Aperion or any of its programs .Violating any other policy or procedure of Aperion, whether or not set forth in this handbook This citation relates to Complaint IN00425889. 3.1-3(t)

Based on interview and record review, the facility failed to ensure a resident was free from theft, related to a staff member not returning her change after picking up food for her for 1 of 2 residents reviewed for misappropriation of property. (Residents C and K) Finding includes: 1. A document, titled Indiana State Department of Health Survey Report System, dated 11/13/23 and provided by the Executive Director (ED) on 1/24/24 at 11:59 a.m., indicated Resident C gave CNA 3 fifty dollars to purchase Taco Bell for her and the CNA did not return the resident's change. When the investigation was completed, it was determined CNA 3 was given fifteen dollars for the Taco Bell and ten dollars to go pick it up. After the investigation was completed, CNA 3 was terminated for violating the company policy. A facility document, titled Concern/Compliment Form, dated 11/14/23 and provided by the ED on 1/24/24 at 11:59 a.m., indicated Resident C gave CNA 3 a total of $50. $20 to buy the food and $30 for gas for the CNA to pick up the food for the resident. The resident indicated she did not get any change and now she wanted her thirty dollars in change back. The summary of pertinent findings indicated the theft allegation was substantiated when CNA 3 admitted to taking Resident C's money. CNA 3 indicated Resident C gave her $25. The food cost $15 and she kept $10 for gas because the resident told her she could keep it. The corrective actions taken was CNA 3 was terminated for violating company policy on getting money from a resident. Resident C's $10 the CNA admitted to taking was reimbursed into her personal funds account. A facility handwritten statement by CNA 3, dated 11/13/23, indicated, on 11/13/23, Resident C gave her $25 to go get her Taco Bell and she was offered $10 in gas money to go get the food and she took it. She went to get the resident's food at approximately 7:30 p.m., and came back to work. A typed facility statement, dated 11/14/23, indicated the Executive Director (ED) spoke with CNA 3 regarding the grievance she received from Resident C, who indicated she had given the CNA $50 ($20 for food and $30 for gas). The resident was complaining she did not get her change back and wanted her $30. CNA 3 indicated she went to get Resident C's food at approximately 7:30 p.m. The resident gave her a total of $25, the food was $15, and she kept the $10 for gas because the resident offered it to her. During an interview, on 1/24/24 at 2:18 p.m., Resident C indicated she gave CNA 3 $46 to get her nachos and three tacos at Taco Bell. The CNA asked the resident if she could keep $10 for gas money and the resident agreed, but CNA 3 kept all the resident's change which was owed back to her. The facility was reimbursing the resident her $10 for the gas money she gave CNA 3. The resident indicated this incident was not the first time CNA 3 had asked her to keep money out for gas. On another occasion when the CNA went to get her food, she had asked the resident if she could keep $5 for gas money. She did not realize Taco Bell was basically across the street from the facility or she would not have let her keep the money for gas. A facility document, titled Human Resources Notice of Corrective Action, dated 11/15/23, indicated CNA 3 was terminated. The rule or policy involved indicated CNA 3 admitted to keeping a resident's $10 for gas money. It was against company policy for any staff member to take any money from a resident. She violated company's policy, which resulted in termination. 2. A facility document, titled Concern/Compliment Form, dated 11/14/23 and provided by the ED on 1/24/24 at 11:59 a.m., indicated Resident K did not get her sixty five cents back for change from a $1.50 candy bar and $1.85 drink. The summary of pertinent findings indicated the concerns were partially substantiated. The CNA (CNA 3) admitted the resident gave her $2 for the vending machine and the resident had fifteen cents in change left over, which the CNA placed in the resident's room. The corrective action taken was the CNA was educated and she was terminated on a different finding. A typed facility statement, dated 11/14/23, by the ED, indicated she had received a grievance regarding Resident K gave CNA 3 $4 to get her a candy bar, which cost $1.50 and a drink, which cost $1.85 and the CNA did not give the resident her sixty five cents in change back to her. During an interview, on 1/24/24 at 2:31 p.m., Resident K indicated she had given CNA 3 $4 to get her a candy bar and drink out of the vending machines and the CNA did not give her back her sixty five cents in change. A current facility handbook policy, dated 01/2023 and provided by the ED on 1/24/24 at 1:45 p.m., indicated .Violations of Conduct Standards That Constitute Grounds for Immediate Dismissal .Violating any federal state or local laws, rules or regulations applicable to Aperion or any of its programs .Asking a resident for money or other gifts or approaching a resident with the intention of solicitating money or other gifts This citation relates to Complaint IN00425889. 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure a resident was free from mental and verbal abuse and intimidation, failed to ensure a staff member intervened while a resident was being mentally and verbally abused and intimidated, and failed to provide 72-hour psychosocial follow-up for 1 of 3 residents reviewed for abuse. (Resident B) Resident B indicated while being abused by the Executive Director, she thought she was going to be hit, her personal space was invaded, she was in fear for her life, and following the incident she thought the Executive Director (ED) sent an unidentified man hit man into the facility to harm her in retaliation for the ED being suspended. Finding includes: On 9/28/23 at 9:45 a.m., the Business Office Manager (BOM) indicated the previous ED was no longer the ED at the facility anymore. A document, titled Indiana State Department of Health Survey Report System, dated 9/28/23 at 12:39 p.m., indicated on 9/20/23 at 9:15 a.m., during a meeting between the previous ED and Resident B, Resident B indicated the previous ED took her walker out of her hands and was rude to her. After a thorough investigation, the five-day follow-up indicated the previous ED acted in an unprofessional manner leading Resident B to believe she had to discharge from the facility. When the Interim ED spoke to Resident B, he offered her to return to the facility. During an interview, on 9/28/23 at 11:00 a.m., the Interim ED indicated he had spoken (verbal counseling) to the previous ED within the past few weeks for how she was treating the managers and staff in general. She had treated some of the managers mean and staff members rudely and mean. She called out managers in the morning meeting instead of waiting to get them by themselves. She called out staff members in the hallways, instead of taking them into an unoccupied room. Many staff members were intimidated by her and afraid of losing their jobs if they reported her, so they would not report her to him when he came to visit the facility. He discovered the intimidation and fear of retaliation of staff members' jobs by the previous ED after he terminated her. During an interview, on 9/28/23 at 1:36 p.m., Resident B was observed sitting in her wheelchair, in her room, with her ex-husband sitting on her bed. She indicated, on 9/20/23, she was getting dressed to go home to see her dogs when the previous Executive Director busted in the door of her room. Breakfast had just been served onto her bedside table in front of her. She was sitting in her recliner with her bedside table across the front of her chair with her breakfast on it. She had just started eating her toast. Her ex-husband was sitting on her bed. The previous ED asked Resident B why her ex-husband was at the facility. The resident indicated he was at the facility because he took care of her and her animals. The previous ED indicated to the resident, he had to leave the facility. The resident indicated to the previous ED, if he had to leave, then she had to leave also, since he was her caregiver. The previous ED indicated she did not have to leave, but her ex-husband had to leave because he was not allowed to stay the night at the facility with her. Resident B indicated if he left, then she would leave also because he was her caregiver, since there was not enough staff at the facility to care for her in a timely manner. The previous ED indicated then the resident was to leave also. The previous ED jerked the bedside table out from in front of her and came at her like an angry bull. She invaded her personal space with her face up close to the resident's face and her arms pulled back and her chest puffed out indicating she was to leave the facility now. Resident B indicated to the previous ED, she was invading her personal space and told her to step back, which she did step back out of her face. The resident indicated at that time; she was scared to death of the previous ED. She thought the previous ED was going to hit her when she was invading her personal space. The previous ED left the room, but five minutes later, she came back to the room with three to four nurses and boxes to pack her belongings. Resident B had already begun to pack her belongings and the previous ED asked Resident B what she was doing, and the resident indicated she was leaving as the previous ED had told her to do. The previous ED indicated to her; she never told her to leave. She admitted on [DATE]. The Maintenance Director got her ex-husband a nice chair to sleep in, since he was with her every night providing care for her. He took care of her because there was not enough staff to care for her in a timely manner. She left with her belongings the day of the incident and went back home with her ex-husband. Resident B indicated after the previous ED was asked to leave the facility and she had returned as a resident, one evening she observed a tall African American male walking down the hallway towards her. She thought the previous ED hired this man as a hit man to come and kill me in retaliation for her being sent home. The Interim ED called and asked her to come back to the facility the next night (9/21/23) after she went home. The facility bus picked her up at her house and brought her back to the facility. She was anxious to come out of her room when the previous ED was in the facility, but after she was terminated, Resident B started going out to activities. She used to be very social when she lived at home. During an interview, on 9/28/23 at 2:00 p.m., Resident B's ex-husband indicated he stayed at the facility overnight each night from 6:00 p.m. until 10:00 a.m., the next day. His wife was incontinent, and it took the staff so long to answer her call light at times. If he did not stay and take care of her, she would wet on herself and he did not want that to happen. Depending on how well she was doing each day determined whether he spent the night to provide care for her or not. One of the nurses told him to park out back and gave him the code to the back door to the facility, so he could leave and come back into the facility as he pleased. He was present when the previous ED came down to the resident's room, on 9/20/23. She got right up into her face, invading her personal space and was yelling at her indicating he had to get out of the facility because he could not stay there. He was taken back while the yelling was going on and was in shock. He did not even know what to do because he was not believing what he was witnessing. During an interview, on 9/28/23 at 2:25 p.m., Qualified Medication Aide (QMA 6) indicated the previous ED and Housekeeping delivered boxes to Resident B's room for her to pack her belongings. The day before (9/19/23) the previous ED was standing in the hallway yelling at CNAs 7 and 8, but she did not know why she was yelling at them. During an interview, on 9/28/23 at 2:20 p.m., LPN 9 indicated the previous ED was in the hallway on the day before the incident with Resident B (9/19/23) being very loud and angry indicating I need all the CNAs in room [ROOM NUMBER] now. She was upset because a housekeeper had told her a CNA refused to pack the resident's belongings up in room [ROOM NUMBER] after the CNA was told the resident was being discharged . The record for Resident B was reviewed on 9/28/23 at 3:10 p.m. Diagnoses included, but were not limited to, diabetes mellitus type II, need for assistance with personal care, depression, generalized anxiety disorder, weakness, and chronic kidney disease stage 3. An Admission Minimum Data Set (MDS) assessment, dated 8/24/23, indicated the resident's Brief Interview for Mental Status was coded at an 11, which indicated the resident had mild cognitive impairment. A psychiatry progress note, dated 9/15/23 at 1:00 a.m., indicated the visit was for her initial psych evaluation and medication management and to address an increase in her anxiety symptoms. She was started on Buspirone (an anti-anxiety medication) 5 mg (milligrams) by mouth three times a day that visit. She had no history of psychotropic medication use prior to her facility admission. She had generalized weakness. She had a changed sleep pattern. Her appearance/behavior was calm and cooperative. Her mood was depressed. She had mild judgement impairment and mild insight impairment. Her attention/concentration was good. Diagnoses for this visit was moderate major depressive disorder, and generalized anxiety disorder. A psychiatry progress note, dated 9/18/23 at 1:00 a.m., indicated the visit was to complete the Mini Mental State Examination (MMSE), which the resident scored a 28/30, which indicated no cognitive impairment. Her Preadmission Screening and Resident Review (PASRR) indicated she had not had previous psychiatric admissions or outpatient mental health services prior to being admitted to the facility. She was dependent for all Activities of Daily Living (ADL) except for feeding herself and she was incontinent. She had no use of psychotropic medication use prior to being admitted to the facility. Her cognition function was intact. Her appearance/behavior was calm and cooperative. Her mood was depressed. She had a fair short-term memory. She had mild impairment of her judgement and insight. Her depression screening test completed on 8/30/23, indicated she was positive for depression. The dementia assessment completed on 8/25/23, indicated she scored 3/6, which indicated she was somewhat dependent with a moderate functional impairment. A progress note, dated 9/20/23 at 9:16 a.m., indicated Resident B's discharge paperwork was explained to her and she refused to sign the Against Medial Advice (AMA) paperwork. The AMA paperwork was signed by two nurses. The resident was provided with medications as approved by the facility corporate office. She was transported from the facility to home by her husband's vehicle. She took her personal walker with her. There was a lack of 72-hour follow-up in the resident's record for psychosocial monitoring following mental and verbal abuse and intimidation by the previous ED. A care plan for Resident B indicated she had a history of being a social person and enjoying people. During an interview, on 9/28/23 at 4:03 p.m., CNA 7 indicated she came around the Harmony nurses' desk when she heard a loud commotion from down the hall. She heard yelling as she picked up room trays from breakfast. The previous ED was yelling at Resident B and Resident B was telling the previous ED she was not staying at this facility if her ex-husband could not stay with her. She walked up to Resident B's room and observed the previous ED to be standing in front of the resident who was sitting in her recliner. The previous ED was pointing her finger at the resident standing above her as the resident was sitting in her recliner. The previous ED was towering over the resident because she was a tall and larger lady. When asked if 0 was quiet and 10 was extremely loud, CNA 7 indicated the previous ED was yelling at a level 10 at the resident. When asked why she did not intervene when the previous ED was yelling at the resident, CNA 7 indicated she was intimated by the previous ED and now afraid of her due to a situation she and CNA 10 experienced the day before (9/19/23). She was told to go to another resident's room with the previous ED, on 9/19/23, where she waited for CNA 10 to arrive. When CNA 10 arrived at the resident's room, the previous ED along with the Housekeeping Supervisor in attendance in the room, the previous ED started screaming at a level 10 with aggressive screaming because she and the Housekeeping Supervisor thought CNAs 7 and 10 refused to pack the discharged resident's belongings. CNA 7 indicated they both wanted to wait to pack her belongings until closer to her being discharged because she had dementia and they did not want her to have any behaviors when she seen them packing her belongings up. If the previous ED was mad at a resident for something, she was fiery mad and aggressive with the resident. The ADON (Assistant Director of Nursing) and the Wound Doctor had to have heard the screaming across the hallway because they were over there working on a resident's wounds. She felt she was bullied by the previous ED and was scared to break up the interaction between the previous ED and Resident B because of her being screamed at the day before. During an interview, on 9/28/23 at 4:31 p.m., the ADON indicated the day prior to the incident with Resident B (9/19/23), she and the Wound Physician was in the room across the hallway from the resident who was to be discharged later that day. They both overheard the previous ED yelling at two CNAs while in the resident's room. When asked how loud she was yelling if 0 was quiet and 10 was extremely loud, she indicated she was yelling at a level 9. The Wound Physician made the statement Someone's in trouble. The ADON indicated she could hear anger in the previous ED's voice while yelling at the CNAs. On the day of the incident, (9/20/23), between the previous ED and Resident B, the previous ED told the ADON and the DON (Director of Nursing) to go down to Resident B's room with her to be her witness when she talked to her. Both the ADON and DON went to the resident's room with the previous ED. The previous ED clarified with Resident B why she was not staying at the facility. Resident B indicated because the previous ED kicked her out of the facility. The previous ED indicated she had not kicked her out and Resident B indicated when she kicked her ex-husband out of the facility, she kicked her out also. The previous ED was re-clarifying and backsliding to cover herself on kicking the resident out of the facility because after she left the resident's room, she came from the Redbud hallway to her office talking angrily on her cell phone in the hallway, saying I want her out of here now today repeatedly. In staff meetings, she called managers out and was passive-aggressive with them. She picked on staff and made it difficult on staff if she did not like you. The previous ED ran the facility like a Tyrant ruler by staff working under fear and intimidation. During an interview, on 9/29/23 at 11:26 a.m., CNA 8 indicated Resident B was her resident the day of the incident between her and the previous ED (9/20/23). The incident happened around breakfast time. Her ex-husband had been in her room staying with her every night to help provide care for her, which all the CNAs where so glad he was there because she did require a lot of care at times and required a lot of emotional care and attention. CNA 8 had been in her room at least twice that day already. The previous ED walked into the room as CNA 8 was walking to the resident's room, so she stayed outside the room, because she did not go in resident's rooms when management or nurses were in their rooms out of respect for the resident's privacy. The previous ED was fussing at Resident B, but she did not know why she was fussing at her. The resident was sitting in her recliner with her walker in front of her and the previous ED was standing in front of her walker. Her bedside table was at the side of her recliner. The previous ED was screaming at the resident at a level 10 if 0 was quiet and 10 was extremely loud. After she was finished fussing at the resident, the previous ED stormed out of the resident's room and she pointed to CNA 8 and instructed her to get the resident and her husband some boxes. She pointed to the floor tech girl and instructed her to get the resident and her husband some boxes. The floor tech girl got the boxes for the resident and her husband and CNA 8 got a cart for them, so they were able to wheel their belongings out of the facility to their car. CNA 8 indicated when the previous ED stormed out of the resident's room and pointed at her, instructing her to get the boxes, she felt like a child and her mom was scolding her. She did not intervene during the screaming at the resident because she was shocked it was happening and she was intimidated by the previous ED. A document, titled Human Resources Notice of Corrective Action, dated 9/25/23 and provided by the Interim ED on 9/29/23 at 12:29 p.m., indicated the Previous ED was terminated on 9/25/23, after an allegation of verbal and mental abuse was brought forward about her. After an investigation was complete, it was found that her actions were in violation of Center for Medicare and Medicaid Services (CMS) and the Indiana Department of Health's abuse regulations and the facility's policy on abuse and the companies code of conduct. During a phone interview, on 9/29/23 at 12:19 p.m., the previous ED indicated the Business Office Manager (BOM) told her Resident B's husband was living there at the facility. She went to the resident's room and found her and her husband in the room. She asked the resident if he was spending the night in her room and the resident indicated she had permission for her husband to sleep at the facility with her. She indicated she spoke to them and told them on the day she admitted he was only allowed to spend one night. The previous ED told them both he was not allowed to sleep at the facility at night, that's when the resident began to escalate and raise her voice toward the previous ED and indicated if the previous ED was kicking out her husband, she would be living also. The previous ED told her that was fine if that was the way it had to be and the resident then escalated more, saying the previous ED was kicking her out of the facility. She tried to tell the resident again she was able to stay, but her husband was not able to sleep in her room anymore. At some point during the conversation, the walker got moved from out in front of the resident and the previous ED did not know how it got moved. The resident accused the previous ED of abusing her and threatening her. She indicated the Regional [NAME] President terminated her on Monday (9/25/23) for causing psychosocial harm to Resident B. During a phone interview, on 9/29/23 at 12:43 p.m., CNA 10 indicated the previous ED indicated she needed to talk to her on the day before the incident between her and Resident B (9/19/23). A CNA was busy and was not packing up a resident's belongings, who had been discharged . She was not going to pack up the belongings at that time, because that resident would have behaviors. CNAs 7 and 10 were in the room along with the Housekeeping Supervisor when the previous ED was screaming at CNAs 7 and 10. When asked what the level of loudness was of the previous ED's voice if 0 was quiet and 10 was extremely loud, she indicated a level 8. The Wound Nurse from the facility and the Wound Physician was in the room across the hall working on a resident's wounds and they heard the previous ED screaming at the CNAs. She was being aggressive with the CNAs for no reason. CNA 10 was confused as to why the previous ED was coming at her like that. There was a monthly in-service that day and the previous ED brought up packing up resident's belongings. CNA 7 made a comment and the previous ED got very aggressive with her during the meeting raising her voice at CNA 7 and cut her off, so she was not able to speak. During an interview, on 9/29/23 at 1:51 p.m., Floor Tech 12 indicated she was cleaning the floors on the 300 Hallway when the incident occurred between the previous ED and Resident B. When the previous ED came out of room [ROOM NUMBER], she pointed her finger at her and CNA 8 instructing them to get boxes for the resident in room [ROOM NUMBER]. She had never seen the previous ED get upset like that before with a resident. She got three big sized boxes and took them and sat them at the side of Resident B's door in the hallway, since there were management staff in her room talking with her. 30-45 minutes after the incident with the previous ED, Resident B and her husband packed their belongings and left the facility. During an interview, on 9/29/23 at 2:20 p.m., the Interim DON with the Social Service Director in attendance, indicated she and the ADON witnessed the previous ED being angry and aggressive while walking down the Redbud hallway carrying on a conversation regarding Resident B needing to leave the facility today. She told her and the ADON to go to Resident B's room with her to be her witness as to what was being said because she did not want her saying she had been inappropriate with her or threatened her. After she, the ADON, and the previous ED left Resident B's room, she, and the Social Service Director (SSD) went to Resident B's room to talk to her privately. Resident B and her husband indicated she was being thrown out of the facility by the previous ED. The DON indicated after the previous ED was terminated, Resident B started coming out of her room more and socializing with other residents. She would do activities now, where she mainly stayed in room before the previous ED was terminated. The SSD indicated she did not perform a psychosocial assessment on her as required following the abuse allegation. A current policy, titled Abuse Prevention and Reporting-Indiana, dated with a revision date of 10/28/22 and provided by the Interim ED on 9/28/23 at 3:15 p.m., indicated The facility affirms the right of our residents to be free from abuse .This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse .This will be done by .Immediately protecting residents involved in identified reports of possible abuse .Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker .mental and psychosocial well-being. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Mental and Verbal Abuse: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. Examples of mental and verbal abuse include, but are not limited to .Yelling or hovering over a resident with the intent to intimate; threatening residents, including but limited to depriving a resident of care of withholding a resident from contact with family and friends .Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics .What constitutes abuse .The facility may not discharge, demote, suspend, threaten, harass or deny a promotion or other employment-related benefit to an employee, or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done by the employee; or file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee A current policy, titled Verbal/Mental Abuse Allegation Staff to Resident Quality Assurance Checklist, undated and provided by the Interim ED on 9/29/23 at 3:46 p.m., indicated Immediate: Alleged staff member removed from all resident contact. Alleged staff member escorted from the facility. Alleged staff member placed on suspension pending investigation .Resident assessed for psychological injury & documented .Resident placed on report for 72 hour follow up documentation on incident .INVESTIGATION/PREVENTATIVE MEASURES .SS (Social Services) Psychosocial Assessment This Federal tag relates to Complaint IN00418301. 3.1-27(a)(1) 3.1-27(b)

Based on observation, interview and record review, the facility failed to ensure a resident's plan of care was followed while ADL (Activities of Daily Living) care was being provided for 1 of 1 resident being reviewed for accidents. (Resident C) Resident C sustained a laceration, the size of a pea, on the left side of her forehead just above a raised knot approximately the size of a quarter and an acute displaced oblique fracture of the right fifth finger (a broken right fifth finger). Finding includes: A document, titled Facility Reported Incident, dated 4/1/22, indicated on 4/1/22 at 1:01 p.m., CNA 1 was providing personal hygiene care for Resident C when the resident slid from the bed and was unable to stop herself and CNA 1 was unable to completely stop the resident. CNA 1 was able to lower the resident to the floor. The resident had a right hand X-ray completed, which indicated she had an acute fracture of the fifth metacarpal. The record for Resident C was reviewed on 4/5/22 at 3:00 p.m. Diagnoses included, but were not limited to, [CONDITION(S)], tremor, seizures, idiopathic peripheral autonomic [CONDITION(S)] and restless leg syndrome. A Quarterly MDS (Minimum Data Set) assessment, dated 2/21/22, indicated the resident's functional status for ADL's were scored as follows: - Bed Mobility (how the resident moved to and from a lying position, turned side to side and positioned her body while in bed or an alternative piece of sleep furniture) Self Performance=4 (Total Dependence, full staff performance every time during the entire seven day period) Support=3 (two person physical assist) - Toilet Use (how resident used the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages bosomy or catheter; and adjusts clothes. Did not include emptying of bedpan, urinal, bedside commode, catheter bag or bosomy bag) Self Performance=4 Support=3 - Functional Limitation in Range of Motion: Upper Extremity (shoulder, elbow, wrist and hand)=2 (Impairment on both sides) Lower Extremity (hip, knee, ankle and foot)=2 An EMAR (Electronic Medication Administration Record), dated April 2022, indicated an order was written on 4/1/22 to indicate Care in Pairs every day and night shift scheduled for 12:00 a.m., and 12:00 p.m., and had been signed off in the documentation box for each date and time from 4/1/22 to 4/5/22 to indicate Care in Pairs was being completed from 4/1/22 to 4/5/22. A document, titled Response History, dated 4/5/22, indicated the following dates and times Resident C was provided the ADL bed mobility with only one staff member's assistance for the time period of 3/23/22 through 4/5/22: On 3/23/22 at 2:54 a.m., and 10:32 p.m. On 3/24/22 at 9:30 a.m. On 3/25/22 at 12:15 a.m., and 8:04 p.m. On 3/26/22 at 7:28 a.m., 8:04 p.m., and 10:46 p.m. On 3/27/22 at 6:40 p.m., and 11:23 p.m. On 3/28/22 at 7:13 a.m. On 3/29/22 at 2:02 a.m., and 4:30 p.m. On 3/30/22 at 3:27 a.m., 8:59 a.m., 3:50 p.m., and 11:05 p.m. On 3/31/22 at 9:35 a.m. On 4/1/22 at 1:39 a.m., 6:53 a.m., 2:55 p.m., and 11:21 p.m. On 4/2/22 at 3:24 p.m. On 4/3/22 at 9:59 p.m., and 11:40 p.m. On 4/4/22 at 6:43 a.m. On 4/5/22 at 5:10 a.m., and 6:55 a.m. The resident had a care plan, which indicated she had a problem with ADL self-care performance deficit, initiated on 8/7/20 and revised on 12/1/21, related to [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], tremors, chronic pain and required a Hoyer lift for transfers with a physical assist of two persons. The interventions included, but were not limited to, 2/22/21 with a revision date of 4/1/22, provide Care in Pairs at all times, 8/7/20 with a revision date of 3/9/22, the resident was totally dependent on staff for repositioning and turning in bed every 2 hours and as necessary. 8/11/20, the resident had contractures and tremors of the upper extremities. 8/7/20 with a revision date 5/16/21, the resident was totally dependent on staff for toilet use, peri-care and incontinence care. The resident had a care plan, which indicated she was at risk for falls, initiated on 8/7/20 and revised on 5/18/21, related to she had [CONDITION(S)], impaired mobility, impaired balance, fall risk medium use, supra catheter, history of tremors and [CONDITION(S)]. The interventions included, but were not limited to, 8/7/20, Follow the facility fall protocol. 3/24/22, Transfer with two assists and the Hoyer lift to the Broda chair related to resident choice. A current document, titled Visual/Bedside Kardex Report, dated 4/5/22, was provided by the DON on 4/5/22 at 4:15 p.m. The DON indicated at that time, this document was the plan of care the CNAs followed to provide care for Resident C. The report included, but were not limited to, the following Special Instructions: Safety-Follow the facility fall protocol. Monitor the resident for safety. Resident C was prescribed anti-anxiety medication, which were associated with an increased risk of confusion, loss of balance, amnesia and cognitive impairment (which looks like dementia) and an increased risk for falls with broken hips and legs. Bed Mobility-the resident was totally dependent on staff for repositioning and turning in bed every two hours and as necessary. Utilize pillows for support and padding between bony prominences. ADL-Care in Pairs at all times A progress note, dated 4/1/22 at 4:15 a.m., indicated Resident C had a witnessed fall, in her room, while a CNA was providing incontinent care. She was lying on her side and she slid off the bed onto the floor. She was assisted off the floor by three staff members and a Hoyer lift. She complained of right hand fifth digit pain. She had a small abrasion to the left side of her head. The action taken was the resident was assisted up by three staff members with the Hoyer lift and she was provided first aid. The interventions were an X-ray to the right hand and the staff was educated to always do cares in pairs with the resident. During an interview, on 4/5/22 at 4:25 p.m., Resident C indicated she had fallen out of bed this past Friday (4/1/22) or Saturday (4/2/22) morning at approximately 3:30 a.m. There was only one CNA who provided care for her, which was CNA 1, who frequently provided care for her, by herself. She was laying on her side facing the door and she was holding onto the bed frame like she always did when she laid on her side during ADL care. CNA 1 left her bedside to go to the bathroom to wet another wash cloth, which was something most of the CNAs normally did when there was only one CNA providing care for her because there was no one else to get additional supplies or wet wash clothes if they were needed. The second and third shift CNAs often provided incontinent care for her using only one CNA. CNA 1 was halfway to the bathroom when she began to fall off the bed. The resident indicated she yelled out, CNA 1 turned around and looked at her as she was falling off the bed, but CNA 1 was too far away from her to assist her to the floor or to break her fall. By the time CNA 1 got over to the resident, she was already laying on the cement floor between the dresser and the bed. She landed on the cement floor on her stomach and partially on her left side with her right hand caught under her chest and this was how she believed she broke her pinky finger. She hit her left temple area on the floor and sustained a cut and goose egg above her left eye and a broken right pinky. At the time of the interview, the following observations were made: The resident had a scabbed laceration, the size of a pea, on the left side of her forehead just above a raised knot the approximate size of a quarter. She was unable to straighten her bent right pinky. She had slight discoloration to the outside of the right hand by the pinky finger. She complained of pain to her right pinky finger. She attempted to straightened her pinky, but was unable. She was able to straighten the other four digits on the right hand to some degree. She was not able to make a fist with her right hand due to pain in her pinky when she tried to bend it completely in a closed position. An unidentified CNA entered the resident's room carrying a drink in and offered the resident a drink indicating she had brought her drink into her room prior to dinner. The CNA gave the resident a drink indicating to the resident if she needed another drink prior to dinnertime she needed to turn on her light and she would come back in and give her a drink. The CNA indicated to Resident C she would be bringing in her dinner tray shortly to feed you. During an interview, on 4/5/22 at 12:18 p.m., with the AIT (Administrator in Training), DON (Director of Nursing) and RNC (Regional Nurse Consultant) in attendance, the DON indicated she reported on 4/1/22, Resident C slide out of bed and CNA 1 assisted her to the floor while being provided ADL care. The resident fractured her right pinky. During an interview, on 4/5/22 at 1:36 p.m., the DON and CNA 1 was in attendance. CNA 1 indicated Resident C was lying on her left side leaning over towards the opposite side of the bed (away from CNA 1) while she was providing peri-care for her. She reached for the brief and as she was reaching for the brief, the resident lost her balance and started falling towards the floor on the opposite side of the bed from where CNA 1 was standing. CNA 1 ran over to, that side of the bed, in an attempt to catch the resident, but she could not catch her. CNA 1 did get her hands under her mid-section before she hit the floor, but she could not assist her to the floor in anyway. Resident C landed on her stomach while hitting her head on the cement floor. CNA 1 indicated that particular day, the resident was leaning to the opposite side of the bed more than she typically did when she provided incontinence care for her. The resident was gripping the bed frame with her right hand as she was falling trying to hold herself onto the bed, so that was how she probably broke her finger. CNA 1 was supposed to have another staff member with her while performing care with Resident C because she was one of the residents who was supposed to be cared for by Care in Pairs, but she did not have the second person with her and that was her fault. CNA 1 indicated she had worked at the facility for three years and had cared for this resident the majority of the time and she typically cared for her by herself and she had never had a problem with this resident prior to that day. During an interview, on 4/5/22 at 2:58 p.m., the DON indicated CNA 1 was written up for not providing care in Care in Pairs while providing ADL care for Resident C. A document, titled Human Resources Notice of Corrective Action, dated 4/1/22, indicated CNA 1 received a verbal warning on 4/1/22, related to a resident being a Care in Pairs due to false Allegations towards staff and CNA 1 was the only staff member providing care for the resident when this resident fell from bed. CNA 1 was education in Care in Pairs. A current facility policy, titled Fall Prevention Program, dated as revised 11/21/17 and provided by the DON on 4/5/22 at 1:00 p.m., indicated Purpose: To assure the safety of all residents in the facility, when possible .Guidelines .Care plan incorporates .Preventative measures .Standards .Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care 3.1-45(2)

Based on record review and interview, the facility failed to identify a significant weight loss, notify the physician of the weight loss and implement interventions to prevent further weight loss for 1 of 6 residents reviewed for nutrition. (Resident F) Resident F had a 17% weight loss in 14 days. Finding includes: The record was reviewed on 3/3/22 at 12:25 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 1/11/22, indicated the resident was at risk for nutritional problems. The interventions included, but were not limited to, provide and serve the diet as ordered, notify the medical provider and the resident representative of any unplanned weight changes. A care plan, dated 1/11/22, indicated the resident was to consume foods with a regular consistency and a regular texture diet. The interventions included, but were not limited to, monitor and record intake every shift, monitor weight as indicated and to provide the diet as ordered. The resident had the following weights: a. On 1/13/22, the weight was 182.0 pounds. b. On 1/14/22, the weight was 180.2 pounds. c. On 1/15/22, the weight was 180.8 pounds. d. On 1/16/22, the weight was 180.0 pounds. e. On 1/17/22, the weight was 179.8 pounds. f. On 1/18/22, the weight was 179.6 pounds. g. On 1/19/22, the weight was 175.4 pounds. h. On 1/19/22, the weight was 169.0 pounds. i. On 1/20/22, the weight was 169.0 pounds (which is a 7% weight loss since 1/13/22) j. On 1/21/22, the weight was 171.2 pounds. k. On 1/22/22, the weight was 169.8 pounds. l. On 1/24/22, the weight was 158.0 pounds (which is a 13% weight loss since 1/13/22) m. On 1/25/22, the weight was 157.8 pounds. n. On 1/26/22, the weight was 155.2 pounds. o. On 1/27/22, the weight was 150.2 pounds (which is a 17% weight loss since 1/13/22) The progress notes between 1/20/22 and 1/27/22 did not include the weight loss, notification to the physician or any nutrition notes. A progress note, dated 1/27/22 at 11:05 a.m., indicated the physician was notified of the residents significant weight loss. The physician ordered the resident to be sent to the emergency room with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 3/4/22 at 1:27 p.m., the DON (Director of Nursing) indicated the physician should have been notified of the residents significant weight loss prior to 1/27/22. They also should have asked the physician if any changes were needed for the diuretics. A current policy, titled Weight Assessment and Intervention, dated 2020 and received from the ED (Executive Director) on 3/3/22 at 3:00 p.m., indicated .Weights are monitored monthly or more often as recommended by the interdisciplinary care team. The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Weight data will used as one step in determining if changes to the nutritional plan of care are needed to prevent or slow unintentional weight loss within the limits of the resident's clinical condition .Any weight change of 5% or more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietitian, Dining Services Manager, or other member of the interdisciplinary team within 24 hours. Verbal notification must be confirmed in writing .The threshold for significant unplanned and undesired weight loss shall be based on the following criteria .1 month severe loss greater than 5% This Federal tag relates to Complaint IN 762. 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure the correct dose of an opioid was administered to a resident for 1 of 3 residents reviewed for medication administration (Resident B). Resident B had two emergency room (ER) visits and required the administration of [MEDICATION(S)] (a medication to reverse the effects of opioids). Finding includes: During an interview, on 3/3/22 at 4:06 p.m., a friend of the resident indicated a concern regarding the resident had been overdosed on medication and the medication error was not reported. The record for Resident B was reviewed on 3/3/22 at 11:58 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Narcotic count sheet for [MEDICATION(S)], dated 2/11/22 at 1:00 p.m., indicated 0.5 ml of [MEDICATION(S)] solution was signed out. A Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 2/11/22 at 1:53 p.m., indicated the resident had a change in mental status, the resident complained of pain, the pain medication was given and the resident went unresponsive. The physician was notified and an order to send the resident to the hospital for evaluation was received. An emergency room progress note, dated 2/11/22 at 2:06 p.m., indicated the resident was only responsive to sternal rub. The resident was given 0.5 mg dose of [MEDICATION(S)] at 1:00 p.m., and went unresponsive so EMS (emergency medical services) was called and brought the resident to the emergency room . He was given [MEDICATION(S)] with a positive response. Suspect his decrease in responsiveness was due to the [MEDICATION(S)]. The clinical impression was an adverse effect of a drug. A progress note, dated 2/11/22 at 8:52 p.m., indicated the resident was not responding to verbal stimulus. A call was placed to his responsible party, 911 was called and the resident was transported to the hospital. An emergency room progress note, dated 2/11/22 at 9:07 p.m., indicated the resident was just discharged from their ER two hours ago. The resident presented with a similar issue, was here earlier after becoming unresponsive after a dose of [MEDICATION(S)]. He was given [MEDICATION(S)] in the ER and responded. The residents heart rate was tachy at 99 per minute and his blood pressure low at 90/65 and respirations were 10 per minute. The resident was unresponsive. The resident responded to [MEDICATION(S)], the same thing he was at the ER for three hours ago. Since the resident responded to the [MEDICATION(S)], suspect the facility either needs to decrease his dose or increase the time between doses. During an interview, on 3/3/22 at 2:50 p.m., the DON indicated on 2/11/22 the resident was given a dose of [MEDICATION(S)] concentrate of 0.5 ml (milliliter) instead of the physician ordered .25 ml and went to the emergency room twice. A medication error was not completed since she was not aware of the incorrect dose given until the time of the interview. She also was not aware the resident was given [MEDICATION(S)] at the hospital. A current policy, titled, Medication Administration Policy, revised on 1/1/2015 and received from the DON on 3/4/22 at 10:16 a.m., indicated, .Only a licensed nurse (RN, LPN) may .prepare .administer .and/or record the administration of medications .Medication must be administered in accordance with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .If a medication and/or treatment error occurs, the licensed nurse will .immediately notify the attending physician .Describe the error and the resident's response in the Nurse's notes .Complete the Incident Report .Identify the error on the 24 Hour Report .Monitor the resident's status This Federal Tag relates to Complaint IN 364. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident admitted with an indwelling urinary catheter was assessed for the on-going need for the use of the catheter for 1 of 2 residents reviewed for catheter use (Resident 13). Finding includes: During an interview, on 06/12/19 at 10:24 a.m., Resident 13 indicated she has had a catheter for over a year and had not seen a specialist about the catheter. She would like to get rid of the catheter because it is embarrassing to have and it really hurts in that area. The record for Resident 13 was reviewed on 06/14/19 at 9:25 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated as revised on 09/28/18, addressed the problem the resident had an indwelling urinary catheter related to [MEDICAL CONDITION] bladder. During an interview, on 06/14/19 at 1:47 p.m., the Director of Nursing (DON) indicated the resident was admitted to the facility, with the indwelling catheter, after surgery for [REDACTED]. The resident had not seen a urologist since admission and the facility had not tried to remove the catheter. During an interview, on 06/18/19 at 9:43 a.m., the Physical Therapist (PT) indicated the resident arrived to the facility around 1 and a half years ago. She had back surgery due to compression of the spinal cord and was a total assist and paralyzed after the surgery. Over the last year and a half, she had regained movement and has been walking for over 3 weeks now. She has no limited range of motion and has pretty good bed mobility. A review of the Foley Catheter Evaluation for Resident 13 indicated the evaluations were completed on 09/27/18 which was signed on 11/02/18 and another evaluation completed on 06/05/19. During an interview, on 06/18/19 at 1:12 p.m., the Regional Nurse Consultant indicated a Foley catheter evaluation should have been completed every 6 months for the resident. During an interview, on 06/18/19 at 4:01 p.m., the Regional Nurse Consultant indicated she could not locate a specific policy for the use of a Foley catheter use. 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to complete nutrition assessments after significant weight changes and failed to obtain weekly weights after admission for 3 of 5 residents reviewed for nutrition (Resident 62, 16 and 59). Findings include: 1. On 06/13/19 at 11:14 a.m., Resident 62 was in his room, in bed, asleep. On 06/14/19 at 12:57 p.m., Resident 62 was in his bed, asleep, his lunch tray was on his bed side table at the end of the bed. On 06/18/19 at 11:32 a.m., Resident 62 was in his bed asleep. The record for Resident 62 was reviewed on 06/20/19 at 1:16 p.m. [DIAGNOSES REDACTED]. A review of Resident 62's weights, indicated the following: a. On 03/06/19 at 1:43 p.m., he weighed 195.6 pounds. b. On 03/25/19 at 7:58 p.m., he weighed 190.4 pounds. c. On 04/30/19 at 5:14 p.m., he weighed 174.8 pounds. d. On 05/04/19 at 10:50 a.m., he weighed 174.6 pounds. e. On 05/21/19 at 8:50 p.m., he weighed 146.0 pounds. f. On 06/08/19 at 2:40 p.m., he weighed 164.6 pounds. No other weights were located in the record. Resident 62 had the following discharges: a. On 03/15/19, he had a psychiatric inpatient stay and returned to the facility on [DATE]. b. On 04/19/19, he had a psychiatric inpatient stay and returned to the facility on [DATE]. c. On 5/19/19, hospital stay after a fall and returned on 5/21/19. A physician's orders [REDACTED]. A readmission dietary evaluation, dated 04/30/19, indicated the resident required limited assistance with eating and to continue the current plan of care. A dietary progress note, dated 05/07/19 at 2:20 p.m., indicated the resident had a weight of 174.6 pounds which was a loss of 8.3% x 30 days. The resident's weight loss might have been related to recently being at the hospital and returning a few days ago. The resident was on [MEDICATION NAME] with possible side effect of an increased appetite. The resident was started on a house supplement three times a day on 04/08/19, at times would refuse it and to continue with the supplement at this time. The resident was noted to have behaviors and was looking for new placement. A physician's orders [REDACTED]. A dietary progress note, dated 06/13/19 at 11:07 a.m., indicted the resident had a weight of 164.6 pounds which was a loss of 15.8 % x 90 days and was a significant weight loss. The weight loss might be contributed to a recent hospitalization . He was started on [MEDICATION NAME] on 05/20/19 to help increase his appetite and started on a house supplement three times a day on 05/23/19. The resident fell on [DATE], 05/19/19 and 05/23/19. A [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated as revised on 06/11/19, addressed the problem the resident was not able to consume regular consistency foods and require a mechanically altered diet. He was at risk for weight loss due to his recent decline in health and refusal to eat at times. Interventions, initiated on 03/06/19 indicated to monitor and record intake every shift and provide diet as ordered. Interventions, initiated on 06/11/19, indicated to monitor weight as ordered, notify physician of significant weight changes, position for eating and drinking safely and refer to speech therapy for evaluation and treatment as indicated. No other interventions related to weight loss or nutrition were located. No other dietary progress notes were located. No Interdisciplinary Team (IDT) notes related to the resident's weight loss were located. No documentation the resident's physician was notify of the weight loss or rapid weight gain was located. During an interview, on 06/20/19 at 1:15 p.m., the DON indicated on 05/19/19 the resident had an unwitnessed fall in his room, was sent to hospital and was admitted . He returned to the facility on [DATE]. The resident had a psychiatric inpatient stay and returned to the facility with a weight loss. The IDT reviewed falls, behaviors, medication concerns or errors or refusals, and also recommendations from psych or therapy or dietician. The IDT meets weekly. The resident received a house supplement four times a day which the dietician increased on 06/13/19 and he received an appetite stimulate. According to the facility policy, residents were to be weighed weekly x 4 weeks upon admission and it was not clear on why this did not happen for Resident 62. If a large weigh difference was noticed, the resident should have been reweighed. The IDT track the weights and have monthly weight meetings. The nurse who worked when the weight was obtained should have notified the physician and should have documented the notification in the progress notes. Weigh gains should also be reweighed and the physician notified. A current facility policy, titled Weight Measurement not dated and received from the Executive Director on 06/19/19 at 9:05 a.m., indicated Policy: Resident's weights are taken upon admission, upon readmission and as indicated. Procedure: A baseline weight will be established upon admission. The resident will be weighed weekly for four (4) weeks after admission and monthly thereafter. Weekly weighing may be resumed if there is a significant change in condition, food intakes declined over time or there is evidence of altered nutrition status. Consistent weighing process and technique is used to determine accurate body weight measurement. This includes weighing the resident: At approximately the same time of day, using the same scale. 2. The record for Resident 16 was reviewed on 6/13/19 at 1:43 p.m. [DIAGNOSES REDACTED]. A physician order, dated 1/18/19, indicated a diet of NAS (no added salt), mechanical soft texture, may have double portions and nectar consistency for fluids. The resident had the following weights: a. 1/17/19 144.2 pounds b. 2/20/19 135. 2 pounds- a significant weight loss of 6.24% weight loss in one month. c. 4/2/19 133.2 pounds. 7.63 % in 3 months. There was no nutrition assessment in the electronic record after the significant weight loss and no new interventions. A care plan, dated 1/19/19 and revised on 3/6/19, indicated the resident was unable to consume regular consistency foods and fluids and required a mechanically altered diet. The interventions included, but were not limited to, monitor weight as indicated. During an interview, on 6/18/19 at 4:04 p.m., the ADON indicated there was no nutrition note in the electronic record in the assessment section and no progress notes about the weight loss. She indicated the dietician should have been notified for a nutritional assessment and usually the resident would have more frequent weights and a care plan for nutrition would be initiated. 3. The Record for Resident 59 was reviewed on 6/18/19 at 3:13 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident had the following weights: a. 10/21/18 167.6 pounds b. 11/7/18 155 pounds-a significant weight loss of 7.52% in one month. c. 6/1/19 157.8 A care plan, dated 11/14/18, indicated the resident received a regular diet with mechanical texture thin consistency. The interventions included, but were not limited to, monitor weights when available. During an interview, on 6/20/19 at 2:07 p.m., the DON indicated there was no nutrition note and no progress notes about the weight after the resident had a significant weight loss on 11/7/19. She indicated the resident should have been re-weighed and the resident's significant weight loss should have been discussed during the IDT (interdisciplinary team) meeting. A current facility policy, titled Weight Measurement not dated and received from the Executive Director on 06/19/19 at 9:05 a.m., indicated Policy: Resident's weights are taken upon admission, upon readmission and as indicated. Procedure: A baseline weight will be established upon admission. The resident will be weighed weekly for four (4) weeks after admission and monthly thereafter. Weekly weighing may be resumed if there is a significant change in condition, food intakes declined over time or there is evidence of altered nutrition status. Consistent weighing process and technique is used to determine accurate body weight measurement. This includes weighing the resident: At approximately the same time of day, using the same scale. A current policy, titled Nutritional Assessment not dated and received from the ED on 6/19/19 at 4:05 p.m., indicated, .The resident's nutritional status will be evaluated in order to identify any nutrition-related problems and degree of nutrition risks. A nutritional plan of care and interventions will be documented 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to protect residents from sexual abuse from a known sexually inappropriate resident (Resident K) for 2 of 3 residents reviewed for abuse (Residents H and J). The Immediate Jeopardy began on (MONTH) 21, (YEAR), when Resident K was allowed to touch a resident in a sexual manner. The Administrator, Director of Nursing, and Regional Nurse Consultant were notified of the Immediate Jeopardy on (MONTH) 16, 2019 at 5:47 p.m. The Immediate Jeopardy was removed on (MONTH) 18, 2019, but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include: On 1/15/19 at 7:32 a.m., Resident K was observed sitting in the Harmony unit dining room at the back table waiting on breakfast. On 1/15/19 at 1:15 p.m., Resident K was observed sitting at the back table in the Harmony unit dining room with Resident J. 1. During a telephone interview on 1/16/19 at 6:00 a.m., CNA 5 indicated she had came into work at 6:00 p.m., the evening of 12/21/19, and was helping take residents to their rooms after dinner when she observed Resident K sitting in the hallway across from the nurses station and knew she needed to get him into his recliner due to he had sexually inappropriate behaviors with two of the residents on the Harmony unit and he was supposed to be in his recliner, in bed or in an activity after meals to reduce his sexual inappropriate behaviors with female residents on the unit. As she was starting towards him to take him to his room, she was called away by the nurse to assist with an emergency. She told Resident K to stay where he was and she would be with him in a minute. She assisted the nurse and returned to the nurses station, but Resident K was no longer there. She indicated there were two female resident rooms he gravitated to, so she went to both those rooms, but he was not in either room. After searching for Resident K, she found him in Resident H's room sitting next to the side of her bed, in his high back wheelchair. Resident H was laying on her right side facing Resident K, dressed in a hospital gown and a brief. CNA 5 indicated she observed Resident K with his right hand palm up, pushed all the way up to his wrist in the front of Resident H's brief on her skin. She indicated when she addressed him as to what he was doing, he ignored her, and refused to remove his hand, so she had to physically remove his hand by grasping his elbow and she guided his hand out of Resident H's brief. She transported him back to his room and reported the incident to the LPN 10. a. Record review for Resident K was completed on 1/16/19 at 10:18 a.m. [DIAGNOSES REDACTED]. unspecified. Resident K's Quarterly MDS (Minimum Data Set) Assessment, dated 10/26/18, indicated his BIMS (Brief Interview Mental Status) was 8, which indicated he was moderately impaired cognitively. The resident had a Care Plan dated 4/4/18, which addressed the problem he had a mood problem and received [MEDICATION NAME] related to his Mood Disorder due to known physiological condition AEB Sexually inappropriate, irritability, and intrusive wandering. Interventions include, but were not limited to, 4/4/18-Administer medications as ordered. Monitor/document for side effects and effectiveness. Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. Behavioral health consults as needed (psychogeriatric team, psychiatrist etc) . The resident had a Care Plan dated 9/8/17, which addressed the problem he intrusively wandered into other residents' rooms. Interventions included, but were not limited to, 9/8/17-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Monitor location every 15 min (minutes), Monitor wandering behavior and attempted diversions, Provide divisional activities: food, toileting, conversation, 1-1, redirection. The resident had a Care Plan, dated 2/10/17 to current, which addressed the problem he exhibited sexually inappropriate behaviors as evidenced by inappropriately touching or gesturing other residents and staff members. Interventions included, but were not limited to, 2/13/17-Administer medications as ordered, Anticipate and meet the residents needs, Resident will remain on every 15 minute safety checks There was no assessment the resident had the cognitive ability to consent to a sexual relationship. b. The record review for Resident H was completed on 1/16/19 at 3:50 p.m. [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 12/21/18, indicated she had a BIMS of 5, which meant she was severely cognitively impaired mentally. There was no assessment the resident had the cognitive ability to consent to a sexual relationship. 2. Confidential interview was conducted during the course of the survey. The Confidential interviewee indicated the QMA and the Activities Aide 15 was going into the dining room after dinner when Resident J was attempting to exit the dining room in her wheelchair and Resident K was sitting at the first table in the Harmony dining room, which he normally ate in the quiet room due to his sexual inappropriate behaviors with female residents. He had turned his wheelchair around, so that he was able to reach Resident J. Resident K had his hand up Resident J's shirt. This incident was reported to LPN 10 who talked to Resident K about his behavior. Resident K was supposed to eat in the quiet room due to his sexual inappropriate behaviors with the female residents. The record review for Resident J was completed on 1/16/19 at 3:42 p.m. [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] indicated the resident's BIMS indicated 11, which meant she was moderately cognitively impaired. She had a Care Plan for Impaired cognitive function/dementia or impaired thought processes related to dementia and impaired decision making. She had a Care Plan for feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by ineffective coping, low self esteem tearfulness, motor agitation, withdrawal from care/activities, related to restricted physical activity. She had a Care plan for problematic manner in which resident acts characterized by inappropriate sexual behavior (verbal or physical related to need for affection. Interventions included, but were not limited to, Avoid types of conversation that could encourage or initiate inappropriate behavior, constant supervision in recreation programs. During an interview on 1/16/19 at 4:25 p.m., Resident J indicated there was one resident at the facility that bothered her and that was Name of Resident K. She indicated he He fondled my breasts and shoulders. She indicated he had done it on several occasions and she had told him to stop, but he did not stop when she told him to. She indicated she had told nursing staff that he fondled her. There was no assessment to indicate the resident had the cognitive ability to consent to a sexual relationship. During an interview on 1/16/19 at 4:30 p.m., LPN 11 indicated the staff was told by management Residents J and K's sexual relationship was consensual because they both knew what they were doing. She indicated the resident K's (Name of family member) was not happy with him being sexually inappropriate with this particular resident. She indicated the staff had been told over a year ago by the previous DON these incidents did not have to be reported because they were consensual between the two residents. She indicated due to his sexual inappropriate behaviors, when he was awake he was to be in his recliner, in bed or in an activity to discourage him from being sexually inappropriate with female residents. A current policy titled Abuse Prevention and Reporting-Indiana dated 11/18/16, provided by the Administrator on 1/15/19 at 9:13 a.m., contained the following Guidelines: The resident has the right to be free from abuse . Pre-Employment Screening of Potential Employees: Staff obligations to prevent and report abuse, neglect .Dementia management and resident abuse prevention; How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff .A notice will be posted stating an employee's obligation for reporting suspected crime and I to file such a report without retaliation .Internal Reporting Requirements and Identification of Allegations: Employees and Volunteers are required to report any incident, allegation or suspension of potential abuse, neglect . they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the survey agency any allegation of abuse, neglect . and to local law enforcement and the state survey agency if they have a suspicion that a crime was committed .Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway: Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility .Investigation Procedures: The appointed investigator will at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident, if interview. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents . Timing of Reporting: All alleged violations involving abuse . are reported immediately, but not 1 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction long term care facilities) in accordance with State law through established procedures . The immediate jeopardy that began on 12/21/18, was removed on 1/18/19, when the facility completed and submitted the report to ISDH related to the 1/15/18 incident between Residents J and K, Facility Staff in-servicing was initiated on abuse, reporting and investigation requirements specifically related to unusual occurrences and ability to consent to sexual relationship. Audits were being conducted to identify other residents who may have been effected and to monitor any other concerns and further allegations of abuse. Increased monitoring of residents with sexually inappropriate behaviors. Alternative placement was being sought for residents involved in the 1/15/18 incident, and other residents were interviewed to identify any other residents who may have been abused. But the noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy due to the need for on-going education and monitoring for compliance. 3.1-27(a)(1)

Based on interview and record review, the facility failed report a sexual abuse allegation for 1 of 3 residents reviewed for abuse (Resident J and K) The Immediate Jeopardy began on (MONTH) 21, (YEAR), when the facility failed immediately report and allegation of sexual abuse to the Administrator and ISDH. The Administrator, Director of Nursing, and Regional Nurse Consultant were notified of the Immediate Jeopardy on (MONTH) 16, 2019 at 5:47 p.m. The Immediate Jeopardy was removed on (MONTH) 18, 2019, but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: Confidential interview was conducted during the course of the survey. On 1/15/19 at 6:30 p.m., the interviewee indicated the QMA 3 and the Activities Aide 15 was going into the dining room after dinner when Resident J was attempting to exit the dining room in her wheelchair and Resident K was sitting at the first table in the harmony dining room, which he normally ate in the quiet room due to his sexual inappropriate behaviors with female residents. He had turned his wheelchair around, so that he was able to reach Resident J. Resident K had his hand up Resident J's shirt. This incident was reported to LPN 10 who talked to Resident K about his behavior. Resident K was supposed to eat in the quiet room due to his sexual inappropriate behaviors with the female residents. 1. The record review for Resident J was completed on 1/16/19 at 3:42 p.m. [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] indicated she was cognitively impaired. 2. Record review for Resident K was completed on 1/16/19 at 10:18 a.m. [DIAGNOSES REDACTED]. unspecified, and acquired absence of unspecified upper limb above elbow. Resident K's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated his BIMS was 8, which indicated he was moderately impaired cognitively. The resident had a Care Plan dated 9/8/17, which addressed the problem he intrusively wandered into other residents' rooms. Interventions included, but were not limited to, 9/8/17-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Monitor location every 15 min Monitor wandering behavior and attempted diversions, Provide divisional activities: food, toileting, conversation, 1-1, redirection. The resident had a Care Plan dated 2/10/17, which addressed the problem he exhibited sexually inappropriate behaviors as evidenced by inappropriately touching or gesturing other residents and staff members. Interventions included, but were not limited to, 2/13/17-Administer medications as ordered, Anticipate and meet the residents needs, Resident will remain on every 15 minute safety checks During an interview on 1/16/19 at 4:00 p.m., the Administrator indicated she did not report an incident between Residents J and K last night (1/15/18) because she was told Resident K was rubbing Resident J's leg and these two residents have had a touchy and feely relationship since Resident J was admitted . She indicated both of them were able to have a consensual relationship and Resident K gravitated toward Resident J because he thought she was his ex-wife. She indicated his wife was aware of the sexual inappropriate behaviors and was understanding of them. A current policy titled Abuse Prevention and Reporting-Indiana dated 11/18/16, provided by the Administrator on 1/15/19 at 9:13 a.m., contained the following Guidelines: The resident has the right to be free from abuse . Pre-Employment Screening of Potential Employees: Staff obligations to prevent and report abuse, neglect . they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the survey agency any allegation of abuse, neglect . and to local law enforcement and the state survey agency if they have a suspicion that a crime was committed . Timing of Reporting: All alleged violations involving abuse . are reported immediately, but not 1 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction long term care facilities) in accordance with State law through established procedures . The immediate jeopardy that began on 12/21/18, was removed on 1/18/19, when the facility completed and submitted the report to ISDH related to the 1/15/18 incident between Residents J and K, Facility Staff in-servicing was initiated on abuse, reporting and investigation requirements specifically related to unusual occurrences and ability to consent to sexual relationship. Audits were being conducted to identify other residents who may have been effected and to monitor any other concerns and further allegations of abuse. Increased monitoring of residents with sexually inappropriate behaviors. Alternative placement was being sought for residents involved in the 1/15/18 incident, and other residents were interviewed to identify any other residents who may have been abused. But the noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy due to the need for on-going education and monitoring for compliance. 3.1-28(c)

Based on interview and record review, the facility failed investigate and implement interventions to prevent a sexual abuse allegation for 1 of 3 residents reviewed for abuse (Resident J and K). The Immediate Jeopardy began on (MONTH) 21, (YEAR), when the facility failed to investigate and implement interventions to prevent a sexual abuse allegation. The Administrator, Director of Nursing, and Regional Nurse Consultant were notified of the Immediate Jeopardy on (MONTH) 16, 2019 at 5:47 p.m. The Immediate Jeopardy was removed on (MONTH) 18, 2019, but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: Confidential interview was conducted during the course of the survey. On 1/15/19 at 6:30 p.m., the interviewee indicated the QMA 3 and the Activities Aide 15 was going into the dining room after dinner when Resident J was attempting to exit the dining room in her wheelchair and Resident K was sitting at the first table in the harmony dining room, which he normally ate in the quiet room due to his sexual inappropriate behaviors with female residents. he had turned his wheelchair around, so that he was able to reach Resident J. Resident K had his hand up Resident J's shirt. This incident was reported to LPN 10 who talked to Resident K about his behavior. Resident K was supposed to eat in the quiet room due to his sexual inappropriate behaviors with the female residents. 1. The record review for Resident J was completed on 1/16/19 at 3:42 p.m. [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] indicated she was cognitively impaired. 2. Record review for Resident K was completed on 1/16/19 at 10:18 a.m. [DIAGNOSES REDACTED]. unspecified, and acquired absence of unspecified upper limb above elbow. Resident K's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated his BIMS was 8, which indicated he was moderately impaired cognitively. The resident had a Care Plan dated 9/8/17, which addressed the problem he intrusively wandered into other residents' rooms. Interventions included, but were not limited to, 9/8/17-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Monitor location every 15 min, Monitor wandering behavior and attempted diversions, Provide divisional activities: food, toileting, conversation, 1-1, redirection. The resident had a Care Plan dated 2/10/17, which addressed the problem he exhibited sexually inappropriate behaviors as evidenced by inappropriately touching or gesturing other residents and staff members. Interventions included, but were not limited to, 2/13/17-Administer medications as ordered, Anticipate and meet the residents needs, Resident will remain on every 15 minute safety checks During an interview on 1/16/19 at 4:00 p.m., the Administrator indicated she did not report an incident between Residents J and K last night (1/15/18) because she was told Resident K was rubbing Resident J's leg and these two residents have had a touchy and feely relationship since Resident J was admitted . She indicated both of them were able to have a consensual relationship and Resident K gravitated toward Resident J because he thought she was his ex-wife. She indicated his wife was aware of the sexual inappropriate behaviors and was understanding of them. She indicated this allegation was not investigated or intervention implemented at the time to prevent further abuse. A current policy titled Abuse Prevention and Reporting-Indiana dated 11/18/16, provided by the Administrator on 1/15/19 at 9:13 a.m., contained the following Guidelines: The resident has the right to be free from abuse . they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator .Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway: Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility .Investigation Procedures: The appointed investigator will at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident, if interviewable. Any written statements that have been submitted will be reviewed along with any pertinent medical records or other documents The immediate jeopardy that began on 12/21/18, was removed on 1/18/19, when the facility completed and submitted the report to ISDH related to the 1/15/18 incident between Residents J and K, Facility Staff in-servicing was initiated on abuse, reporting and investigation requirements specifically related to unusual occurrences and ability to consent to sexual relationship. Audits were being conducted to identify other residents who may have been effected and to monitor any other concerns and further allegations of abuse. Increased monitoring of residents with sexually inappropriate behaviors. Alternative placement was being sought for residents involved in the 1/15/18 incident, and other residents were interviewed to identify any other residents who may have been abused. But the noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy due to the need for on-going education and monitoring for compliance. 3.1-28(d)

Based on observation, interview and record review, the facility failed to notify family members and Physicians regarding resident's change of condition status for 2 of 6 residents being reviewed for notification of change (Residents G and N). This deficient practice resulted in Resident G not receiving timely care for a neurological change and change in health condition resulting in death and Resident N was hospitalized by direct admission for [MEDICAL CONDITION]. Findings include: During an interview on [DATE] at 5:07 a.m., LPN 2 indicated she observed the rapid neurological and physical decline of Resident G starting from the date she fell on ([DATE]) until she died ([DATE]). She indicated she had left the morning of [DATE]. When she returned that night for her next shift on [DATE] at 10:00 p.m., there was a group of CNAs standing at Resident G's door. When she asked the CNA's what was wrong, she was told by the CNA's, Resident G had fallen that afternoon and she was not acting like herself, and the resident could not bear weight during transfers since the fall. LPN 2 indicated at that time, from her assessment of Resident G, she was not as coherent mentally after the fall as what she was at her normal baseline prior to the fall. She was normally alert and oriented to at least person and she knew the names of consistent staff. LPN 2 indicated the resident's left hip X-ray results indicated there were no fractures or dislocations. She called the X-ray results to the DON (Director of Nursing) and sent the results to the resident's Physician. LPN 2 indicated the resident had been on Hospice services prior to her fall on [DATE], but she was not actively dying at the time of the fall. Hospice wrote orders ,[DATE] days after the fall for pain and anxiety medication due the resident was now actively dying. LPN 2 indicated the resident's X-ray results were returned to the facility on [DATE] at 9:21 a.m. She indicated the results indicated the pelvis, left hip and left femur had a [MEDICATION NAME] fracture, which was slightly impacted. She had a transcervical [MEDICAL CONDITION] femoral neck. The resident's X-ray examination of her rib cage revealed she did not have definite evidence of a recent fracture, but clinical correlation was required. LPN 2 indicated Resident G's first left femur and hip X-rays indicated she had no recent fracture or dislocation, but she did not think she and the CNA assisting her to straighten out Resident G's leg was able to get it straightened out well enough when the technician completed the first set of X-rays. LPN 2 notified the resident's Physician, Resident G's (Name of Family Member) and the DON the results of the second left pelvis, hip and femur X-rays. She indicated it was at that time, the DON and the Hospice on call nurse told this resident's (Name of Family Member) she would not pass her cardiac clearance test because she was actively dying. LPN 2 indicated the resident's (Name of family member) wanted her to go to the hospital to be evaluated and treated. She was told by management to tell him the resident was actively dying and the facility staff would keep her comfortable instead of sending her to the hospital. Resident G's (Name of the family member) agreed to leave her at the facility and keep her comfortable. During an interview on [DATE] at 2:22 p.m., CNA 23 indicated she was working on [DATE] when Resident G fell . Resident G fell around 3:00 p.m. She was found on the floor by a staff member. CNA 23 indicated she went to get RN 6, who was the nurse on duty for the Harmony unit that evening because someone one called in, so she did not normally work on that unit. CNA 23 indicated Resident G was laying on her left side under the sink and the Activity Aide 15 went to get RN 6. No one touched the resident until the RN 6 got there. RN 6 rubbed her hand on the resident's leg then she grabbed her left shoulder and her leg and lifted her up into a sitting position. While the resident was siting on the floor she was saying Ow, Ow, Ow, Ow, due to she was in pain The RN 6 said She is okay, let's put her in her wheelchair. The RN 6 did her assessment (vitals and rubbed the side of the residents femur bone in the back and the front and asked the resident if she was okay and the resident said I think so. RN 6 and CNA 24 picked her up and slid her into the chair. CNA 24 notified RN 6 the resident was complaining of hurting all over. Resident G told CNA 23 she had to go to the bathroom and CNA 23 tried to toilet her, but she was only able to bear weight on the right side and the left leg was in a bent position. The DON and the RN 6 was at the nurses station. The RN 6 indicated her leg got in that bent position all the time. The DON indicated Let's be cautious and get an X-ray anyway. During an interview on [DATE] at 10:21 a.m., the RN 6 indicated this resident fell at 3:05 p.m., but she was not sure of the date that she fell . She thought the date was [DATE]. RN 6 indicated she assessed her ROM and her vitals, then she and CNA 23 assisted her back into her wheelchair. CNA 23 and the other CNA (she could not remember that CNA's name) cleaned the resident up and the resident stayed up in her wheelchair. She indicated the resident ate dinner, then was taken to her room to be toileted and the same two CNA's called RN 6 down to the resident's room approximately between 6:00 p.m. and 7:00 p.m., because the resident did not want to bear weight while standing on her left side. RN 6 indicated she reassessed the resident at that time, to discover her ROM was fine and there was no indicators of pain. She indicated the resident was standing by performing a toe touch weight bear with her left side, which the RN 6 indicated was normal for her to do that at times. The RN 6 indicated the CNA's were pushing for me to get an X-ray because they said (Name of Resident) wasn't transferring normally. She indicated the resident was guarding her left hip area with her hand later that evening, but she continued to deny pain. RN 6 indicated the resident's left hip X-rays were negative for fractures or dislocations. RN 6 indicated she did not notify Resident G's (Name of family member) after her fall because she had been working at the facility for two years and she had not see her father visit during that time, so for all she knew she did not have a responsible person other than herself. She indicated she did not give the resident the option to go to the hospital after she fell because she knew X-rays could be performed at the facility. Resident G's record was reviewed on [DATE] at 12:10 p.m. [DIAGNOSES REDACTED]. A Fall-Initial Occurrence Note dated [DATE] at 3:05 p.m., indicated Resident G had an un-witnessed fall on [DATE] at 3:05 p.m. in her room. She was found laying on her floor on her left side in front of the sink. She indicated she was trying to get her clothes. Neurological checks were initiated. The residents Physician was notified. The residents Neurochecks were reviewed: The Neurochecks-72 HR (Hour) dated on [DATE] at 3:05 p.m., indicated the residents pupils were equal, reactive to light and both were 1 mm (millimeters) in size and she was able to follow a finger with her eyes. She responded to simple commands and responded appropriately, indicated the resident did not have any verbal expressions of pain, her most recent pain level was level 2 on a pain scale of 0 being no pain and 10 being the worst pain. She has all movement and sensation in all four extremities with strong bilateral hand grasps. 15 Minute Neurochecks-72 HR dated [DATE] at 3:35 p.m., indicated the only change was the resident's pain, indicated she verbally expressed pain at a pain level of 2 and she displayed non-verbal signs of pain. The comment section indicated leg muscles very tight. 15 Minute Neurochecks-72 HR dated [DATE] at 3:50 p.m., indicated the only change was the resident's pain assessment, indicated she verbally expressed pain at a level pain 2 and she displayed non-verbal signs of pain. The comment section indicated guarding left hip/thigh muscles very tight in BLE (Bilateral Lower Extremities). 30 Minute Neurochecks-72 HR dated [DATE] at 4:50 p.m., indicated the only change was the resident's pain assessment, which was dated [DATE] at 10:02 p.m., indicated she verbally expressed pain at a pain level 2 and she displayed non-verbal signs of pain. The comment section indicated guarding left hip/leg not applying pressure to LLE BLE muscles very tight. Order obtained to complete STAT x ray of left hip and femur. 4 hours Neurochecks-72 HR dated [DATE] at 9:50 p.m., indicated the only change was the resident's pain assessment, which was dated [DATE] at 10:02 p.m., indicated she verbally expressed pain at a pain level 2 and she displayed non-verbal signs of pain. The comment section indicated guarding left hip/thigh. 4 hours Neurochecks-72 HR dated [DATE] at 1:50 a.m., indicated the resident's vital signs had changed. Her temperature was 99.8 F, Her Pulse was 101 and her Respirations were 22. The pupil assessment indicated her bilateral pupil sizes were 2 mm. They were 1 mm. Her pain level stayed the same, except there was no comment in the comment section. 4 hours Neurochecks-72 HR dated [DATE] at 5:50 a.m., indicated the resident's vital signs had changed. Her Temperature was 99.4 F, Pulse was 122 and Respirations were 24. Resident G's orientation could not be assessed because she was not responding verbally at that time. The pupil assessment indicated her pupil sizes remained at 2 mm and she was not able to follow a finger with her eyes. She did not respond to simple commands and her appropriateness could not be assessed because she was unable to respond verbally. Her pain could not be assessed because she was unable to verbalize her pain. She did have nonverbal signs of pain. The comment section indicated guarding left leg, yells in pain when touched or moved. 4 Hours Neurochecks 72 dated [DATE] at 4:30 p.m., indicated her pupil size is different. Her pupil sizes were 3 mm instead of 2 mm in size. The pain assessment was dated [DATE] at 4:33 p.m. The resident could express pain at a level 5 with and pain with a pain scale of 0 is no pain and 10 is the worst pain. She displayed no non verbal gestures indicating she was in pain. Upon assessing her extremities, the nurses assessment indicated the resident's bilateral hand grasps were weak. 8 Hours Neurochecks-72 dated [DATE] at 1:50 a.m., indicated the resident's temperature was 99.5 and her Respirations were 22. Her pupil size was 2 mm. She did not voice any complaints of pain nor were there any non verbal expressions of pain. The comment section indicated Does not always respond appropriately per pt (patient) norm (normal). 8 Hours Neurochecks-72 dated [DATE] at 9:50 a.m., indicated the resident did not verbally express any complaints of pain. She did have non-verbal expressions of pain. Another pain symptom the resident was having was a headache. 8 Hours Neurochecks-72 dated [DATE] at 1:50 a.m., indicated the resident's temperature was 99.2 and her pulse was 120. The nurse was unable to assess her orientation. Her level of Consciousness was lethargic. Her pupil size remained at 2 mm. She did not respond to simple commands and the nurse could not assess her appropriateness. During an interview on [DATE] at 3:21, with RN 26 who indicated Resident G's (Name of family member) admitted her to Hospice back in (MONTH) (YEAR). She indicated she called resident's (Name of family member) every 3 weeks to give him an update unless there was a condition change. She indicated as far as she knew (Name of family member) was a part of her life and he received information from Hospice regarding her. During an interview on [DATE] at 3:50 p.m., the Regional Nurse Consultant indicated Resident G's Physician should have been notified regarding the change in her Neurological Assessment and physical decline for treatment option. 2. During the facility tour on [DATE] at 7:03 a.m., RN 6 was in attendance. The Resident N was sitting on the side of her bed crying without tears, making unintelligible words while crying. On [DATE] at 7:15 a.m., while in another resident's room with his door closed, this resident could be heard crying making unintelligible words loudly from her room and she was inconsolable when staff had tried to calm her down. On [DATE] at 7:20 a.m., CNA 13 and CNA 12 were in this resident's room together attempting to get her partially bathed and dressed to get her up for breakfast. Both CNA's indicated when they worked on the Harmony unit the last time, which was last Tuesday ([DATE]) this resident was complaining of right side pain and she was crying like this and she could not walk like she normally did. CNA 13 indicated at that time, she was instructed to put her in a wheelchair because she was not able to ambulate. She indicated she had to place her in a wheelchair today also because she was not able to ambulate. CNA 13 indicated ambulating was her usual type of locomotion around the unit. The resident's words were unintelligible and she was constantly crying, stopping for a moment at a time, then she would start back up again. She was not able to make her needs known to staff. During an interview on [DATE] at 7:23 a.m., LPN 10 and RN 6 were in attendance. LPN 10 indicated she had not worked on the Harmony unit since last Tuesday ([DATE]). She indicated this resident had these crying spells as a behavior around meals times, but usually approximately an hour after she ate she was happier. She indicated she notified the resident's Physician a couple months ago regarding these crying spells at meal times and laboratory tests were ordered. The RN 6 indicated she had worked at the facility for two years and this resident behaved this way since she started working here, so this was normal for her. During an interview on [DATE] at 7:30 a.m., LPN 10 indicated this resident fell this morning in the hallway in her wheelchair when she stood up and grabbed the handrail in the hallway and lost her balance and fell towards her right side. LPN 10 was observed giving the resident her PRN [MEDICATION NAME] for complaints of right sided pain. She indicated she had scheduled [MEDICATION NAME] this morning at 6:00 a.m. She indicated she texted her Physician today at 7:16 a.m. to notify him about the fall and asked him if she could obtain an X-ray of the resident's right hip area since she was complaining of right sided pain. On [DATE] at 12:15 p.m., the resident was sitting up on the side of her bed yelling out in a crying voice with a pained facial grimace. CNA 13 and CNA 12 came in at that time, to get her up for lunch. When the CNA's turned her onto her left side she continued to cry out, but when they turned her onto her right side, she screamed out in pain. When CNA 13 asked her if she was in pain, she indicated she was in pain all over. Both CNA's indicated during this time, last Tuesday was the first time this resident cried out continuously like this. CNA 13 indicated she usually she cried out, but than you could do something for her to make her happy again, but not the last two days and a week ago. She indicated last Tuesday she was complaining about right sided abdominal pain and she had not had a BM for 3 days, so she and CNA 12 told the nurse. The record for Resident N was reviewed on [DATE] at 12:37 p.m. [DIAGNOSES REDACTED]. Progress notes were reviewed: [DATE] at 8:10 a.m.--The resident's stomach was observed to be hard and distended. She had signs and symptoms of general discomfort. Physician was notified. [DATE] at 10:12 a.m.--Weekly skin assessment completed and there were no issues observed as of that time. [DATE] at 1:27 p.m.--The resident was yelling out, crying difficult to console, offered conversation, left her alone and re-approached with some effectiveness noted. Routine [MEDICATION NAME] [DATE] at 2:43 a.m.--The resident had a soft tissue protrusion noted from her left hip with no bruise, she was generally weaker today, incontinent of urine and her oxygen saturation was 94 % The DON was aware of these condition changes. [DATE] at 3:49 a.m.--The residents temperature was 99.4. [DATE] at 2:39 a.m.--The resident was disoriented to place and time, she can follow directions with guidance and assistance. She was generally weaker today and unsteady on her feet. She was incontinent. She had a treatment to her coccyx being completed. [DATE] at 5:01 a.m.--The resident's pain level was ,[DATE]. She was limping with facial grimacing and she was limping during ambulation. [DATE] at 11:45 p.m.--the resident was crying, yelling, and cursing with a frown on her face. Her pain level was 5 out of 10 on a ,[DATE] pain scale. She was repositioned, given incontinent care and fluid with food. [DATE] at 12:45 a.m.--The resident had laboratory test and a UA done for increased confusion, increased agitation and tearfulness. [DATE] at 9:28 a.m.--Resident had excessive tearfulness. She was offered PRN pain medication in addition to routine pain medication. The MD was notified. He ordered an order to obtain X-rays of her right hip related to excessive tearfulness due to possible pain. The resident was in pain prior to PRN medication administration and was unable to verbalize where the pain was. [DATE] at 1:36 p.m.--A new order for Bactrim ,[DATE] mg take 1 tablet by mouth twice a day for a Urinary Tract Infection for 7 days. [DATE] at 2:17 p.m.--The first antibiotic dose was given. The resident was yelling and screaming with anxiety, tearfulness noted, she was crying around breakfast and was yelling first shift and crying around lunch. [DATE] at 9:22 p.m.-- New order obtained to start IV (Intravenous) hydration NS (Normal Saline) 0.45 % at 75 ml/hour for 3 days. [DATE] at 12:00 a.m.,--A Midline IV (Intravenous Catheter) was place in the right Basilic vein. The resident is confused and agitates and required an assist of one QMA and the Venous Access staff. 0.45 NS at 75 ml/hr was started as order. [DATE] at 9:01 a.m.--IDT (Interdisciplinary Team) fall note--the resident was sitting in her w/c in the hallway. She was crying and attempted to stand up and lost her balance. She fell on to her right side. Pain medication was administered and the MD was notified of the resident's behavior. Labs were requested [DATE] at 9:01 p.m.--new order to direct admit the resident to (Name of the Hospital) for [MEDICAL CONDITION] The progress notes were reviewed from [DATE] to [DATE] for new Physician notification: [DATE] at 8:10 a.m.--the Physician was notified the resident's stomach was hard and distended with signs and symptoms of general discomfort noted upon palpation. The Skin-Pressure/Diabetic/Venous/Arterial Wound Report dated [DATE] at 5:34 p.m., indicated the Resident N developed a new Stage II pressure ulcer (Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is visible, pink or red, moist and may also present as an intact or ruptured serum-filled blister.) while in the facility. The wound measured 0.8 x 0.8 x 0.1 cm The wound was first discovered on [DATE]. There was a light amount serous drainage. There was [DIAGNOSES REDACTED] periwound tissue present. The treatment ordered for the wound was to cleanse the wound with normal saline, then apply skin prep to the periwound. Apply calcium alginate to the wound bed and cover with [MEDICATION NAME] and change the dressing three times weekly and as needed for soilage or displacement. During an interview on [DATE] at 1:01 p.m., CNA 12 indicated last Tuesday ([DATE]) Resident N complained of abdominal pain, she expressed to CNA 13 that she had not had a bowel movement for three days, she was sitting on the edge of the bed with her head tucked between her legs and CNA 12 tried to sit her up and she would not sit up and she was crying early in the morning that day and they told LPN 10 and she assessed her and gave her MOM. CNA 12 placed the resident into a wheelchair because she could not bear weight to stand. She indicated Resident N usually was ambulatory. She was taken to breakfast and she face-planted into her plate of food so she was put back to bed after she was cleaned up. LPN 10 was notified again she was not acting herself because her face was in her food and she was not acting right and LPN 10 told the two CNA's at that time, she gave her MOM. CNA 12 indicated the resident sat up on the side of the bed most of the day with her head tucked between her knees and cried out in pain about her abdomen hurting and sometimes she whaled out and could not be understood. CNA 12 indicated every time she tried to lay her back she would scream out and sit back up the same way. She indicated she was crying out when she came in that morning at 6:00 a.m. She indicated when they tried to turn her she cried out louder. During an interview on [DATE] at 2:18 p.m., LPN 10 indicated the labs on this resident just came back and she had a UTI. She indicated last Tuesday ([DATE]) she gave her MOM, but she did not have any labs or UA done until today. LPN 10 indicated the resident usually ate and she fed herself, but her appetite was not as good today. During an interview on [DATE] at 4:50 p.m., QMA 3 indicated Resident N on [DATE] had started yelling after dinner and she yelled all the way through his shift and she yelled God Please take me and he had never heard her do that before. He changed her incontinent brief last evening and her urine smelled like a Strong ammonia smell and he told RN 1 about this resident's foul smelling urine and she called the doctor and got new laboratory tests and a UA ordered for her. Confidential interview was conducted during the course of the survey. A Confidential Interviewee indicated this resident was diagnosed with [REDACTED]. The Confidential Interviewee indicated she had been placing notes on the communication board, which the nurses used to pass information back and forth between shifts. She indicated that communication board was supposed to be checked daily by the management staff when they had their morning meetings to find out what residents had change of conditions. The Confidential Interviewee indicated on the following dates she had documented changes in this residents condition on the communication board from her shift and other shifts for the managers to review in the morning meeting: [DATE]-She reported the resident had increased agitation to the DON and placed this information on the communication board. [DATE]-She reported the resident had a fatty type tissue on her left hip. [DATE] & [DATE]-She reported the resident had increased tearfulness, which was abnormal for her because she usually cried off and on and this was more constant during the night shift. [DATE]-More increased tearfulness reported again on the communication board. [DATE] & [DATE]-She reported information from her shift and information she found documented in the progress notes from other shifts, but did not get placed on the communication board for the management to see. The resident had increased tearfulness. Increased agitation, increased yelling with tearfulness on the day and evening shifts. [DATE]-She reported to the Physician QMA 3 who cared for Resident N indicated the resident had increased tearfulness, agitation and unsteadiness on her feet, but this particular shift she also had a very strong foul smelling urine (she indicated it smelled like ammonia). She indicated she notified the Physician and received new orders for laboratory tests and a urinalysis. The Confidential Interviewee indicated she had not notified the Physician prior to [DATE] because the nurses working the night shift had to be very careful when they called the Physicians due to they were calling them in the middle of the night and the Physicians did not like being woke up, so that was the purpose of the communication board. The condition changes were past onto the ADON (Assistant Director of Nursing) and DON (Director of Nursing) and one of them notified the Physicians the next day of the change in condition of the resident to get the orders to keep the Physicians from being unnecessarily woke up at night. A Confidential interview was conducted during the course of the survey. A Confidential Interviewee indicated she worked [DATE], and the resident walked to the dining room by herself and sat in the chair and she was agitated and she was the last one at the table and she would not let anyone have her dirty dishes. On [DATE], the resident was brought down to lunch and dinner in a wheelchair, which was abnormal for her because she usually ambulated by herself. She did not eat much for dinner. On [DATE], QMA 3 brought her down for bingo and she only took one to two bites of the cookie and she did not drink anything. During an interview on [DATE] at 7:23 a.m., LPN 10 and RN 6 were in attendance. LPN 10 indicated she had not worked on the Harmony unit since last Tuesday ([DATE]). The RN 6 indicated she had worked at the facility for two years and this resident behaved this way since she started working here, so this was normal for her. The Physician was not notified any other time besides [DATE] and [DATE] during that week when the resident was getting generally weaker, unsteady on her feet, running a low grade temperature, became incontinent, which was not normal for her, having increased crying spells hard to console, and developed a Stage 2 pressure ulcer to her coccyx during this time frame. During an interview on [DATE] at 4:35 p.m., LPN 11 indicated this resident had a Midline with IV fluids infusing because her labs came back that day indicating she was dehydrated. The resident was observed at that time sitting on the side of the bed by the heater, naked, picking at something in the air. She verbally indicated she felt better. She had her eyes wide open and was able to talk and be understood. She was reaching for something in the air, that was not there. Her bilateral lips were observed to be severely cracked and peeling. Her tongue was observed to be dry when she talked. A current policy titled Neurological Assessment undated, provided by the Executive Director on [DATE] at 6:15 p.m., contained the following, Policy: Resident sill have a neurological assessment completed when they experience a head injury or a change in condition that deems it necessary or per physician order [REDACTED].e., headache, change in mentation, vomiting or irregular breathing A current policy titled Physician-Family Notification-Change in Condition dated [DATE], with a revised date [DATE], provided by the Executive Director or [DATE] at 9:15 a.m., contained the following, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family-responsible party in a timely, efficient, and effective manner .Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention, (B) A significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attach or stroke. Clinical complications are such things as development of a stage II pressure sore, onset or recurrent periods of [MEDICAL CONDITION], recurrent urinary tract infection, or onset of depression. (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment This Federal tag relates to Complaint IN 356. 3XXX,[DATE](2)

Based on observation and interview, the facility failed to ensure 2 of 4 medication carts were kept locked. The facility also failed to maintain a safe environment for 5 of 32 resident rooms reviewed for room safety (Room #106, #108, #109, #119, and #123). Findings include: 1. On 2/4/16 at 9:13 a.m., Qualified Medication Aide (QMA) #6 entered a resident's room on the Walnut Hall to take the resident's blood pressure before medication administration. The medication cart was left unattended and unlocked outside of the resident's room. 2. On 02/4/16 at 3:45 p.m., RN #3 left the medication cart unlocked and unattended on the Harmony unit (a locked behavioral unit) while she went to look for a medication in the Emergency Drug Kit. The medication cart keys were left in the lock of the medication cart. RN #3 returned to the cart and removed the keys from the lock. She continued to prepare the medications needed for a resident's medication administration. At 3:55 p.m., RN #3 entered a separate room to administer the resident's medication and left the medication cart unlocked and unattended. During an interview on 2/4/16 at 4:05 p.m., RN #3 indicated the medication cart should have been locked when she stepped away from the cart. A current policy titled Medication Administration General Guidelines, dated 5/1/15, provided by the Director of Nursing on 2/5/16 at 1:15 p.m., indicated .2. Administration .m. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide 3. During observations on the following dates and times: a.) Room 109: 2/2/2016 at 3:31 p.m., loose, long, cords hung from the ceiling to the floor by the entry door. b.) Room 106: 2/2/2016 at 1:51 p.m., the emergency call light had a very short cord. The carpeting was loose from the resident's room into the bathroom. c.) Room 108: 2/2/2016 at 10:43 a.m., the hot water faucet was loose and the base was rusted, jagged and broken where a resident could handle. d.) Room 119: 2/2/2016 at 9:21 a.m., overhead light cord was too short for resident to reach safely. The bathroom emergency pull cord was too short for the resident to use. e.) Room 123: 2/2/2016 at 11:09 a.m., the toilet bowl base was cracked and chipped and the resident could possibly cut their foot on jagged edges. During the environmental tour on 2/4/2016 at 1:30 p.m., with the Maintenance Supervisor, he indicated he was unaware of the number of resident rooms that needed repair. During an interview with the Administrator on 2/4/2016 at 4:30 p.m., he indicated he was aware of minor issues that needed addressed with resident rooms, however, he indicated he had been addressing bigger issues. A current document titled, ACTION PLAN dated 11/21/2015, Indicated the .Administrator and Maintenance supervisor performed Facility rounding weekly to identify areas of concern that need painting or repair .3 days per month will be set aside for painting .Every room in facility will be reviewed monthly for painting needs. 3.1-45(a)(1)

Based on record review and interview the facility failed to ensure immediate notification of the resident's legal representative and physician for intervention, when a resident had a pressure ulcer which deteriorated for 1 of 4 resident's reviewed for notification of change in condition. (Resident B). This deficient practice resulted resulted in a delay of treatment, a decline in a resident's condition (Resident B) where the resident was subsequently transported and admitted to Intensive Care of the local area hospital [MEDICAL CONDITION], and treatment of [REDACTED]. Findings include: 1. The record for Resident B was reviewed on 08-31-15 at 1:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated that at the time the resident was admitted to the facility the resident's skin was intact. The Initial Braden scale (a system used to identify resident's at risk for pressure ulcers), dated 05-19-15 indicated the resident was at risk for the development of pressure ulcers. The resident's plan of care, dated 07-21-15, instructed the nursing staff to Observe/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status. Appearance, Color, wound healing, s/sx (signs/symptoms) of infection, wound size (Length times Width times Depth), Stage. A review of the Interdisciplinary Progress Notes indicated the following: 07-20-15 20:40 (8:40 p.m.) - Coccyx reported as a pink intact area. 07-22-15 14:02 (2:02 p.m.) - Coccyx reported as a pink intact area per 07-20-15 skin note, not new. However orders indicate area to coccyx is open. Will ask nurse to clarify coccyx. 07-22-15 14:57 (2:57 p.m.)- DON (Director of Nurses) said coccyx is open, superficial. Treatment ordered. Will review upcoming wound reports, expect it will heal quickly. 07-23-15 05:28 (5:28 a.m.)- .Tx (treatment) to coccyx, drsg (dressing) intact, no further areas noted. 07-23-15 12:15 (12:15 p.m.) - Skin condition: superficial. 07-24-15 02:26 (2:26 a.m.)- Coccyx continues with tx. as ordered, no redness, or drainage to or around dressing, no c/o (complaints of) verbally, pleasant. 07-28-15 02:39 (2:39 a.m.)- Tx. to coccyx continues as ordered, no bleeding, mild drainage clear/light yellow, are cleaned and dried sterile technique/clean technique, tender to touch area, applied foam derma as ordered, tolerated. 07-29-15 01:28 (1:28 a.m.) - Skin concerns observed: coccyx - treatment in progress. Moist to dry dressing. 07-29-15 05:45 (5:45 a.m.)- Treatment continues to coccyx. Cleansed, applied moist dressing and covered with transparent dressing. Small amount of bloody drainage noted. Complaint of tenderness with touch. Slight odor noted. 07-31-15 02:50 (2:50 a.m.) .coccyx area pink with dk. (dark) brown area by open area, cleansed, wet to dry drsg. (dressing) and covered, tender to touch A review of the Skin/Pressure Report dated 07-21-15 indicated, new wound development, open area to coccyx - abrasion 7.0 cm (centimeters) by 2.0 cm. Acquired in house/pressure. Date first observed 07-20-15 - [MEDICATION NAME], granulation with no signs or symptoms of infection. Periwound intact. Treatment - [MEDICATION NAME] and foam. A physician order, dated 07-21-15 indicated, cleans (sic) open area to coccyx with Normal Saline, pat dry. Apply small amount of [MEDICATION NAME] (a skin barrier treatment) ointment BID (two times a day) and PRN (as needed) for soilage until healed every day and night shift for open area. The order did not indicate the use of a foam dressing, wet to dry dressing or transparent dressing. Further review of the Skin/Pressure Reports indicated on 07-24-15 the area measured .5 cm by .2 cm by .1 cm and was assessed as a Stage Two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure area. A review of the Skin/Pressure report dated 07-31-15, 7 days later, indicated the area was now assessed as a Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often include undermining and tunneling) pressure ulcer and measured 4.6 cm by 3.4 cm by .3 cm. The assessment indicated the area was worsening, had granulation, with slough and was necrotic. The drainage was identified as serosanguinous and the periwound was discolored. A subsequent review of the Skin/Pressure report, dated 08-07-15 indicated the pressure ulcer increased in size to 4.8 cm by 4.2 cm by .3 cm and was assessed as a Stage Four pressure ulcer. The assessment indicated the area was worsening, had slough and eschar with moderate amount of purulent drainage, discoloration and [MEDICAL CONDITION] to the periwound and displayed with signs and symptoms of infection. The nursing staff failed to notify the physician for medical intervention, on 07-28-15 when the area was first noted with mild drainage, and then on 07-29-15 when the area was noted with bloody drainage, a slight odor and complaints of tenderness by the resident to the area, and subsequently did not report the area until it was assessed on 07-31-15 as a Stage Two pressure ulcer when the nurse documented the area had a dark brown area adjacent to the open area and the resident continued to complain of tenderness. Further review of the resident's clinical record indicated the resident had a change in condition and was transported to the local area hospital on 08-08-15. On 8-31-15 at 9 a.m., the ambulance report dated 8-8-15 was reviewed and indicated the resident had a temperature of 101.9 Fahrenheit, a pulse of 115 and respiration rate of 24. The report indicated that when the ambulance crew arrived at the facility, four nurses were holding his hands to prevent them from shaking. A review of the Hospital record on 08-31-15 at 8:30 a.m., for the dates 8-8-15 through 8-19-15 indicated that upon arrival at the local hospital emergency room , the resident's white blood cell count was 19.8 (with a normal range of 3.3 to 10.5) and diagnosed with [REDACTED]. A review of the hospital Wound Care,documentation indicated the resident came from Aperion nursing facility and had decubitus ulcer to coccyx upon arrival to (name of local area hospital). The wound has a strong odor and has eschar on it. The Wound Nurse indicated there was a Large amount of purulent drainage. Photo and measurements completed. The documentation indicated the pressure ulcer measured 5 cm long by 3 cm wide and 5 cm deep with necrotic tissue. The hospital physician notation indicated, the resident presented to the hospital with a deep infected sacral decubitus ulcer and underwent a debridement procedure to the wound. The size of the area treated (by debridement) was approximately 10 cm long by 7 cm wide by 3 cm deep with all necrotic devitalized tissue removed. During an interview on 09-02-15 at 2:00 p.m., the Wound nurse indicated the legal representative for the resident had not been notified of the pressure area, and the nursing staff had been communicating with the resident's spouse. We thought she (in regard to the spouse) was the contact person and didn't know she had some dementia until later on. We talked with her almost daily. During a further interview on 09-03-15 at 10:00 a.m., the Wound Care Nurse verified the nursing staff did not follow the physician orders dated 07-21-15, There are some areas that need to breath and not be covered. A review of the facility policy on 09-02-15 at 11:30 a.m., titled, Change in Condition Physician Notification Overview Guidelines, and dated 01-01-2014, indicated the following: These guidelines were developed to ensure that: 1. All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Medical care problems are communicated to the attending physician in a timely, concise, and thorough manner. Nurse Responsibilities - The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgment requires immediate medical intervention. A review of the facility policy on 09-02-15 at 11:30 a.m., titled Pressure Ulcer and Skin condition Assessment Policy, dated 01-01-2015, indicated the following: Policy: It is the policy of this facility that pressure and other ulcers, (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse, and recorded on the facility approved wound assessment form. Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented. Standards: . 2. Residents identified by the Braden scale of being at risk of a skin breakdown will have a weekly skin assessment by a licensed nurse. 7. At the earliest sign of a pressure ulcer or other skin problem, the resident, legal representative and attending physician will be notified 14. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. 18. The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative of any suspected wound infection. 21 A licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. If observations are acute, physician and responsible party will be notified by change nurse. The Federal tag relates to Complaint IN 682. 3.1-5(a)

Based on observation, record review and interview the facility failed to ensure resident's with pressure ulcers received the necessary treatment and services to promote healing and prevent infection for 3 of 3 resident's reviewed with pressure ulcers in a sample of 4. (Residents B, F and H). This deficient practice resulted in a decline in a resident's condition (Resident B) which [MEDICAL CONDITION], and a Stage Four Pressure ulcer which resulted in a hospitalization for the resident. The resident was admitted to the Intensive Care Unit underwent surgical debridement of the pressure ulcer. Findings include: 1. The record for Resident B was reviewed on [DATE] at 1:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated that at the time the resident was admitted to the facility the resident's skin was intact. The Initial Braden scale (a system used to identify resident's at risk for pressure ulcers), dated [DATE] indicated the resident was at risk for the development of pressure ulcers. The clinical record contained an additional Braden Scale assessment, dated [DATE], where the resident was identified as moderate risk for pressure ulcers. A subsequent Braden scale dated [DATE] indicated the resident remained at risk with a score of 15. The resident's plan of care, dated [DATE], instructed the nursing staff to Observe/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status. Appearance, Color, wound healing, s/sx (signs/symptoms) of infection, wound size (Length times Width times Depth), stage. A review of the Interdisciplinary Progress Notes indicated the following: [DATE] 20:40 (8:40 p.m.) - Coccyx reported as a pink intact area. [DATE] 14:02 (2:02 p.m ) -Coccyx reported as a pink intact area per [DATE] skin note, not new. However orders indicate area to coccyx is open. Will ask nurse to clarify coccyx. [DATE] 14:57 (2:57 p.m.)- DON (Director of Nurses) said coccyx is open, superficial. Treatment ordered. Will review upcoming wound reports, expect it will heal quickly. [DATE] 05:28 (5:28 p.m.)- .Tx (treatment) to coccyx, drsg (dressing) intact, no further areas noted. [DATE] 12:15 (12:15 p.m.) - Skin condition: superficial. [DATE] 02:26 (2:26 a.m.)- Coccyx continues with tx. as ordered, no redness, or drainage to or around dressing, no c/o (complaints of) verbally, pleasant. [DATE] 02:39 (2:39 a.m.) - Tx. to coccyx continues as ordered, no bleeding, mild drainage clear/light yellow, are cleaned and dried sterile technique/clean technique, tender to touch area, applied foam derma as ordered, tolerated. [DATE] 01:28 (1:28 a.m.)- Skin concerns observed: coccyx - treatment in progress. Moist to dry dressing. [DATE] 05:45 (5:45 a.m.) - Treatment continues to coccyx. Cleansed, applied moist dressing and covered with transparent dressing. Small amount of bloody drainage noted. Complaint of tenderness with touch. Slight odor noted. [DATE] 02:50 (2:50 a.m.) .coccyx area pink with dk. (dark) brown area by open area, cleansed, wet to dry drsg. (dressing) and covered, tender to touch [DATE] 00:32 (12:32 a.m.) - Area to coccyx continues. Tx. as ordered. Tender to touch. Resident has discomfort to area, receives Tylenol (an [MEDICATION NAME]) prn (as needed) monitoring fever and s/s of infection. [DATE] 11:17 (11:17 a.m.) Wound bed black in color, strong odor noted. Mild drainage noted to area. The nurse notified the physician and received an order to culture the wound due to malodor and low grade temperature. [DATE] 00:00 (12 a.m.) Malodorous with bloody serous drainage noted on old dressing but not in wound bed. Perimeter of wound black with reddish brown wound bed. Specimen obtained via culture swab. [DATE] 18:15 (6:15 a.m.) - Culture needs to re done due to expired culture swab. Asked for lab tech (technician) to deliver culture swab so this writer can swab wound and send specimen to lab with this run. Per Lab. (Laboratory) they will contact dispatch to attempt to have lab tech. bring a culture swab. In addition the clinical record indicated the facility did not provide an anti pressure reducing device to the resident's bed or wheelchair until [DATE]. [DATE] 03:45 (3:45 a.m.)- Collected specimen via culture swab. Wound bed reddish brown, perimeters black. Small amount of serous drainage. Less odorous than yesterday. Complaint of tenderness with treatment. The culture result dated [DATE] indicated the area included organisms as Pseudomonas Aeruginose - Heavy Growth, [MEDICATION NAME] Faecalis - Heavy Growth, and two Different Gram Negative Road - Heavy Growth. The resident was started on the antibiotic [MEDICATION NAME] 600 mg (milligrams) three times a day. However the facility was notified the organism was resistive to the antibiotic on [DATE]. A review of the Skin/Pressure Report dated [DATE] indicated, new wound development, open area to coccyx - abrasion 7.0 cm (centimeters) by 2.0 cm. Acquired in house/pressure. Date first observed [DATE] - [MEDICATION NAME], granulation with no signs or symptoms of infection. Periwound intact. Treatment - [MEDICATION NAME] and foam. A physician order, dated [DATE] indicated, cleans (sic) open area to coccyx with Normal Saline, pat dry. Apply small amount of [MEDICATION NAME] (a skin barrier treatment) ointment BID (two times a day) and PRN (as needed) for soilage until healed every day and night shift for open area. The physician order did not include the use of an occlusive dressing. Further review of the Skin/Pressure Reports, indicated on [DATE] the area measured .5 cm by .2 cm by .1 cm and was assessed as a Stage Two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure area. A review of the Skin/Pressure report dated [DATE], 7 days later, indicated the area was now assessed as a Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often include undermining and tunneling) pressure ulcer and measured 4.6 cm by 3.4 cm by .3 cm. The assessment indicated the area was worsening, had granulation, with slough and was necrotic. The drainage was identified as serosanguinous and the periwound was discolored. The nursing staff failed to notify the physician for medical intervention, on [DATE] when the area was first noted with mild drainage, and then on [DATE] when the area was noted with bloody drainage, a slight odor and complaints of tenderness by the resident to the area, and subsequently did not report the area until it was assessed on [DATE] as a Stage Two pressure ulcer when the nurse documented the area had a dark brown area adjacent to the open area and the resident continued to complain of tenderness. A subsequent review of the Skin/Pressure report, dated [DATE] indicated the pressure ulcer increased in size to 4.8 cm by 4.2 cm by .3 cm and was assessed as a Stage Four pressure ulcer. The assessment indicated the area was worsening, had slough and eschar with moderate amount of purulent drainage, discoloration and [MEDICAL CONDITION] to the periwound and displayed with signs and symptoms of infection. Further review of the resident's clinical record indicated the resident had a change in condition and was transported to the local area hospital on [DATE]. On [DATE] at 9 a.m., the ambulance report dated [DATE] was reviewed and indicated the resident had a temperature of 101.9 Fahrenheit, a pulse of 115 and respiration rate of 24. The report indicated that when the ambulance crew arrived at the facility, four nurses were holding his hands to prevent them from shaking. A review of the Hospital record on [DATE] at 8:30 a.m., for the dates [DATE] through [DATE] indicated that upon arrival at the local hospital emergency room , the resident's white blood cell count was 19.8 (with a normal range of 3.3 to 10.5) and diagnosed with [REDACTED]. A review of the hospital Wound Care,documentation indicated the resident came from Aperion nursing facility and had decubitus ulcer to coccyx upon arrival to (name of local area hospital). The wound has a strong odor and has eschar on it. The Wound Nurse indicated there was a Large amount of purulent drainage. Photo and measurements completed. The documentation indicated the pressure ulcer measured 5 cm long by 3 cm wide and 5 cm deep with necrotic tissue. The hospital physician notation indicated, the resident presented to the hospital with a deep infected sacral decubitus ulcer and underwent a debridement procedure to the wound. The size of the area treated (by debridement) was approximately 10 cm long by 7 cm wide by 3 cm deep with all necrotic devitalized tissue removed. 2. The record for Resident F was reviewed on [DATE] at 2:15 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had routine wound care at a local area hospital prior to admission to the facility. At the time the resident was admitted to the facility, the Nursing Assessment indicated the resident had an area to the right shin and the left heel. The admission documentation, lacked an assessment or description of the two areas. An admission order, dated [DATE], indicated the area to the resident's heel was necrotic/eschar - treatment [MEDICATION NAME] Ag cover with gauze and wrap with conform and change every three days. The Pressure Report, dated [DATE] indicated the area to the left heel measured 1.0 cm by .5 cm - unstageable. A review of the resident's Minimum Data Set assessment, dated [DATE] indicated the resident had a pressure ulcer - was at risk for the development of pressure ulcers and the current pressure ulcer was unstageable with measurements of 1.0 cm by .5 cm by 0.0 cm and eschar. A review of the resident's current plan of care indicated the resident had a pressure ulcer to left heel related to immobility. Interventions to this plan of care included Monitor dressing to ensure it is intact and adhering. A review of the documentation from the local hospital wound care center indicated the following: [DATE] - left calcaneous (heel) [MEDICATION NAME] blue gauze and conform. Prevalon boots at night. Pressure Injury/Pressure Ulcer 1.6 cm. by 1.4 cm. by 0.2 cm. Small amount of exudate serosanguineous red/brown. Wound status - open The area was debrided and the measurements post procedure were 1.7 cm. by 2.1 cm. by 0.2 cm. - Stage Two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.). [DATE] - left calcaneous, Pressure Injury/Pressure Ulcer - Wound status 'open' - 1.3 cm. by 1.3 cm by 0.1 cm with serosanguineous drainage, red/brown in color with necrotic tissue. The area was debrided and post treatment the area measured 1.5 cm. by 2.0 cm by 0.3 cm. - Stage Three (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). [DATE] - left calcaneous (heel) Pressure Injury/Pressure Ulcer - Wound status 'open' 1.5 cm. by 1.2. cm. by 0.1 cm. Necrotic amount large (67 - 100 %). The area was debrided and post treatment the area measured 1.2 cm. by 1.5 cm. by 0.2 cm., with necrotic/eschar, [MEDICATION NAME]/slough exudates,and subcutaneous tissue dedrided. Orders: [MEDICATION NAME] Blue/Gauze, Conform, tape, change daily. Prevalon boot left heel during day and at night. Protein supplement two times a day. During an interview on [DATE] at 9:35 a.m., the Wound Nurse indicated the resident was transported to the local area Wound Care Clinic on [DATE] for a scheduled appointment. A review of the Wound Care Physician Orders, dated [DATE], instructed the nursing staff to continue to use [MEDICATION NAME]/gauze and conform as previously ordered. The physician also indicated the resident required Prevalon boots during day and/or left heel at night. The wound status was assessed as open and measured 2.0 cm. by 1.5 cm. by 0.1 cm. and was assessed as Stage Three with large amount of necrosis - eschar. The area was again debrided and the measurements post debridement were 1.5 cm by 1.3 cm. by 0.2 cm. During an observation on [DATE] at 9:40 a.m., with the Wound Care Nurse in attendance, the resident was assisted from the wheelchair to bed. During this observation, the resident had bedroom slippers on. After the resident was positioned in bed, Licensed Nurse #6 pulled up the resident's left pant leg and removed the left sock. The pressure ulcer to the left heel lacked the physician ordered treatment/dressing. A request was made to measure the left heel pressure ulcer. The Wound Care Nurse indicated the area measured 1.6 cm. by 1.1 cm. by 0.0 - unstageable and necrotic. In addition, although the Wound Care center ordered the specialized pressure relieving Prevalon boot for the resident, the facility failed to provide the boot until [DATE]. 3. The record for Resident H was reviewed on [DATE] at 11:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set assessment, dated [DATE], indicated the resident required extensive assistance with bed mobiity/transfer, was always incontinent of bowel and bladder and had a Stage Two pressure ulcer. A review of the current Braden Scale assessment, dated [DATE], indicated the resident was assessed at High Risk for the development of pressure ulcers with a score of 12. The assessment indicated the resident's sensory perception was slightly limited, was assessed as very moist, chairfast, with very limited mobility, a nutrition problem and problem with friction/shear. The physician order, dated [DATE], instructed the nursing staff to cleanse coccyx wound with wound cleanser, pat dry, cover with bordered foam. Change every three days or as needed for soilage. A review of the facility Pressure Ulcers/Wound Report, dated [DATE], indicated the pressure ulcer measured .2 by .6 by 0.1 - Stage Two. During an observation on [DATE] at 9:45 a.m., with Licensed Nurse #7 in attendance as well as the Wound Care Nurse, the resident was assisted to bed and a body assessment was completed. Certified Nurse Aide #5 removed the resident's slacks, and then removed the incontinent brief. During this observation the pressure ulcer to the resident's coccyx lacked a dressing. The Certified Nurse Aide indicated when she prepared the resident for breakfast early this morning, she (in reference to the resident) was wet and the dressing was not on her but lying inside the brief. I told the nurse but at the time she was busy with doing Accuchecks. Licensed Nurse #7 verified she had been informed by the Certified Nurse Aide. At the time of the observation, the Wound Nurse measured the area and indicated the area measured .5 cm. (length) by .8 cms (width) with edges macerated and some necrosis. A review of the facility policy on [DATE] at 11:30 a.m., titled Pressure Ulcer Prevention, and dated [DATE], indicated the following: Purpose: To prevent and treat pressure sores. Procedure: . 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. 9. Pressure reduction mattress may be used for moderate/high risk. Pressure relieving mattress will be used for residents at severe risk for break down. 10. Use pressure reducing pads in chairs (all types) to protect bony prominence's for residents identified as Moderate/High/Severe risk. 11. Use positioning devices to relieve all pressure from heels, toes and malleoli. NOTE: Daily skin checks will be done by CNAs (Certified Nurses Aides) during routine care. A review of the facility policy on [DATE] at 11:30 a.m., titled Pressure Ulcer and Skin Condition Assessment Policy, dated [DATE], indicated the following: Policy: It is the policy of this facility that pressure and other ulcers, (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse, and recorded on the facility approved wound assessment form. Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented. Standards: . 2. Residents identified by the Braden scale of being at risk of a skin breakdown will have a weekly skin assessment by a licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. 5. If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock area and groin. 6. Care givers are responsible for promptly notifying the charge nurse of skin observations, including: a. redness/swelling . e. excoriations, f. wound drainage, . i. any type of lesion, . j. skin discolorations. 7. At the earliest sign of a pressure ulcer or other skin problem, the resident, legal representative and attending physician will be notified 14. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record 16. Dressing which are applied to pressure ulcers, skin tears, wounds, [MEDICAL CONDITION] or incisions shall include the date and initials of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness and signs and symptoms of infection.18. The licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative of any suspected wound infection. 21. A licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. If observations are acute, physician and responsible party will be notified by change nurse. This Federal tag relates to Complaint IN 682. 3XXX,[DATE](a)(1) 3XXX,[DATE](b)(2)

Based on interviews and record reviews, the facility failed to provide physician notification, appropriately, for clarification related to the need for lab orders for a resident on chronic anticoagulant therapy. Resident B had an INR of 10.25 (critical bleeding time), sustained a fall with a resulting brain bleed and was hospitalized . (Resident B) The facility also failed to notify the physician timely for lab results and weight gain for a resident with [MEDICAL CONDITION], in a timely manner, (Resident F) for 2 of 4 residents reviewed for physician notification, in a sample of 11. Findings include: 1.) The clinical record for Resident B was reviewed on 7/14/15 at 11:00 a.m. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Physician orders, dated 3/10/15, indicated INR, one time only for [MEDICATION NAME] (an anticoagulant, used to prevent blood from clotting, [MEDICATION NAME] is generic form) therapy for 1 day, do on 3/10/15. Nursing notes indicated Resident B went to the hospital for a procedure on 2/24/15. Hospital notes indicated Resident B had a left and right heart catheterization and a coronary angiogram on 2/24/15. Hospital discharge instructions for admission to the facility, dated 2/25/15, indicated an order for [REDACTED]. Nurses notes, indicated the following: 3/13/15 at 6:00 a.m., writer was getting report from night nurse when writer noticed (Resident B) standing in doorway. (Resident B) started to fall forward but twisted around and landed on his back, head bouncing off the floor, (Resident B) was knocked unconscious for a few seconds, back of head bleeding. (Resident B) confused. 911 called, vital signs obtained, within normal limits. Son notified at 6:20 a.m. and MD (physician) notified at 6:25 a.m., report called to ER (emergency room ) at 6:28 a.m. 3/13/15 at 8:05 a.m., (name of hospital) ER called, gave report to writer, sending (Resident B) back (to facility), CT normal, Cervical spine x-ray normal, glued laceration on back of head d/t (due to) huge hematoma, resident sleepy. 3/13/15 at 8:15 a.m., (Resident B) back from ER head still bleeding, Writer called MD to see if we can get STAT (immediate) labs, MD ordered PT/INR, CBC, BMP and UA. 3/13/15 9:30 a.m., (Resident B's) head in back very swollen, neuro checks continue resident alert, opens eye spontaneously when spoken to, answers questions appropriately, vital signs obtained, voices no complaints at this time, will continue to monitor. 3/13/15 at 12:30 p.m., STAT PT/INR results INR 10.5, PT 127 seconds. (Resident B) stating nausea and is more confused. MD made aware. 911 called. EMTs (emergency medical technician) arrived. (Resident B) taken to ER. 3/13/15 at 4:47 p.m., (name of hospital) ER nurse called, said Resident B had another CT scan done, he has a massive brain bleed and is being sent to (name of hospital) for emergency surgery. Lab results for Resident B, dated 3/13/15, specimen collected at 10:30 a.m., indicated critical results related to the length of time it takes for blood to clot. A prolonged PT means that the blood is taking too long to form a clot. The following results were listed: [MEDICATION NAME]- indicated H (high) greater than 120.0 (normal limits: 8.9 - 11.5) INR- indicated Critical result noted 10.25 (seconds) (normal limits: 2.0 - 3.0) During an interview, on 7/17/15 at 10:40 a.m., the interim Director of Nursing indicated residents with anticoagulant orders, such as [MEDICATION NAME] (generic form is [MEDICATION NAME]), usually have lab orders for PT/INR. If there aren't any lab orders, the nurse should contact the physician for clarification. In this case, the physician was not notified for clarification. 2.) The clinical record for Resident F was reviewed on 7/16/15 at 9:40 a.m. [DIAGNOSES REDACTED]. a.) Nurses notes, dated 5/7/15 at 3:29 p.m., indicated: New order received to change [MEDICATION NAME] dose and recheck INR in 1 week (5/14/15). Message left for (name of family member) and pharmacy notified and lab ordered. Lab results, dated 5/14/15, indicated the following results were reported to facility staff on 5/14/15 at 5:00 p.m. PT- 12.8, indicated H (high) (normal limits: 9.5 - 11.8) INR- 1.2, indicated H (high) (normal limits: 0.9 - 1.1) Documentation indicated the physician was notified of the high results on 5/18/15, 4 days after they were reported to the facility. Resident F's care plan for anticoagulant therapy, related to the [DIAGNOSES REDACTED]. Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. Labs as ordered. Report abnormal lab results to the MD. The DON indicated, during an interview on 7/17/15 at 1:20 p.m., the lab order was collected on 5/14/15, however, there was not documentation to indicate when the results were communicated with the physician until 5/18/15. Lab results, especially abnormal values, were expected to be communicated with the physician as soon as the results were communicated with the attending nurse. b.) The following weights were documented for Resident F: 4/28/15 165.8 4/30/15 171.8 5/09/15 181.0 On 5/15/15 at 10:45 p.m., nurses notes indicated Resident F had gained 16 pounds in two weeks, bilateral lower extremities had +3 [MEDICAL CONDITION], lungs sounded congested, and the family was worried because Resident F was not on [MEDICATION NAME] (diuretic). MD notified of changes and family concerns. New orders for [MEDICATION NAME], increase in Potassium, and weigh daily. A care plan for [MEDICAL CONDITION], dated 4/28/15 included the following interventions: - Monitor weight as ordered. - Monitor/document/report, signs and symptoms of [MEDICAL CONDITION]: dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate ([MEDICAL CONDITION] lethargy and disorientation. During an interview, on 7/17/15 at 1:20 p.m., the DON indicated daily weight increases of two or more pounds were expected to be shared with the physician, especially for residents with a [DIAGNOSES REDACTED]. She did not know why Resident F's weight gains were not communicated to the physician until 5/15/15. Nurses were expected to provide such notification as soon as possible. 3.1-5(2) 3.1-5(3)

Based on record review and interviews, the facility failed to provide anticoagulant monitoring, appropriately, for 2 of 4 residents reviewed for anticoagulant therapy in a sample of 11. (Resident B and F) Resident B did not have bleeding labs drawn timely, sustained a fall resulting in a brain bleed and had a subsequent INR level of 10.25 (bleeding time) after the fall. Findings include: 1.) The clinical record for Resident B was reviewed on 7/14/15 at 11:00 a.m. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Physician orders, dated 3/10/15, indicated INR, one time only for [MEDICATION NAME] (an anticoagulant, used to prevent blood from clotting, [MEDICATION NAME] is generic form) therapy for 1 day, do on 3/10/15. Nursing notes indicated Resident B went to the hospital for a procedure on 2/24/15. Hospital notes indicated Resident B had a left and right heart catheterization and a coronary angiogram on 2/24/15. Hospital discharge instructions for admission to the facility, dated 2/25/15, indicated an order for [REDACTED]. Nurses notes, indicated the following: 3/13/15 at 6:00 a.m., writer was getting report from night nurse when writer noticed (Resident B) standing in doorway. (Resident B) started to fall forward but twisted around and landed on his back, head bouncing off the floor, (Resident B) was knocked unconscious for a few seconds, back of head bleeding. (Resident B) confused. 911 called, vital signs obtained, within normal limits. Son notified at 6:20 a.m. and MD (physician) notified at 6:25 a.m., report called to ER (emergency room ) at 6:28 a.m. 3/13/15 at 8:05 a.m., (name of hospital) ER called, gave report to writer, sending Resident B back (to facility), CT normal, Cervical spine x-ray normal, glued laceration on back of head d/t (due to) huge hematoma, resident sleepy. 3/13/15 at 8:15 a.m., (Resident B) back from ER head still bleeding, Writer called MD to see if we can get STAT (immediate) labs, MD ordered PT/INR, CBC, BMP and UA. 3/13/15 9:30 a.m., (Resident B's) head in back very swollen, neuro checks continue resident alert, opens eye spontaneously when spoken to, answers questions appropriately, vital signs obtained, voices no complaints at this time, will continue to monitor. 3/13/15 at 12:30 p.m., STAT PT/INR results INR 10.5, PT 127 seconds. (Resident B) stating nausea and is more confused. MD made aware. 911 called. EMTs (emergency medical technician) arrived. (Resident B) taken to ER. 3/13/15 at 4:47 p.m., (name of hospital) ER nurse called, said (Resident B) had another CT scan done, he has a massive brain bleed and is being sent to (name of hospital) for emergency surgery. Lab results for Resident B, dated 3/13/15, specimen collected at 10:30 a.m., indicated critical results related to the length of time it takes for blood to clot. A prolonged PT means that the blood is taking too long to form a clot. The following results were listed: [MEDICATION NAME]- indicated H (high) greater than 120.0 (normal limits: 8.9 - 11.5) INR- indicated Critical result noted 10.25 (seconds) (normal limits: 2.0 - 3.0) During an interview, on 7/17/15 at 10:40 a.m., the interim Director of Nursing indicated residents with anticoagulant orders, such as [MEDICATION NAME] (generic form is [MEDICATION NAME]), usually have lab orders for PT/INR. If there aren't any lab orders, the nurse should contact the physician for clarification. In this case, the physician was not notified for clarification. 2.) The clinical record for Resident F was reviewed on 7/16/15 at 9:40 a.m. [DIAGNOSES REDACTED]. a.) Nurses notes, dated 5/7/15 at 3:29 p.m., indicated: New order received to change [MEDICATION NAME] dose and recheck INR in 1 week (5/14/15). Message left for (name of family member) and pharmacy notified and lab ordered. Lab results, dated 5/14/15, indicated the following results were reported to facility staff on 5/14/15 at 5:00 p.m. PT- 12.8, indicated H (high) (normal limits: 9.5 - 11.8) INR- 1.2, indicated H (high) (normal limits: 0.9 - 1.1) Documentation indicated the physician was notified of the high results on 5/18/15. Resident F's care plan for anticoagulant therapy, related to the [DIAGNOSES REDACTED]. - Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. - Labs as ordered. Report abnormal lab results to the MD. The DON indicated, during an interview on 7/17/15 at 1:20 p.m., the lab order was collected on 5/14/15, however, there was not documentation to indicate when the results were communicated with the physician until 5/18/15. Lab results, especially abnormal values, were expected to be communicated with the physician as soon as the results were communicated with the attending nurse. 3.1-48(a)(6) 3.1-48(c)(2)

Based on observations, interviews, and record review, the facility failed to maintain resident transfer equipment in a safe working condition (Sara Lift 3000 sit to stand lift slings and knee straps) and failed to properly utilize the Sara Lift 3000 transfer slings, according to manufacturer's guidelines, for 2 of 2 residents observed during a transfer, (Residents B & C), and for 3 of 3 Sara Lift 3000 slings observed for safe, functional use. This deficient practice had the potential to cause harm to 9 of 9 residents utilizing the Sara Lift 3000. (Residents B, C, D, E, F, G, H, I, & J) The immediate jeopardy began on 2/19/15 when the facility failed to remove dysfunctional transfer equipment when the facility was aware of the condition of the transfer equipment and the potential harm. The HFA and DON were notified of the immediate jeopardy on 3/4/15 at 4:45 p.m. The immediate jeopardy was removed on 3/5/15, but the non-compliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: During a facility tour with the Healthcare Facility Administrator (HFA) and the Director of Nursing (DON), on 3/3/15 at 1:25 p.m., 3 sit to stand lifts (Sara Lift 3000) were noted with missing belt buckles to the knee support straps. 2 of 3 sit to stand lifts were missing one belt buckle. 1 of 3 sit to stand lifts was missing two belt buckles. A transfer sling was noted with frayed, worn out fabric and broken buckles. The HFA indicated he was not aware of the missing belt buckles. He indicated a medical equipment professional was at the facility on 2/19/15 to review and assess equipment. The equipment professional deemed the lifts functional for use. The DON indicated, at this time, during tour, the transfer slings were deemed functionally intact. The issues with the transfer slings were cosmetic and did not affect the actual use during a transfer. During the tour observations, stickers were noted on 3 of 3 lifts. The stickers were dated 2/15 (February 2015). The HFA indicated, during a tour interview, the stickers indicated the lifts were functional for use, as they were put there by the equipment professional. Two Sara Lift 3000's were in use on the East hall. CNA #1 demonstrated the use of the Sara Lift 3000 sit to stand lift (actual residents were not involved with demonstration) on the East hall, on 3/3/15 at 1:40 p.m. CNA #1 indicated she used the knee support straps to secure resident's legs. However, she was not able to use the knee support straps on one of the lifts because the buckle clips (x2) were missing. She indicated there was only one working clip on the other lift used on the East hall. On the South Magnolia hall, on 3/3/15 at 2:00 p.m., during an interview, CNA #4 indicated there was one lift for use and demonstrated the use of the Sara Lift 3000 (actual residents were not involved with demonstration). CNA #4 stated, "First, you secure the resident's legs with the buckles." As she demonstrated, she indicated there was only one buckle clip, the other buckle was missing. She indicated she would not use that particular lift and would need to find a lift with 2 buckles clips in place, one strap/buckle for each leg. During an interview, on 3/3/15 at 2:10 p.m., LPN #2 indicated and confirmed the sit to stand lifts were used for 9 residents. (Residents B, C, D, E, F, G, H, I, & J) On 3/3/15 at 2:55 p.m., during an interview, the HFA indicated a former employee notified him about the poor condition of the mechanical lifts on 2/13/15. He (the HFA) notified a medical equipment company. The earliest a company professional could visit was 2/19/15. On 2/19/15, an equipment professional deemed all equipment useable and functional. An email correspondence confirming the equipment review was presented on 3/3/15 at 3:00 p.m., from the HFA. Contents of the email included a summary of each Sara 3000 lift, as follows: Control #FR13- ...Missing belt for knee support; needs replaced. Control #FR11- ...Missing belts for knee support; needs replaced. Control #FR16- ...Missing belts for knee support; needs replaced. On 3/4/15 at 11:44 a.m., CNA #1 and CNA #3 were observed using the Sara Lift 3000 and a transfer sling to transfer Resident B to the toilet. The knee support straps were not used. The waist support belt on the sling was not used. It was tucked under Resident B's arms with the belt straps dangling. CNA #1 and CNA #3 indicated the knee support straps did not have belt buckles and the transfer sling was broken and could not be used, properly. CNA #3 demonstrated one belt buckle was missing on the waist support belt part of the transfer sling. CNA #1 indicated as long as 2 nursing staff were attending the transfer, her understanding was it was ok to use the lift. During an observation and interview on 3/4/15 at 11:55 a.m., CNA #3 indicated Resident C was transferred to the toilet with the use of the sit to stand lift and still had the transfer sling around him. The transfer sling was observed without waist support belt buckles. Resident C indicated the transfer sling was used only under his arms and was not buckled because there weren't any buckle clips. Resident C's statement was verbally confirmed by CNA #3. The HFA indicated he was not aware the transfer slings were non functional and would remove them from use, immediately, during an interview and observation of the transfer slings, on 3/4/15 at 12:10 p.m. A phone interview was conducted on 3/4/15 at 3:37 p.m., with the medical equipment professional. He verbally confirmed he visited the facility to inspect equipment on 2/19/15. He indicated he laid 3 transfer slings along the hallway for inspection. He showed and verbally informed the HFA, DON, and the maintenance director, the concerns with the broken, missing buckles, and frayed fabric. He recommended to them, to not to use these slings because they could not be used, appropriately. On 3/4/15 at 3:55 p.m., the maintenance director indicated, during an interview, the medical equipment professional told him, the HFA, and DON, the transfer slings were in bad condition and should not be used. He indicated, during the observation with the equipment professional, the DON indicated the facility had more transfer slings and would not use those transfer slings. The Sara Lift 3000 manufacturer's Instructions For Use was received from the HFA, on 3/4/15 at 12:20 p.m. The instruction guide indicated, on page 8, to "position the sling around the resident's back so that the bottom of the sling lies horizontally about two inches or five centimeters above the resident's waistline, with the resident's arms outside the sling. Ensure that the support strap is separated and brought loosely around the body, and is not twisted or trapped behind the resident's back." A warning box, on page 10, stated, "Warning: The sling chest support strap must always be applied and fastened when using the sling." Another warning box stated, "Warning: Always check that all the sling attachment clips are securely connected and fully in position before and during the lifting cycle, and in tension as the resident's weight is gradually taken up." Preventive Maintenance Schedule, on page 21, provided instructions and obligations for caregivers. The caregiver obligations indicated to "examine the sling, straps and clips for damage or fraying as required, before each use, and visually check sling attachment points, before each use. Do not use if damaged." The immediate jeopardy that began on 2/19/15 was removed 3/5/15 when the facility removed the 3 transfer slings from resident use and repaired the knee support belt buckle clips on the 3 Sara 3000 lifts. Nursing staff in-services and competency checks for use of the Sara 3000 lifts were completed prior to the start of each shift. Interviews conducted with facility nursing staff on 3/5/15 and 3/6/15 indicated in-services were provided and competencies were assessed, appropriately. The non-compliance remained a lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility continued with staff training and continued on going compliance rounds to ensure proper use of transfer slings. This Federal tag relates to Complaint #IN 860. 3.1-45(a)(2)

Based on record review and interview the facility failed to ensure an order for [REDACTED]. Findings include: On 5/28/14 at 12:05 P.M., the record review for Resident B was completed. [DIAGNOSES REDACTED]. The resident was admitted to the facility 4/3/14, after being in the hospital. The hospital record indicated the resident was admitted for [MEDICAL CONDITION], leg [MEDICAL CONDITION] and leg pain. The hospital records dated 4/3/14, indicated Resident B was ordered to take [MEDICATION NAME] ( a blood thinning medication) 3 milligrams by mouth daily, as well as Enoxaprin ( a blood thinning medication) 90 milligrams subcutaneously (beneath first layer of tissue) daily until INR >(greater than) 2. A lab was drawn on 4/4/14. The results were: PT ([MEDICATION NAME] Time-a measure of time it takes for the plasma of blood to clot), INR (International Normalized Ratio an amount of time one person's blood clots compared to a control sample). The lab indicated Resident B's INR was 2.8 The lab had a handwritten notation that indicated the lab was faxed to the physician on 4/4/14 by RN #1. The MAR (Medication Administration Record) dated 4/4/14 through 4/7/14, indicated the medication Enoxaprin 90 milligrams was given by RN #2 on these dates even though the INR was 2.8. The physician's orders [REDACTED]. The nurses notes dated 4/7/14 12:00 P.M., indicated, "...Swelling with dark purple discoloration noticed to left top of hand. Doctor notified. Doctor to see patient. Doctor ordered a venous doppler of left upper extremity and x-ray of left wrist immediately...1:00 P.M. Doctor asked if the resident had an IV (intravenous) in left hand previously. Writer called hospital and was told at the hospital before arriving to facility an IV had been removed from the right hand. 1:20 P.M. X-ray company here to do the wrist x-ray, company indicated cannot do venous doppler so resident sent to hospital to have doppler completed . 4/8/14- 11:00 P.M.- [MEDICAL CONDITION] (swelling) to left hand. Dark purple, blue and red bruise 40 centimeters by 18 centimeters from fingers up resident arm. Area of back of hand raised, hard to touch. Resident complaining of pain of a "6" on scale of 1-10. Continue to monitor, doctor aware. 4/9/14-8:00 A.M.- Area on left hand/left arm dark purple, blue and red bruising noted. Raised area on back of hand hard to the touch. Ice applied per treatment order. Resident complain of pain of "5" on scale of 0-10. 4/10/14-10:15 A.M. - +4 [MEDICAL CONDITION] to left hand, left hand is deep purplish in color on top, however, the palm of her hand and underneath fingers are pale pink in color, moves hand and fingers freely. Hand and fingers are warm to touch. Denies pain. Bruising noted to the underneath areas of left upper and lower extremity Bruising noted to right side of mid back. Denies pain. Doctor notified. 11:00 A.M. New order to send resident to ER (emergency room ) for evaluation and treatment. 4/11/14- 7:15 A.M.- Called hospital and resident admitted with [DIAGNOSES REDACTED]. In an interview with the Director of Nursing on 5/29/14 at 1:30 P.M., she indicated for resident's receiving blood thinning medications, she expected the nurses would assess the resident and follow the doctor's orders and notify him if there were changes. This Federal Tag relates to the investigation of complaint IN 416. 3.1-35(g)(2)

Based on interview and record review, the facility failed to assess and monitor bruising and swelling for a resident on blood thinning medication resulting in hospitalization for [MEDICATION NAME] toxicity for 1 of 3 residents reviewed for medication monitoring in a sample of 7. (Resident B) Findings include: On 5/28/14 at 12:05 P.M., the record review for Resident B was completed. [DIAGNOSES REDACTED]. The resident was admitted to the facility 4/3/14, after being in the hospital. The hospital record indicated the resident was admitted for [MEDICAL CONDITION], leg [MEDICAL CONDITION] and leg pain. The hospital records dated 4/3/14, indicated Resident B was ordered to take [MEDICATION NAME] (a blood thinning medication) 3 milligrams by mouth daily, as well as Enoxaprin (a blood thinning medication) 90 milligrams subcutaneously (beneath the first layer of tissue) daily until INR >(greater than) 2. A lab was drawn on 4/4/14. PT ([MEDICATION NAME] Time- a measure of time it takes for the plasma of blood to clot) INR (International Normalized Ratio-an amount of time one person's blood clots compared to a control sample). The lab indicated Resident B's INR was 2.8 The lab had a handwritten notation that indicated the lab was faxed to the physician on 4/4/14, by RN #1. The MAR (Medication Administration Record) dated 4/4/14 through 4/7/14, indicated the medication Enoxaprin 90 milligrams was given by RN #2 on these dates even though the INR was greater than 2 (2.8) on 4/4/14. The nurses notes dated 4/7/14 at 12:00 P.M., indicated, "...Swelling with dark purple discoloration noticed to left top of hand. Doctor notified. Doctor to see patient. Doctor ordered a venous doppler of left upper extremity and x-ray of left wrist immediately...1:00 P.M. Doctor asked if the resident had an IV (intravenous) in left hand previously. Writer called hospital and was told at the hospital before arriving to facility an IV had been removed from the right hand. 1:20 P.M. X-ray company here to do the wrist x-ray, company indicated cannot do venous doppler so resident sent to hospital to have doppler completed. 4/8/14- 11:00 P.M.- [MEDICAL CONDITION] (swelling) to left hand. Dark purple, blue and red bruise 40 centimeters by 18 centimeters from fingers up resident arm. Area of back of hand raised, hard to touch. Resident complaining of pain of a "6" on scale of 1-10. Continue to monitor, doctor aware. 4/9/14-8:00 A.M.- Area on left hand/left arm dark purple, blue and red bruising noted. Raised area on back of hand hard to the touch. Ice applied per treatment order. Resident complain of pain of "5" on scale of 0-10. 4/10/14-10:15 A.M. - +4 [MEDICAL CONDITION] to left hand, left hand is deep purplish in color on top, however, the palm of her hand and underneath fingers are pale pink in color, moves hand and fingers freely. Hand and fingers are warm to touch. Denies pain. Bruising noted to the underneath areas of left upper and lower extremity Bruising noted to right side of mid back. Denies pain. Doctor notified. 11:00 A.M. New order to send resident to ER (emergency room ) for evaluation and treatment. 4/11/14- 7:15 A.M.- Called hospital and resident admitted with [DIAGNOSES REDACTED]. The documentation titled "Daily Skilled Nurses Notes", indicated no concern with bruising from admitted [DATE] through 4/7/14. The documentation for 4/7/14 under skin area, all shifts was checked, "Skin WNL (within normal limits)". The day shift had nothing documented under the comments section regarding skin. The form also had a section marked "[MEDICAL CONDITION] (if check, complete below) and nothing was documented. The Evening shift comments section indicated, "...resident sent to hospital for doppler of left hand. Hematoma (bruising) to left hand and wrist (sic) and forearm." Nothing was documented in comments section for Night shift. 4/8/14- Skin section indicated bruising to left hand for all shifts, and other concerns noted for left hand in the comments section, that the left arm was swollen and bruised, the resident had limited range of motion, and that the doppler was negative. 4/9/14- Skin section indicated bruising to left hand for all shifts and other concerns for left hand check marked. Comments section for all shifts, indicated left hand hematoma and bruising with [MEDICAL CONDITION], purple, blue and red coloring. 4/10/14- Indicated the "resident went out to hospital...." The hospital transfer documentation form dated 4/13/14, indicated the resident was in the hospital from 4/10/14 through 4/13/14, and the reason for the admission was [MEDICATION NAME] toxicity and [MEDICAL CONDITION]. A hospital order sheet dated 4/11/14 indicated, "...Dress the wound on the dorsum of the left hand with [MEDICATION NAME] to [MEDICATION NAME] and Kerlix twice daily and as needed...." In an interview with the ADON (Assistant Director of Nursing) on 5/29/14 at 11:00 A.M., she indicated when a resident was receiving a blood thinning medication she would have expected the nurses to have measured the bruising and assess the swelling to see if it is getting worse or not and if it is getting worse to notify the doctor. She also expected the staff to follow the physician orders [REDACTED]. This Federal Tag relates to the investigation of complaint IN 416. 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3)

Based on record review, observation and interview, the facility failed to prevent resident to resident sexual abuse for 1 of 1 resident who had an allegation of sexual abuse (Resident B). This practice resulted in Resident B becoming upset to the point of having tears in her eyes when she recounted the incident of the sexual abuse by another resident (A). The facility also failed to ensure resident to resident physical abuse and staff to resident verbal and physical abuse were prevented. This deficient practice affected 5 of 5 residents who had allegations of abuse in a sample of 6 (Residents B, C, D, E, and F). Findings included: 1. During the facility tour with the house supervisor, on 6/25/2011 at 10:10 A.M., Resident B was identified as having made an allegation of abuse toward Resident A. Resident B's clinical record was reviewed on 6/25/2011 at 2:35 P.M. Resident B's [DIAGNOSES REDACTED]. Resident B's admission MDS (minimum data set) assessment dated [DATE] indicated a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating she was alert, oriented, and able to make independent decisions. Resident B's progress notes indicated on 8/21/11 at 3:00 P.M., "Res. (resident) c/o (complained of) being assaulted by another resident. Nurse mgr. (manager), social srvs. (social services), and administrator notified of incident." The facility conducted an investigation into the allegation with the following information in the investigation file. LPN #1 had filed an "Accident/Incident Report" with the following information: "Date of incident 8-19-11. Time of incident, 4 P.M. Location incident occurred, Hallway Resident in wheelchair. Unobserved Physical assault/Altercation. Describe exactly what you observed or heard: Resident wrote a complaint stating another resident 'grabbed' her inappropriately and came into her room and unzipped his pants while she was in bed." LPN #1 had written a statement dated 8/21/11 at 2:30 P.M. indicating "I was called in to (Resident B's) room. (Resident B) informed me that she was 'grabbed' inappropriately at her 'private parts.' Told her that she would need to write up the incident as it happened and that the nurse mgr (manager), social services, physician, and the center administrator would have to be notified." Resident B's hand written note indicated "[DATE] 2:30 p.m. This is to let you know that (name of Resident A), on the nineteen (sic) of aug. (August) at about 4:00 pm (sic) across from the Nurse (sic) station He (sic) reach (sic) over & touch me on the brests (sic). Then he touch (sic) my p. parts below. And it also happen (sic) once before in my room. I told him to stop quit, dont (sic) touch anymore & leave me alone. He does this allmost (sic) ever (sic) day. and i (sic) don't like it. So Im (sic) afide (sic) his (sic) (name of Resident G-Resident A's sister) won't like it becase (sic) I'm telling what been happing (sic). So I going to sit with (Resident H) from now on in the dinning (sic) room." There was a notation of "I wrote this for (name of Resident B). I think she need help with (sic). Thank you (Resident H)." There was an addition at the bottom of the note of "on the time he cane (sic) in my roon (sic), he also unzipped his pants and put his hand in them and I told him again he would have to leave because I had to go to the bathroom." Signed by Resident B. There was a written note by the SSD dated 08/21/2011 with the following information: "(Name of SSD) spoke with (Resident B) in her room ... her sister was present during this time.... (Resident B) stating 'on Friday afternoon, around 4 pm or so, I was sitting in the hallway by the nurses station, (Resident A) came and sat down beside me, since they were spraying his room. I noticed he was acting odd, that he kept looking at the nurses station, then down each hallway. He then reached over and grabbed by breast. I pushed his arm away, told him that I'm a resident here, I don't want him to do that, and I didn't want blood on my shirt since he had blood on his hands'. SSD asked 'Blood was on his hands?' '(Resident B) replied 'Yes, from where he picks behind his ear'. (Resident B) then states, 'I closed by eyes because my head was hurting. That's when he grabbed me between my legs. I pushed his hand away and told him he needs to quit. He then said 'I want some of that.' then he smacked his own hand and said 'Bad!'. I told him again that he ought not be doing that and pointed to (RN #1) coming down the hall, and said that he can't be doing things like that in a place like this.' SSD asked if anything else happened then, and she replied 'No, but is happened earlier too.' SSD asked 'When?'. (Resident B) then states; 'It was in the middle of the week, not sure what day. I was in my room because my stomach was upset and my head hurt bad. He came in my room and I told him that I didn't want to talk. He sat down in the chair next to my bed and said he just wanted to talk. I asked him where (name of Resident G) was, and he said she was asleep. He then reached over and grabbed my breast. I told him to stop. He then reached over and grabbed between my legs, and I told him to stop again. I turned on my call light because I wasn't feeling well. He then unzipped his pants and placed his hand down his pants. I told him he needs to stop that, that the nurse is on her way. He looked like he was made (sic), zipped up his pants, and left the room. SSD asked if these 2 times were the only times. She said 'Yes, but he will stand at my door and stare at me. That's why I close my door most times.'. She then stated, 'I don't want to get no one in trouble, but I don't like him doing that." The SSD had interviewed Resident A on 8/21/11 with the following written statement. "(Name of SSD) spoke with (name of Resident A) outside at the gazebo. SSD asked him if was in (Resident B's) room, he replied 'yes'. When asked what happened, he replied 'nothing'. Asked what night it was, and he replied 'Monday'. He then states 'Was just visiting. I've no problems with (name of Resident B).... SSD asked if he & (Resident B) are friends, and he replied 'yeah, yeah'. Then asked if they were more than friends, and he replies 'no, just friends'.... SSD asked if he visits with (Resident B), and he replies 'sometimes'. Asked if they ever kissed, and he replied 'no, no'. Asked if any thing like that goes on, and he replies 'oh, no'. SSD left (Resident A) sitting in the gazebo." The conclusion, written by the SSD on 8/22/11, was "The facts given by (Resident B) cannot be confirmed. (Resident A) confirmed they are friends, yet states they are only friends. (Resident B) is alert & oriented X 3. (Resident A) is currently on Q15 (every 15) mins (minute) checks due to incident involving a fell ow neighbor occurred (sic) on 8/17/2011. (Resident A) has been referred for inpatient psy (sic) stay, and is awaiting transfer." Resident B was interviewed on 8/25/2011 at 3:30 P.M., she said essentially the same events that she had told the nurse and SSD on 8/21/2011. As she talked she had tears in her eyes which were slowly running down her cheeks. She indicated she didn't want anyone to be in trouble, but Resident A had hurt her feelings and she had told him to stop. She indicated she had been eating at the same table as Resident A and his sister Resident G, but she had asked to move to a different table after she had told the facility. During an interview with the DON on 8/25/2011 at 2:40 P.M., she indicated Resident A was placed on every 15 minutes checks after he had hit Resident D and then on 1 to 1 after Resident B's allegation of sexual abuse. She did not know how this incident could have occurred as the resident was on every 15 minute checks. The 15 minutes checks form was reviewed for 8/19/2011. The form indicated at 4:00 P.M., the resident was in Bingo and at 4:15 P.M., he was in the S. Hallway. Resident A was independently ambulatory. Resident A had been placed on one to one on 8/22/2011. The interdisciplinary progress notes indicated at 5:10 P.M. ".... 1-1 initiated @ this time...." Resident A was transferred to a behavioral unit on 8/23/2011. 2. Resident A's clinical record was reviewed on 8/25/2011 at 1:55 P.M. Resident A's [DIAGNOSES REDACTED]. Resident A's Quarterly MDS (minimum data set) assessment dated [DATE] indicated a BIMS (Brief Interview for Mental Status) score of 12/15 indicating he was moderately impaired cognitively. Resident A's interdisciplinary progress notes dated 8/17/2011 at 7:55 P.M. indicated "Res. heard entering building, writer seen Res (Resident A) propelling sister (Resident G) from lobby hallway towards Walnut nursing station, heard (name of Resident A) say 'why do you have that,' (Resident A) grabbed hoyer pad from res. (Resident D) lap-pulling (L) (left) hand towards (R) (Right) side et then swing open hand ((L) hand) back to (L) side et hit (Resident D) on (L) forehead, writer immediately separated residents et requested (Resident A) to ambulate to his room, paged supervisor immediately - had (Resident D) sitting c (with) writer...." Resident A's interdisciplinary progress note dated 8/18/2011 at 3:00 A.M. indicated "Res resting quietly in room. No (indicated by a circle with a line through it) behaviors noted this shift. 15 min checks (indicated the a check mark) initiated related to previously noted behavior...." Resident A was reassessed by the psychiatric services nurse practitioner on 8/19/2011 with notations of "Pt. hit another resident yesterday. Continues to be verbally aggressive, agitated, fixated on specific residents.... Continues to specifically mention 3 residents by name and remains unable to discuss or agree to nonviolent conflict resolution attempts. Pt. has hx and presentation suggestive of [MEDICAL CONDITION] d/t (due to) [MEDICAL CONDITION] ([MEDICAL CONDITION] - [MEDICAL CONDITION]) and CKD Stage 4 ([MEDICAL CONDITION]) with superimposed [MEDICAL CONDITION]. He remains aggressive, agitated and unable to track attempts to find non-violent ways to address his concern with 3 specific residents." The recommendations was "Immediate inpatient psych stabilization pending STAT labs + [MEDICATION NAME] (anti-psychotic medication) 250 mg (milligrams) BID (2 times a day) if unable to transfer NOW." Resident A was transferred to a behavioral unit on 8/23/2011 as the facility was unable to find an empty bed in all units contacted. Resident D's clinical record was reviewed on 8/25/2011 at 2:53 P.M. Resident D's [DIAGNOSES REDACTED]. Resident D's Admission MDS (minimum data set) assessment, dated 8/3/2011, indicated Resident D was unable to be interviewed and she was assessed as moderately impaired for decision making skills. She was assessed for wandering in the facility. During an interview with LPN #4 on 8/25/2011 at 3:10 P.M., she indicated Resident D always wanders in the facility. She indicated Resident A had been pleasant before this incident. She was the nurse in the building when this had occurred and had seen what had happened and Resident A had said to Resident D "why do you have that?" referring to the hoyer pad she had with her in the wheelchair. She indicated the incident had happened so fast, she could not stop it. 3. A "Grievance/Complaint Report" dated 4/30/11 was reviewed. Resident F had filled a complaint against a CNA who works at night. The facility had investigated and had reported this to the ISDH on 5/2/2011. The SSD had interviewed Resident F on 4/30/2011 with a written interview. Resident F had said "I got the girl mad... she said she's not going to take care of me anymore because of something I said. She then stated 'I'm [AGE] years old, I can't remember what I said. I tried to apologize, yet when she left she was so mad.' (Resident F) then stated 'I refused to take a shower. I used my walker today to walk to my bathroom.'" RN #1 had interviewed Resident F on 4/30/2011 with Resident F saying "The girl was going to give me a shower in my w/c (wheelchair). I got the girl mad - she said she wasn't going to take care of me anymore. She said I said something. I tried to apologize - she was so mad. She wanted to give me a shower, but I didn't want a shower...." CNA #1's written statement dated 4/30/2011 indicated,"At approximately 8:15 A.M. while in the Dining Rm. (room), (Resident F) stated that 'the one with the stringy hair that works night said she is not going to take care of me anymore because of something I said.' ... reported this to the East Nurse who immediately went to call (the Administrator). The grievance is under the Social Service door." LPN #2's written statement dated 4/30/2011 indicated, "It was reported to me from (CNA #1) @ 8:20 A.M. that Resident F told her the CNA at night stated she was not going to take care of her because of the things she said. She was asked what she had said et (Resident F) states she only asked why she isn't getting a shower...." CNA #2's written statement dated 4/30/2011 indicated, "....(Resident F) asked (CNA #1) who was the stringy hair (sic) that works nights. We didn't say a name, but we know who she was talking about, and she stated that she said she wasn't going to take care of her, cause she knows what she said about her...." LPN #3's written statement dated 4/30/2011 lacked any indication of any problems during her shift. CNA #3's written statement dated 4/30/2011 lacked any indication of any problems during her shift. CNA #3 was suspended on 4/30/2011 and terminated on 5/2/2011 for "inappropriate in her approach c (with) resident...." Resident F's clinical record was reviewed on 8/25/2011 at 4:11 P.M. Resident F's [DIAGNOSES REDACTED]. Resident F's quarterly MDS (minimum data set) assessment BIMS (Brief Interview for Mental Status) dated 2/4/2011 indicated a total score of 11 indicating moderate cognitive impairment. 4. Review of an "Accident/Incident Report" dated 8/19/2011 at 2:05 P.M. indicated Resident E had reported to "staff that (CNA #4) was mistreating him and slammed him in his chair - states he is afraid (CNA #4) may do something to him." The SSD interviewed Resident E on 8/19/2011. The SSD has written "he heard that someone wasn't being nice to him. (Resident E) stated 'I don't want to get anyone in trouble'. SSD informed (Resident E) that he is here to help him, and needs to know if someone is mistreating him. (Resident E) then stated 'well... today he slammed me in my chair.' When asked 'who?' (Resident E) stated '(CNA #4).' (Resident E) then stated 'I don't want to say nothing... I don't want him to be mad.' SSD reassured (Resident E) that he did the right thing in talking about it, and no one will be mad at him. SSD asked (Resident E) if anything else happened, and (Resident E) replied 'No, just he slammed me in my chair'. Resident E then stated 'I don't care if the girls help me get ready, I don't want him to'...." CNA #4 was suspended on 8/19/2011. The termination form indicated "Reported that (CNA #4) had 'slammed a resident in his w/c.' Investigation completed 8/22/2011 - (CNA #4) will be terminated because he probably handled res. inappropriately." Resident E's clinical record was reviewed on 8/25/2011 at 3:10 P.M. Resident E's [DIAGNOSES REDACTED]. Resident E's quarterly MDS (minimum data set) assessment BIMS (Brief Interview for Mental Status) dated 8/16/2011 indicated a total score of 12 indicating moderate cognitive impairment. During an interview with the DON on 8/25/2011 at 3:30 P.M., she indicated she thought CNA #4 had most likely slammed Resident E into his wheelchair and so he was terminated. 5. Review of a FAX/Incident report regarding Resident C dated 4/29/11 indicated "Resident spoke with MDS (minimum data set) coordinator asked residen (sic) how she was and she stated 'I hurt' continues to say that the CNA that works at noc (night) is rough with me. She just pulls and tugs on me like a dog. The CNA works at night...." The CNA was suspended pending an investigation. Review of the statement dated 4/29/2011 written by the MDS coordinator indicated "This writer spoke c (with) pt (patient) this am. I asked her how she was she stated 'I hurt.' ... say that the CNA that works @ noc is rough c me. 'She just pulls & tugs on me like a dog.' ... She said she doesn't want to complain or get anyone in trouble." The hand written statement by CNA #5 on 4/29/2011, indicated ".... stated she was in pain.... After nurse gave her medicine I procede (sic) to get (Resident C) ready. I helped (Resident C) wash up and noticed a small scab on her left leg I then called nurse back in to show her and she said it was already reported as she was walking out (Resident C) yelled hurry up its hot in here (sic). I then assist with putting resident's shirt on then pants. She then got upset again stating that her pants were to tight to get her others now. By this time (Resident C) was very agitated. I got (Resident C) a new pair of pants and assisted with putting them on." CNA #5's written report for the date of 4/29/2011 indicated Resident C was in a "bad mood -said she was in pain." The conclusion of the investigation dated 5/2/2011 indicated "IDT (interdisciplinary team) met this day and discussed all information submitted in the allegation of abuse with (Resident C). It is concluded the Aide was inappropriate in her approach to (Resident C). The aide will be terminated on this date May 2, 2011." Resident C's closed clinical record was reviewed on 8/25/2011 at 1:25 P.M. Resident C's [DIAGNOSES REDACTED]. She was admitted to the facility for therapy and was discharged home on[DATE]. Resident C's Admission MDS (minimum data set) assessment dated [DATE] indicated a BIMS (Brief Interview for Mental Status) score of 15/15 indicating she was cognitively intact. Review of the "Resident Abuse Prevention" policy provided by the DON on 8/25/2011 at 4:30 P.M. indicated "It is the policy of this company that each facility will take all necessary action (sic) to protect residents from any form of abuse...." This federal tag relates to complaint IN 480. 3.1-27(a)(1) 3.1-27(a)(3) 3.1-27(b)

Based observation, record review, and interview, the facility failed to ensure a resident had sufficient fluids to prevent dehydration resulting in the hospitalization of 1 of 1 resident with dehydration in a sample of 3 (Resident A). Findings include: 1. During the facility tour on 3/4/11 at 10:10 A.M., with the DON (Director of Nurses), Resident A's over bed table was on the right side of the resident's bed, but there was no water pitcher on the table. His call light was clipped to the curtain beside the bed out of the reach of the resident who was lying in bed. During an interview with the DON on 3/4/11 at 10:30 A.M., she indicated the resident didn't have water at his bedside, but the staff would take him fluids of cranberry juice during the day. Resident A's clinical record was reviewed on 3/4/11 at 10:38 A.M. Resident A's [DIAGNOSES REDACTED]. Resident A was admitted to the facility on [DATE]. A "Dehydration Risk Assessment" was completed on 2/1/11. The total score was 8 indicating the resident was at high risk for dehydration. The facility dietitian assessed Resident A on 2/3/11 with the following observation of the resident's mental status: "alert, confused, able to make needs known at times." The dietitian recommendations were: "Estimated fluid needs ... 1955 c.c. (cubic centimeter)/day.... Res. (resident) needed extensive assistance at meal. Labs indicate elevated BS (blood sugar), adequate electrolyte balance...." The dietitian indicated Resident A's eating ability was "set-up, partial assist, and full assist." The nurses' notes dated 2/3/11 indicated ".... Takes fluids well...." The DM's (dietary manager) progress note written of 2/8/11 at 12:27 P.M. indicated "(name) is on a NAS (no added salt) diet due to dx (diagnosis)[MEDICAL CONDITION](hypertension) Weight 142.6 #.... Normal intakes 50-75% at meals fluids 700-900 cc at meals. (name) is total assist at meals with no chewing/swallowing issues...." The daily Dehydration Assessment for February 2011 indicated the resident was "at risk - monitor." This assessment had not been completed on 2/1/11, 2/2/11, 2/4/11, 2/5/11, 2/6/11, 2/7/11, 2/8/11, 2/9/11, 2/10/11, 2/11/11, 2/12/11, 2/13/11, 2/14/11, 2/15/11, and 2/16/11. He was sent to the ER (emergency room ) on 2/16/11 for dehydration. The Dietary Intake Record for February 2011 indicated Resident A had a total fluid intake of 0 on 2/1/11, 0 on 2/2/11, 600 ml (milliliters) on 2/3/11, 680 ml, 2/4/11, 720 ml. on 2/5/11, 720 ml. on 2/6/11, 720 ml. on 2/7/11, 720 ml. on 2/8/11, 840 ml. on 2/9/11, 480 ml. on 2/10/11, 600 ml. on 2/11/11, 580 ml. on 2/12/11, 720 ml. on 2/13/11, 480 ml. on 2/14/11, 480 ml. on 2/15/11, 480 ml. on 2/16/11. He was sent to theER on [DATE] for evaluation and treatment of [REDACTED]. The nurses' notes dated 2/16/11 indicated the following: 2:45 P.M. "Res family... requesting a KUB (kidney,ureters,bladder)(an X-ray of the abdomen) done on res. d/t (due to) abdominal pain,. Res, also having itching...." 3:10 P.M. "..KUB results....'Abdomen is unremarkable....'" 6:20 P.M. "... res to have CBC (complete blood count) & BMP (basic metabolic panel)... STAT (immediately).... Res. did not eat well @ (at) dinner. Was fed a pureed diet by staff et res. let food run out of his mouth...." 7:35 P.M. "Rec. (Received) call from lab c (with) critical lab results. BUN (blood urea nitrogen) 98, sodium 163. Called results for (name of physician). He states to send resident to ER." The labs obtained on 2/16/11 indicated the following: The BUN was 98, which was a critical high level, with normals of 8-26 mg/dL, the creatinine was 3.53, which was high, with normals of 0.70 - 1.20 mg/dL, the sodium was 163, which was a critical high, with normals of 136-144 mmol/L, the chloride was 129, which was high, with normals of 98-108 mmol/L, the WBC (white blood cell) was 14.6, which was high, with normals of 4.5 - 10.4, the HGB (hemoglobin) was 16.9, which was high, with normals of 11.7 - 16.0 gm/dL, the HCT(hematocrit) was 50.2, which was high, with normals of 36 - 47.1 %. According to "Lippincott Manual of Nursing Practice Handbook" third edition, pages 352 & 353 in the section of "fluid and electrolyte imbalance,: indicated "2. Hemoglobin and hematocrit will be increased with hypovolemia (low fluid or dehydration). 3. Blood urea nitrogen and creatinine will be increased with hypovolemia, and with electrolyte imbalances caused by [MEDICAL CONDITION]. 5.... chloride is directly related to sodium." One cause of "[MEDICAL CONDITION] (high sodium)" was listed as "water deprivation...." The nurses' notes dated 2/16/11 at 10:15 P.M. indicated "Called (name) ER for update on res. Was informed res is being admitted with [MEDICAL CONDITION], pneumonia, dehydration et acute RF ([MEDICAL CONDITION])." A progress note from the hospital dated 2/20/11 indicated the resident had "1. acute [MEDICAL CONDITION] related to dehydration. 2. [MEDICAL CONDITION]." Resident A's Admission Plan of Care dated 2/1/2011 indicated a problem of "Pot. (potential) for dehydration r/t (related to) new admission to ECF (extended care facility)." The interventions included, but were not limited to, "1, Nurses will monitor/document signs/symptoms of dehydration for 5 days. 2. Evidence of dehydration will be reported to physician immediately. 3. FSM (Food Service Manager) will determine fluid preferences of the resident. 4. FSM will provide fluid preferences of the resident at bedside, on hydration cart & with meals. 5. CNA's will doc. (document) fluid consumption and report resident fluid tolerances to charge nurse. 6. The fluid intake will be reviewed by the NAR (nutrition at risk) committee each week for 4 weeks or until stabilized. 7. Observed for symptoms of UTI." Resident A's Care Plan for "Dehydration" dated 2/2/2011 for the problem of "At risk for dehydration" indicated the resident "will consume at least 1200-1800 cc (cubic centimeters) of fluids per day to meet calculated requirements." The approaches included, but were not limited to ".... Monitor for physical signs/symptoms of dehydration...." Resident A returned to the facility on [DATE] with [DIAGNOSES REDACTED]." A "Dehydration Risk Assessment" was completed on 2/24/11. The total score was 8 indicating the resident was at high risk for dehydration. The dietitian completed a reassessment of the resident on 3/3/11. This reassessment indicated Resident A had estimated fluid needs of 1980 cc/day. The February 2011 "Intake and Output Record" indicated the following intakes: 2/24/11- 360 cc for one shift only 2/25/11 - 2040 cc 2/26/11 - 1560 cc 2/27/11 - 1460 cc 2/28/11 - 1460 cc There were no entries before 2/24/11. The March 2011 "Intake and Output Record" indicated the following intakes: 3/1/11 - 1080 cc 3/2/11 - 1580 cc 3/3/11 - 1320 cc 3/4/11 - 1720 cc The March 2011 "Dietary Intake Record" indicated Resident A had gotten 1440 ml of fluids on 3/1/11, 1440 ml of fluids on 3/2/11, 1080 ml of fluids on 3/3/11. Review of the undated "Hydration Program" provided by the DON on 3/7/2011 at 11:15 A.M., indicated "In an effort to keep each resident hydrated, bedside water will be provided and other fluids will be offered at and between meals. Procedural Guidelines: A. All residents will be offered fluids with each meal. Fresh ice water will be at the bedside of each resident unless the resident specifies that they do not like ice water.... F. Fluid intake is to be documented using the Food Consumption Record or an Intake and Output Record." This federal tag refers for complaint IN 620. 3.1-46(b)

Based on observation, record review, and interview, the facility failed to implement approaches to prevent a significant weight loss in a 3 week period for 1 of 2 residents with weight loss in a sample of 3 (Resident B). Findings include: 1. Upon interview, during the facility tour on 3/4/11 at 10:05 A.M., with the DON (director of nurses) Resident B was identified as having weight loss. Resident B was observed on 3/4/11 at lunch at 12:45 P.M. She ate 40% of her food and 80% of the fluids. Resident B's clinical record was reviewed on 3/7/11 at 9:26 A.M. Resident B's [DIAGNOSES REDACTED]. Resident B's admission weight was 117 pounds on 2/8/11. Resident B's next weight was 109.4 pounds on 2/28/11. She was reweighed later in the week and weighed 109.2 pounds. This was a 7.6 % weight loss within 3 weeks per the facility calculation. Resident B's weight on 3/7/11 was 112 pounds. The resident was weighed after lunch. The dietary manager's progress note dated 2/16/11 at 8:06 A.M., indicated ".... weight is 117 #... intakes bkfst (breakfast) 15-50%, lunch 75%, Dinner 25-50%. Fluids 600-900 cc per meals. Will recommend add Choc Healthshakes tid between meals due to low intakes and dx (diagnosis) dehydration...." There was a physician's orders [REDACTED]." Review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) indicated a lack of documentation of the chocolate Health Shakes for February or March 2011. During an interview with LPN #1 on 3/7/11 at 10:30 A.M., she indicated she didn't chart the health shake intakes anywhere in the clinical record. When Resident B was interviewed on 3/7/11 at 11:45 A.M., she indicated she didn't get any shakes between meals. The visitor in the room with her indicated she had not seen any shakes for the resident, either. Resident B's "Nutritional History/Assessment" dated 2/17/11 indicated she had "some depletion of visceral prot (protein) stores, received vitamin supplements.... present diet intake inadequate to meet needs, wt. (weight) loss likely, will request [MEDICATION NAME] ES to stimulate appetite." The physician ordered "[MEDICATION NAME] ES (extra strength) oral susp (suspension) 625 mg (milligrams)/day (for) anorexia." on 2/21/11. This order was for 30 days. This order was clarified on 2/22/11 with the reason for the medication as "appetite stimulant." The MAR (Medication Administration Record) for February 2011 indicated the [MEDICATION NAME] was circled on 2/23, 2/24, 2/26, 2/27, 2/28. The 2/25 date was blank. This charting indicated the resident didn't receive any of the [MEDICATION NAME]. There was a DC (discontinued) on 2/28/11. During an interview with the DON on 4/7/11 at 11:50 A.M., she didn't know why the resident didn't receive the [MEDICATION NAME] as there was no explanation on the back of the MAR. The nurses' notes indicated on 2/23/11 and 2/16/11, the resident had refused all medications, but all of the other days she was compliant with taking medications or there was no explanation written in the nurses' notes as to the reason the [MEDICATION NAME] as held. The food intake documentation for February 2011 indicated the following: 2/21/11 intake of 10% at breakfast only, with refusals for lunch and dinner 2/22/11 intake of 25% at breakfast and dinner with refusal for lunch 2/23/11 intake of 100% at lunch, 22% at dinner, and refusal for breakfast 2/24/11 intake of 30% at dinner and nothing at breakfast and lunch. 2/25/11 intake of 25% at breakfast and lunch, and 50% at dinner 2/26/11 intake of 25% at breakfast and lunch, and 100% at dinner 2/27/11 intake of 25% at breakfast and lunch, an 75% at dinner 2/28/11 intake of 50% at breakfast, 10% at lunch, and bites at dinner The physician's orders [REDACTED]." The food intake documentation for March 2011 indicated the following: 3/1/11 intake of 15% at breakfast, 50% at lunch and dinner 3/2/11 intake of 25% at breakfast and lunch, 50% at dinner 3/3/11 intake of 50% at breakfast, refused lunch, 25% at dinner 3/4/11 50% at all 3 meals 3/5/11 50% at breakfast and dinner, 30% at lunch 3/6/11 50% at breakfast and dinner, 75% at lunch 3/7/11 50% at breakfast and lunch The dietitian's note dated 3/3/11 indicated "Mar (March) wt (weight) 109.4 # down 7.6 # in 30 days (6%). Wt. loss due to low food intake. Res having emesis, intake 25%. Receiving shake tid. Will add fortified foods...." Resident B's care plan, date 2/15/11, for the problem of "(Name) is at risk nutritionally due to thereuptic (sic) diet need, 2/18/11 low intakes, 3/3/11 encanced (sic) diet need" The approaches were 1. Diet as ordered (NAS) (no added sodium) (enhanced). 2. Honor food preferences. 3. Monitor intakes, weight, and labs as available. 4. Healthshakes tid. Supplements as ordered." The undated "Weight Management Recommendations" provided by the DON on 3/7/11 at 1:20 P.M., indicated "1. The resident's weight is to be obtained at the time of admission to the facility and should be monitored each week until it is determined that the new resident's weigh is stable. If a resident leaved the facility and returns to the facility following an acute spell of illness, the facility should: If possible, weigh the resident before they leave the facility and document. Weigh the resident upon return to the facility and document. Monitor the weight of the resident each week until it is evident that the resident's weight has stabilized. 2. The physician, the registered dietitian, and the responsible/legal representative are to be notified immediately when a resident has demonstrated a significant unplanned weight loss or gain....Respond promptly to the physician orders [REDACTED]." This federal tag relates to complaint IN 620. 3.1-46(a)(1)

BASED ON RECORD REVIEW AND INTERVIEW, THE FACILITY FAILED TO ENSURE THERE WAS A MEDICAL REASON FOR THE USE OF A URINARY CATHETER FOR 3 OF 6 RESIDENTS WITH CATHETERS, FAILED TO PREVENT URINARY TRACT INFECTIONS IN 3 OF 6 RESIDENTS WITH CATHETERS, RESULTING IN RESIDENT A BEING hospitalized for [REDACTED]. FINDINGS INCLUDED: 1. RESIDENT A'S CLOSED CLINICAL RECORD WAS REVIEWED ON [DATE] AT 10:53 A.M. RESIDENT A'S [DIAGNOSES REDACTED]. RESIDENT A WAS admitted on [DATE]. THE NURSES' ADMISSION ASSESSMENT INDICATED RESIDENT A HAD A URINARY CATHETER WHEN HE WAS admitted on [DATE]. RESIDENT A'S TRANSFER ORDERS DATED [DATE] FROM THE HOSPITAL LACKED an order for [REDACTED]. RESIDENT A'S admission orders [REDACTED]. RESIDENT A HAD A [DIAGNOSES REDACTED]. REVIEW OF THE URINARY CONTINENCE EVALUATION DATED [DATE] INDICATED IT WAS UNKNOWN IF THE resident had a history of [REDACTED]. THE REASON FOR THE CATHETER WAS RETENTION, RESIDENT A WAS SENT TO THE emergency roiagnom on [DATE] AND RETURNED TO THE FACILITY WITH an order for [REDACTED]. ON [DATE] RESIDENT A WAS PLACED ON [MEDICATION NAME] 500 MG. DAILY FOR 7 DAYS FOR A UTI, THIS WAS DISCONTINUED ON [DATE] AND THE RESIDENT WAS ADMINISTERED BACTRIM DS (AN ANTIBIOTIC) FOR A UTI. NURSES' NOTES INDICATED ON [DATE] AT 2:15 P.M., "F/C (FOLEY CATHETER) LEAKING. CHANGED (INDICATED BY A TRIANGLE) PER ORDER USING 16 FR (FRENCH) 10 CC. (CUBIC CENTIMETER BULB). GOOD URINE RET (RETURN). RES. TOL. (TOLERATED) WELL." physician's orders [REDACTED]. [DATE] 9:00 P.M. "CATH CARE Q SHIFT." [DATE] TREATMENT ADMINISTRATION RECORDS (TARs) LACKED THIS ORDER AND THE DOCUMENTATION OF THIS TREATMENT BEING COMPLETED. THE HOSPICE NOTES INDICATED: [DATE] "PT. WAS IN BED HWEN (SIC) I ARRIVED. GAVE PT CBB (COMPLETE BED BATH) SEMI SHAVE RAZOR died (ON) ME. CATH CARE. PT WAS ABLE TO ASSIST WITH CARE. WHILE DOING CATH CARE I NOTICED BLOOD AROUND THE HEAD OF THE PENIS AND IT LOOKED SWOLLEN. WILL LET (NAME OF HOSPICE) AND FACILITY NURSE KNOW FINDINGS BUT OTHER THAN THAT NO NEW SKIN ISSUES." [DATE] "PT'S PENIS VERY [MEDICAL CONDITION] WITH SMALL AMOUNT OF SEROSANGUINOUS DRAINAGE NOTED AROUND CATHETER. CONTACTED (NAME), NP (NURSE PRACTITIONER), WHO WILL MAKE VISIT TODAY. PT. STATES IS A LITTLE SORE WHEN CATHETER IS MOVED. FACILITY NURSES (NAMES) REPORT THAT PENIS WAS NOT LIKE THIS LAST WEEK. UPON MOVING PENIS MORE, NOTED PURULENT DRAINAGE FORM FISTULA AROUND CATHETER." [DATE] "NEW ORDERS FROM (NAME) NP. 1. CLEANSE PENIS AND SCROTUM WITH SOAP AND WATER, PAT DRY. IRRIGATE HEAD OF PENIS WITH SALINE, DRY WITH GAUZE, APPLY [MEDICATION NAME] (AN ANTIBIOTIC) TID (3 TIMES A DAY) X 10 DAYS. 2. ELEVATE SCROTUM ON SMALL PILLOW, THEN PLACE ABD (A DRESSING) PAD BETWEEN SCROTUM AND PENTS (SIC): CHANGE ABD PAD TID WITH TREATMENT. 3. CATH STRAP ON AT ALL TIMES. 4.[MEDICATION NAME] MG. P.O. (BY MOUTH) BID (2 TIMES A DAY) X 10 DAYS. 5. [MEDICATION NAME] 10 MG. PO DAILY X 5 DAYS. 6. [MEDICATION NAME] (A DIURETIC OR WATER PILL) 20 MG. PO DAILY X 3 DAYS. 7. KCL (POTASSIUM, A MINERAL) 10 MEQ PO DAILY X 3 DAYS...." [DATE] "SAW THIS PATIENT ... DUE TO PROBLEMS WITH HIS PENIS. HE HAS A FOLEY CATH HAS AN AREA WHICH BEGAN AS A TEAR AND NOW APPEARS TO BE A FISTULA. HAS A LOT OF FOUL YELLOW DRAINAGE AND IS TENDER TO TOUCH. PENIS IS VERY SWOLLEN, PT UNCIRCUMCISED BUT IS SWOLLEN SO THAT THE FORESKIN CAN NOT BE RETRACTED...." [DATE] ".... PT'S URETHRA ALSO HAS A DEEP TEAR GOING DOWN THE UNDERNEATH SIDE OF PENIS AT CATHETER INSERTION. PT'S CATHETER WAS CHANGED ON ,[DATE] PER (NAME OF FACILITY)...." THE physician's orders [REDACTED]. [DATE] "CLEANSE PENIS AND SCROTUM C (WITH) SOAP AND H20 (WATER), PAT DRY. IRRIGATE HEAD OF PENIS C (WITH) SALINE, DRY C (WITH) GAUZE, APPLY [MEDICATION NAME] (AN ANTIBIOTIC) TID (3 TIMES A DAY) X 10 DAYS. 2. ELEVATE SCROTUM ON SMALL PILLOW, THEN PLACE ABD (A DRESSING) PAD BETWEEN SCROTUM AND PENIS: CHANGE ABE PAD C (WITH) TREATMENT ON PENIS. 3. CATH STRAP ON AT ALL TIMES. 4.[MEDICATION NAME] MG. P.O. (BY MOUTH) BID (2 TIMES A DAY) X 10 DAYS. 5. [MEDICATION NAME] 10 MG. PO DAILY X 5 DAYS. 6. [MEDICATION NAME] (A DIURETIC OR WATER PILL) 20 MG. PO DAILY X 3 DAYS. 7. KCL 10 MEQ PO DAILY X 3 DAYS...." REVIEW OF THE APRIL TREATMENT RECORD (TAR) INDICATED: THE TREATMENTS OF "CLEANSE PENIS AND SCROTUM C (WITH) SOAP AND H20 (WATER), PAT DRY. IRRIGATE HEAD OF PENIS C (WITH) SALINE, DRY C (WITH) GAUZE, APPLY [MEDICATION NAME] (AN ANTIBIOTIC) TID (3 TIMES A DAY) X 10 DAYS. 2. ELEVATE SCROTUM ON SMALL PILLOW, THEN PLACE ABD (A DRESSING) PAD BETWEEN SCROTUM AND PENIS: CHANGE ABE PAD C (WITH) TREATMENT ON PENIS" WERE COMPLETED ON [DATE] ACCORDING TO THE [DATE] TREATMENT RECORD. THE ORDER FOR THE CATH STRAP ON AT ALL TIMES WAS COMPLETED FROM [DATE] UNTIL [DATE] WHEN IT WAS NO LONGER BEING DONE ACCORDING TO THE [DATE] TREATMENT RECORD. THE physician's orders [REDACTED]. CARE PLANS INDICATED: A CARE PLAN FOR THE PROBLEM OF "SWOLLEN PENIS" DATED [DATE] UNTIL [DATE] WITH THE INTERVENTIONS BEING THE ORDERS WRITTEN ON [DATE]. A CARE PLAN FOR THE PROBLEM OF "TEAR ON PENIS ET SCROTUM" DATED [DATE] WITH INTERVENTIONS OF "1. TX AS ORDERED 2. WEEKLY SKIN ASSESSMENT 3. MONITOR FROM (SIC) S/S (SIGNS/SYMPTOMS) OF INFECTION 4. CALL MD AS NEEDED." THE NURSES' NOTES INDICATED: [DATE] 11:20 A.M. "....TEAR ON PENIS C (WITH) NO DRAINAGE...." ON [DATE] RESIDENT A WAS PLACED ON BACTRIM DS 1 TABLET TWO TIMES A DAY FOR A WEEK AND [MEDICATION NAME] (AN ANTIBIOTIC) 3.375 IV (INTRAVENOUS) Q 6 HOURS X 1 WEEK FOR A UTI. THE physician's orders [REDACTED]. [DATE] "CLEANSE PENIS AND SCROTUM C (WITH) SOAP AND WATER, PAT DRY. IRRIGATE HEAD OF PENIS C (WITH) NS (NORMAL SALINE), DRY C (WITH) GAUZE & APPLY [MEDICATION NAME] (AN ANTIBIOTIC) TID (3 TIMES A DAY) X 10 DAYS." THE [DATE] TAR INDICATED: ON [DATE] THE TREATMENTS OF "CLEANSE PENIS AND SCROTUM C (WITH) SOAP AND WATER, PAT DRY. IRRIGATE HEAD OF PENIS C (WITH) NS (NORMAL SALINE), DRY C (WITH) GAUZE & APPLY [MEDICATION NAME] (AN ANTIBIOTIC) TID (3 TIMES A DAY) X 10 DAYS" FOR THE treatment of [REDACTED]. NURSES' NOTES INDICATED: [DATE] 2:00 P.M. "CONT (CONTINUE) ATB (ANTIBIOTIC) IV ET (AND) ORAL [MEDICAL CONDITION] ([MEDICAL CONDITION] RESISTANT STAPH AUROUS) IN HIS URINE ET FOR TEAR IN PENIS...." ON [DATE] THE RESIDENT WAS PLACED ON [MEDICATION NAME] 500 MILLIGRAMS ONE TIME A DAY FOR 7 DAYS FOR A UTI. THE [DATE] TAR INDICATED: "CATH STRAP ON AAT (AT ALL TIMES)" WITH A START DATE OF [DATE]. THERE WERE INITIALS INDICATING THIS TREATMENT WAS COMPLETED AS ORDERED. physician's orders [REDACTED]. [DATE] "CHANGE FOLEY CATH. (CATHETER) Q (EVERY) MONTH DUE [DATE]. FOLEY CATH CARE Q. SHIFT." REVIEW OF THE JANUARY, FEBRUARY, MARCH, APRIL, AND [DATE] TAR'S INDICATED A LACK OF an order for [REDACTED]. THE QUARTERLY MDS (MINIMUM DATA SET) assessment dated [DATE] INDICATED RESIDENT A HAD MODIFIED INDEPENDENCE WITH SOME DIFFICULTY IN NEW SITUATIONS ONLY FOR HIS DECISION MAKING SKILLS. HE WAS ASSESSED AS BEING TOTALLY DEPENDENT WITH THE ASSISTANCE OF ONE PERSON TO USE THE BATHROOM. HE HAD AN INDWELLING URINARY CATHETER AND WAS CONTINENT OF HIS BOWELS. HE HAD A URINARY TRACT INFECTION IN THE PAST 30 DAYS. NURSES' NOTES INDICATED: [DATE] AT 4:30 A.M. "UA (URINALYSIS) OBTAINED AS ORDERED. [DATE] AT 2:20 P.M. "REPORT TO (NAME OF PHYSICIAN) OF UA C&S (CULTURE & SENSITIVITY) ET T (TEMPERATURE) 99.4 GAVE ORDER FOR ATB (ANTIBIOTIC)." physician's orders [REDACTED]. [DATE] AT 2:20 P.M. "[MEDICATION NAME] 500 MG (MILLIGRAMS) PO (BY MOUTH) Q (EVERY) DAY X 5 DAYS." THE HOSPICE NOTES INDICATED: [DATE] NO TIME ".... PT'S PENIS IS STILL SWOLLEN BUT DOES LOOK MINIMALLY BETTER, WITH NO DISCHARGE AT THIS TIME...." [DATE] NOT TIME ".... PENIS REMAINS SWOLLEN BUT NO MORE DRAINAGE...." ON [DATE] THE RESIDENT WAS PLACED ON [MEDICATION NAME] 500 MILLIGRAMS ONE TIME A DAY FOR 5 DAYS FOR A UTI. ON [DATE] THE RESIDENT WAS PLACED [MEDICATION NAME](AN ANTIBIOTIC) 500 MILLIGRAMS TWO TIMES A DAY FOR 7 DAYS FOR A UTI. ON [DATE] THE RESIDENT WAS PLACED ON KEFLEX (AN ANTIBIOTIC) 500 MILLIGRAMS EVERY 6 HOURS X 7 DAYS FOR A UTI. ON [DATE] [MEDICATION NAME] DISCONTINUED. THE [DATE] TAR INDICATED: "CATH STRAP ON AAT (AT ALL TIMES)." THERE WERE INITIALS INDICATING THIS TREATMENT WAS COMPLETED AS ORDERED. "FOLEY CATH CARE EVERY SHIFT." THIS ORDER WAS INITIALED AS COMPLETED FOR ALL, BUT 6 SHIFTS OF THE MONTH. "CHANGE FOLEY CATH Q MONTH 16 FR/30 ML" WITH [DATE] AS THE DATE OF THE CHANGE. THIS ORDER WAS INITIALED AS COMPLETED ON [DATE] AND [DATE]. THE [DATE] TAR INDICATED: "CATH STRAP ON AAT (AT ALL TIMES)." THERE WERE INITIALS INDICATING THIS TREATMENT WAS COMPLETED AS ORDERED. "FOLEY CATH CARE EVERY SHIFT." THIS ORDER WAS INITIALED AS COMPLETED ALL DAYS OF THE MONTH. "CHANGE FOLEY CATH Q MONTH 16 FR/30 ML" WITH [DATE] AS THE DATE OF THE CHANGE. THIS ORDER WAS INITIALED AS COMPLETED ON [DATE]. ON [DATE] THE RESIDENT WAS PLACED ON [MEDICATION NAME] 1 GRAM IV EVERY 8 HOURS FOR 1 WEEK FOR A UTI. ON [DATE] THE RESIDENT WAS PLACED ON BACTRIM DS (AN ANTIBIOTIC) 1 TABLE TWO TIMES A DAY. THE [MEDICATION NAME] WAS DISCONTINUED WHEN THE BACTRIM DS WAS STARTED. THE [DATE] TAR INDICATED: "CATH STRAP ON AAT (AT ALL TIMES)." THERE WERE INITIALS INDICATING THIS TREATMENT WAS COMPLETED AS ORDERED. "FOLEY CATH CARE EVERY SHIFT." THIS ORDER WAS INITIALED AS COMPLETED ALL DAYS OF THE MONTH. "CHANGE FOLEY CATH Q MONTH 16 FR/30 ML" THIS ORDER WAS COMPLETED ON [DATE]. ON [DATE] THE RESIDENT WAS PLACED [MEDICATION NAME] MILLIGRAMS TWO TIMES A DAY FOR A UTI. NURSES' NOTES INDICATED: [DATE] 10 P.M. "N.O. (NEW ORDER) FOR UA C ET. S (URINALYSIS WITH CULTURE & SENSITIVITY)." THE UA WAS NOT OBTAINED UNTIL [DATE] (5 DAYS AFTER IT WAS ORDERED). THE UA WAS CALLED TO THE PHYSICIAN. HE DECIDED TO WAIT UNTIL THE C & S WAS COMPLETED BEFORE PRESCRIBING ANY MEDICATIONS. ON [DATE] THE PHYSICIAN [MEDICATION NAME] MG (ANTIBIOTIC) TWO TIMES A DAY FOR 7 DAYS. NURSES' NOTES INDICATED: [DATE] 3:45 A.M. "CNA NOTIFIED WRITER THAT RES. DIDN'T HAVE ANY OUTPUT. ENTERED RES. RM (ROOM) ET RES HAD VERY LABORED BREATHING B/P ,[DATE]. P 132. R 26. RES. ALERT ET SAID HE DIDN'T FEEL GOOD. ABD (ABDOMEN) VERY DISTENDED. RES NOTED TO HAVE MODERATE AMT (AMOUNT) BLOOD IN BRIEF COMING FROM PENIS." [DATE] 4:00 A.M. "911 HERE @ THIS X (TIME) ET TRANSPORTED TO ER." [DATE] 11:10 "RES admitted for UROSEPSIS AND [MEDICAL CONDITION]." THE [DATE] TAR INDICATED: "FOLEY CATH CARE EVERY SHIFT." THIS ORDER WAS INITIALED AS COMPLETED FOR 7 DAYS. "CHANGE FOLEY CATH Q MONTH 16 FR/30 ML" THIS ORDER WAS TO BE COMPLETED ON [DATE]. CARE PLANS INDICATED: A CARE PLAN DATED [DATE], FOR THE PROBLEM OF "POTENTIAL FOR INFECTION R/T (RELATED TO) USE OF INDWELLING URINARY CATHETER AEB (AS EVIDENCED BY): DX (DIAGNOSIS) OF [MEDICAL CONDITION]." THE APPROACHES INCLUDED, BUT WERE NOT LIMITED TO, FOLLOW physician's orders [REDACTED]." A CARE PLAN FOR THE PROBLEM OF "POTENTIAL FOR INFECTION R/T (RELATED TO) USE OF INDWELLING URINARY CATHETER DX: (DIAGNOSIS) [MEDICAL CONDITION]." THE APPROACHES INCLUDED, BUT WERE NOT LIMITED TO, FOLLOW MD ORDERS RE CARE OF CATHETER. PROVIDE GOOD PERI CARE Q (EVERY) SHIFT. (CHANGE INDICATED BY A TRIANGLE) Q MONTH CATH CARE Q SHIFT" DURING INTERVIEWS WITH THE DON ON [DATE] AT 10:08 A.M. AND AT 12:01 P.M., SHE INDICATED SHE HAD FOUND THE SAME INFORMATION IN THE CHART. SHE INDICATED THE RESIDENT'S UA SHOULD HAVE BEEN OBTAINED ON [DATE], THE DAY IT WAS ORDERED. SHE INDICATED THE FACILITY POLICY DID NOT INDICATE AN ORDER WAS NEEDED FOR THE URINARY CATHETER. SHE INDICATED AN ORDER WAS NEEDED FOR THE CATH CARE AND TO CHANGE THE CATHETERS. SHE INDICATED SHE DID NOT KNOW HOW THE RESIDENT'S PENIS DEVELOPED A TEAR NOR HOW THE FACILITY HAD NOT SEEN THE TEAR BEFORE HOSPICE HAD FOUND IT. SHE INDICATED THE FACILITY HAD NOT TRIED TO REMOVE THE FOLEY, NOR WAS THERE ANY DOCUMENTATION OF THE RESIDENT'S [MEDICAL CONDITION] IN THE CHART. DURING AN INTERVIEW WITH LPN #1 ON [DATE] AT 2:00 P.M., SHE INDICATED SHE DID NOT KNOW HOW RESIDENT A'S PENIS HAD SPLIT. SHE INDICATED THE NURSE ON THE HALL HAD HER LOOK AT IT. IT WAS SPLIT ON THE UNDERSIDE FROM THE HEAD OF THE PENIS DOWN THE SHAFT OF THE PENIS AND WAS SWOLLEN. SHE INDICATED IT NEVER CLOSED BACK AND REMAINED OPEN, BUT THE EDGES HAD HEALED. SHE INDICATED THE CNAs DO THE FOLEY CARE. 2. RESIDENT E'S CLOSED CLINICAL RECORD WAS REVIEWED ON [DATE] AT 2:01 P.M. RESIDENT E WAS admitted on [DATE]. THE ADMISSION RECORD TO THE HOSPITAL DATED [DATE] INDICATED THE RESIDENT HAD "A FOLEY (URINARY) CATHETER ALL THE TIME BECAUSE OF WEAKNESS." RESIDENT E'S admission orders [REDACTED]. THE TRANSFER ORDERS FROM THE HOSPITAL DATED [DATE] LACKED an order for [REDACTED]. THE NURSES' ADMISSION EVALUATION INDICATED RESIDENT E HAD A CATHETER. THE URINARY CONTINENCE EVALUATION DATE [DATE] INDICATED IT WAS UNKNOWN IF THE resident had a history of [REDACTED]. THE REASON FOR CATHETER USE WAS LEFT BLANK. THERE WAS AN ORDER DATED [DATE] FOR "FOLEY CARE @ (EVERY) SHIFT. FOLEY TO BE CHANGED Q. MONTH 16 FR (FRENCH) 10 CC. (CUBIC CENTIMETERS)." RESIDENT E WAS SENT TO THE emergency roiagnom on [DATE]. RESIDENT E'S REadmission orders [REDACTED]. RESIDENT E'S URINARY INCONTINENCE EVALUATION DATED [DATE] INDICATED IT WAS UNKNOWN IF THE resident had a history of [REDACTED]. THE REASON FOR CATHETER USE WAS LEFT BLANK. THE physician's orders [REDACTED]." THE [DATE] NURSES' NOTE AT 10:35 P.M. INDICATED "PT. (PATIENT) WIFE ASKED WRITER TO DO PT. (VS) (VITAL SIGNS) ,[DATE] (BLOOD PRESSURE), 120 (PULSE), 12 (RESPIRATIONS), T (TEMPERATURE) 104.3 SAT. ,[DATE]% 2L/NC.... SENT TO (NAME OF HOSPITAL) ER (emergency room )...." RESIDENT E WAS SENT TO THE emergency roiagnom on [DATE] AND admitted to the hospital with [REDACTED]." THE CARE PLAN DATED [DATE] INDICATED THE PROBLEM OF "AT RISK FOR UTI (URINARY TRACT INFECTION) D/T (DUE TO) INDWELLING CATHETER FOR [MEDICAL CONDITION] AND DX (DIAGNOSIS) OF [MEDICAL CONDITION]." THE APPROACHES INCLUDED, BUT WERE NOT LIMITED TO, ".... MAINTAIN CLOSED DRAINAGE SYSTEM USE ASEPTIC TECHNIQUE WHEN EMPTYING BAG. F/C (FOLEY CATHETER) CARE Q (EVERY) SHIFT. MONITOR FOR S/SX (SIGNS/SYMPTOMS) OF UTI: (E.G. FOUL/CLOUDY URINE, ELEVATED TEMP. LOW BACK PAIN, OR BURNING/FREQUENCY UPON VOIDING). ALERT MD IMMEDIATELY. CHANGE FOLEY CATH Q. MONTH AND PRN (AS NEEDED)...." DURING AN INTERVIEW WITH THE DON ON [DATE] AT 3:00 P.M., SHE INDICATED RESIDENT E HAD [MEDICAL CONDITION]. 3. RESIDENT G'S CLOSED CLINICAL RECORD WAS REVIEWED ON [DATE] AT 9:20 A.M. RESIDENT G WAS admitted to the facility on [DATE] AND discharged on [DATE]. RESIDENT G'S [DIAGNOSES REDACTED]. RESIDENT G'S NURSES' ADMISSION NOTE INDICATED SHE HAD A FOLEY CATHETER IN PLACE. RESIDENT G'S [DIAGNOSES REDACTED]. RESIDENT G'S admission orders [REDACTED]. THE URINARY CONTINENCE EVALUATION COMPLETED ON [DATE] INDICATED RESIDENT G had a history of [REDACTED]. HER PERCEPTION OF NEED TO VOID WAS UNABLE TO BE DETERMINED. THE TREATMENT RECORD FOR TIME FRAME OF [DATE] AT 1:30 P.M., WHEN SHE ARRIVED AND [DATE] AT 2:00 P.M., WHEN SHE WAS TRANSFERRED TO THE emergency room , LACKED ANY INDICATION OF CATHETER CARE BEING COMPLETED ON THE RESIDENT. DURING AN INTERVIEW WITH THE DON ON [DATE] AT 1:10 P.M., SHE INDICATED SHE DID NOT KNOW IF ANY CATHETER CARE WAS COMPLETED ON THE RESIDENT. SHE FURTHER INDICATED THERE WERE NO ORDERS IN THE RECORD FOR CATHETER CARE. REVIEW OF THE UNDATED POLICY FOR "URINARY CATHETER INSERTION AND REMOVAL" PROVIDED BY THE DON ON [DATE] AT 1:20 P.M., INDICATED "1. INSERTION OF A CATHETER MUST HAVE A PHYSICIAN ORDER. INSERTED CATHETERS ARE MAINTAINED BY A LICENSED NURSE OR PHYSICIAN." REVIEW OF THE UNDATED POLICY FOR "RESIDENT ADMISSION" PROVIDED BY THE DON ON [DATE] AT 1:20 P.M., INDICATED "....CONTACTS PHYSICIAN AFTER ASSESSMENT COMPLETED TO VERIFY ORDERS AND UPDATE PHYSICIAN...." THIS FEDERAL TAG RELATES TO COMPLAINT #IN 130. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)