Every finding on record at Aperion Care Marion LLC

Based on observation, interview, and record review, the facility failed to ensure services were provided to prevent neglect for a resident with a malignant neoplasm (cancer) facial wound for 1 of 3 residents reviewed for wound care. (Resident B) This deficient practice resulted in the resident not receiving services to remove and treat an active maggot wound infestation in the facial wound for more than 7.5 hours. Findings include:An anonymous report made to the Indiana Department of Health indicated Resident B had a wound with maggots in it and the facility refused to send him to the hospital for treatment.Resident B's clinical record was reviewed on 8/19/26 at 10:40 a.m. Diagnoses included adult failure to thrive, squamous cell carcinoma of skin of other parts of face, and malignant neoplasm of connective and soft tissue of head, face and neck. A wound assessment, dated 8/10/26 at 4:58 p.m., indicated he had a wound measuring 6.5 centimeters (cm) long by 4 cm wide on his right cheek.A wound note, dated 8/11/26 at 12:16 p.m., indicated the area had slough (soft, moist layer of dead tissue covering a wound bed) and eschar (dry, dark layer of dead tissue covering a severe wound) with surrounding skin that was red and painful to touch. The current treatment was to be continued per hospice. The resident refused to allow the nurse to clean the wound but allowed the nurse to apply Vaseline gauze and a dry dressing. He received an antibiotic for cellulitis (skin infection) of his right cheek. A nurse's note, dated 8/14/26 at 9:24 a.m., indicated larvae (worm-like juvenile bugs) were observed inside his right cheek wound. Hospice, the medical provider, and the DON were notified. The wound was irrigated (continued rinse with fluid) and cleansed and an attempt was made to cover the wound with a dry sterile dressing. The resident verbalized discomfort and allowed only partial wound coverage. He was educated on the purpose and importance of covering wound but continued to refuse full wound covering. A hospice visit narrative note, dated 8/14/26, indicated the facility reported the presence of fly larvae (maggots) in his wound that morning. Wound care was performed by the facility nurse prior to hospice's arrival, Vaseline gauze was applied and covered with gauze dressing and taped closed. The facility nurse indicated the wound was cleaned with peroxide and all larvae removed. The wound had a mild foul odor. The redness and swelling to his right orbital area (near his eye) continued to improve. A nurse practitioner (NP) note, dated 8/15/26 at 4:00 p.m. indicated the RN reported larvae was noted in facial wound as well as decreased urine output. Orders were provided to irrigate wound with normal saline, change to Dakin's solution (a diluted bleach solution to clean and disinfect wounds) wet-to-dry dressing twice daily, and to contact hospice regarding recurring larvae. The clinical record lacked documentation of assessment of the wound condition, and lacked indication of the new wound orders received on 8/15/26 at 4:00 p.m. until the treatment was documented as completed on 8/15/26 at 11:50 p.m. An NP note dated 8/15/26 at 4:20 p.m., indicated hospice staff refused to irrigate the wound per order and discussed sending patient to hospital to have wound irrigated. The NP informed nursing staff that the hospital emergency room visit was not necessary as orders to irrigate the wound were already given and the orders needed to be followed. The medical director was notified, and it was discussed that hospice wanted to send to the emergency room. Instructions were given to contact family. A hospice visit narrative note, dated 8/15/26, indicated the resident was observed leaning heavily towards the left side of his bed, his eyes were closed and he had difficulty opening them. The dressing to his facial wound had been removed by the resident. Staff reported the resident frequently removed the dressing. Hundreds of live maggots were found in his facial wound, and there were several large larva and flies present. He complained of pain when the facial wound was touched. He had no urine output for 24 hours and no intake for three days. He was able to state his name and birth date, however, was situationally confused and unable to make decisions for himself at that time. He became agitated with staff when he was asked questions or touched. His son was notified and was thoroughly explained his status, and comfort measures versus aggressive treatment were discussed. The resident's son requested that the resident to be taken to hospital, and the hospice physician agreed. However, after the son spoke with the facility DON, he ultimately decided not to send the resident to hospital. The hospice physician was notified and resident's pain medication was increased. An NP note, dated 8/15/26 at 4:46 p.m., indicated the resident's son was notified to discuss wound care and his request to send him out for wound debridement. Education was provided on resident's advanced facial wound, presence of larvae, and the wound being too advanced for surgical intervention, as he has end stage squamous cell carcinoma of his cheek. It was discussed that his oncologists deemed him to no longer be a candidate for surgical and/or advanced treatment, and recommended the resident being placed on hospice services for comfort care. The son indicated that he no longer wished to have the resident sent out. A nurse's note, dated 8/15/26 at 11:50 p.m., indicated the nurse assisted in wound care of Resident B's face with live larvae present in abundance. The treatment began by removing the petroleum gauze and larvae were noted moving around in the wound inside the resident's cheek at 12:00 o'clock, 3:00 o'clock and 6:00 o'clock areas. Slough was noted in the wound bed in all other areas. A foul odor was coming from wound bed. The wound bed was irrigated to attempt to get the live larvae out and leaving the wound bed. A gauze pad moistened with Dakin's solution was used to swab and wipe out live larvae, requiring multiple attempts too numerous to count to remove them. The removed contents were placed in a suction canister with hydrogen peroxide and Dakin's solution. Finally, most of the visible live larvae were removed using long cotton tipped applicators. After no further larvae were noted, the wound bed was packed with Dakin's soaked gauze for a wet-to-dry treatment then antibiotic ointment applied around wound edges to protect the good tissue and covered with Medipore (breathable hypoallergenic soft cloth tape) tape. Resident B left the dressing alone once all this care was completed. A complete bed change was completed to ensure no larvae had escaped onto his bedding. He was comfortable at that time and no longer complained or discomfort. A nurse's note, dated 8/16/26 at 3:27 p.m., indicated wound care was provided with no active larva present. The resident was educated on the importance of allowing wound care each scheduled time to ensure adequate cleaning and assessment. He tolerated the treatment after receiving routine morphine. During an interview, on 8/19/26 at 11:19 a.m., LPN 5 indicated she entered the resident's room on the morning of 8/14/26 with wound care supplies. As she cleaned Resident B's facial wound, she saw movement around the edges. She noticed one single adult maggot and the rest were larvae. She notified the DON, hospice, and the facility's NP. She was instructed by the DON to irrigate the wound with normal saline. Resident B was known to refuse care and refuse to have his dressing changed. He would put his fingers in the dressing and removed the dressings. She irrigated the wound and from what she saw, she was able to remove the maggot and the larvae. During an interview, on 8/19/26 at 11:36 a.m., Resident B's son indicated a hospice nurse contacted him with one of the facility's nurses in the background, and they wanted his father to be sent to the hospital due to hundreds of maggots being in his dad's facial wound. He agreed with sending Resident B to the hospital. Someone else from the facility called him back, he thought it was the head of the nurses. She told him that his dad did not need to be sent to the hospital and told him that the larvae were good to be in the wound. He was not told whether the maggots were medicinal maggots or just flies. Then the hospice nurse called him back and asked if he was sure that he did not want his dad sent out and that there were hundreds of maggots crawling off his face onto his bed and that he could send him out to the hospital if he wanted him to go. During an interview, on 8/19/26 at 12:15 p.m., Hospice RN 2 indicated the facility contacted the hospice agency to let them know there was larvae found in Resident B's facial wound. When she arrived at the facility, the facility nurse had just completed wound care and indicated that she got the wound cleaned out. Hospice RN 2 observed the dressing on his facial wound, and it had a tight seal. Approximately two to three days prior, she completed wound care and reported to RN 12 that there was a fly in his room. During an interview, on 8/19/26 at 1:11 p.m., the facility's NP indicated she was contacted on 8/14/26 that larvae had been found in Resident B's wound. She gave instructions to irrigate the wound and contact hospice for any wound care changes. On 8/15/26, she received a photograph from one of the facility nurses who was requesting treatment orders. She gave verbal orders to irrigate with normal saline and Dakin's wet to dry dressing twice daily. Resident B was being treated for cellulitis and had prior radiation to the area. The hospice nurse and LPN 15 refused to do the treatment and indicated the resident needed sent to the hospital. She indicated the wound just needed to be cleaned to prevent undo stress. It was simple wound care, they needed to follow her instructions, and they could get rid of the larvae. Resident B's son wanted him sent out and the wound debrided. She called the son and asked him what his end goal was and reminded him that Resident B was on hospice services. The resident's son indicated the nurses had blown the situation out of proportion and was told that there were thousands of maggots in his wound. She indicated to him that he would sit in the emergency room (ER) for 10 hours and that was not the proper way to go. Irrigating and using Dakin's would kill the maggots. Resident B's son rescinded him going to the hospital. She called hospice and indicated that he was not going to be sent to the hospital and the next shift needed to complete the treatment per her instructions. She offered to drive to the facility to complete the treatment, but RN 16 indicated that she could take care of it. By Sunday, the maggots were gone. Resident B was combative, he pulled the dressings off, and when he was more alert, he picked at the scab on his wound and placed it on a napkin for radiology to see. He was known to hit and curse at staff and not allow them to complete dressing changes. During the interview, the photograph was viewed on the facility NP's cell phone. She described the photograph as Resident B's facial wound, showing his upper right cheek with fatty tissue, bone exposure and with approximately 50 to 100 maggots in the wound. She further indicated that she had no concerns with wound care at the facility. There were flies in the building, but she did not notice flies in the resident's room. During an interview, on 8/19/26 at 1:25 p.m., Hospice RN 3 indicated she arrived at the facility at approximately 4:00 p.m. on 8/15/26 and Resident B's bandage was off, but the exterior tape was still on his face. She observed hundreds of maggots in his wound. Very active large maggots were crawling in and out of his wound. She described the maggots as a bowl of spaghetti moving around. The whole wound was covered. She spent 20 minutes talking with Resident B's son, she was factual when explaining how digging the maggots out would be painful, and that it could be an uncomfortable situation. Resident B's son wanted him sent to the ER. She let the facility know that the resident's son wanted him to go to the ER. The facility's NP and the DON vetoed the ER visit. There were no staff available to complete the wound care and to remove the maggots. LPN 15 kindly dismissed her and she left the facility at approximately 5:00 p.m. During an interview, on 8/19/26 at 1:50 p.m., RN 14 indicated there were live larvae in Resident B's facial wound (on 8/14/26). She completed the dressing change. They could not irrigate the wound because the maggots would have shot everywhere. She used Dakin's and gauze and removed the maggots. She put them in a suction canister. She was unable to explain how many maggots were present, but they were imbedded in his wound. The maggots were not on his face until she started cleaning out the wound. Two suction canisters were used due to the amount of gauze used. They double and triple bagged the canisters and took them to the trash. There were maggots between 12 o'clock and 1 o'clock and between 6 o'clock and 5 o'clock of areas of his wound. The maggots were clustered around the edges of his wound and under the wound edges. He was given pain medication before the removal of the maggots. He indicated that he heard the maggots and felt them. He did not touch the wound after that. On 8/19/26 at 2:01 p.m., wound care for Resident B was observed with RN 12, accompanied by the ADON. The ADON described the resident's wound as fatty tissue, with cheek bone exposed, the wound edges were abnormal, and the surrounding are was red. No maggots or larvae were observed in the wound. The ADON indicated the resident had not refused a dressing change at all this week, but his morphine orders had been changed. During an interview, on 8/19/26 at 2:48 p.m., LPN 15 indicated she mentioned to the facility's NP that there were flies landing on Resident B's wound and something needed to be done about it on the Wednesday before the maggots were noticed. On 8/15/26, she worked from 6:00 a.m. to 6:00 p.m., and took over care for Resident B after RN 12 left the facility at 12:00 p.m. At approximately 2:30 p.m. to 3:00 p.m., CNAs reported to her that she needed to look at Resident B. Maggots were observed under the resident's gauze dressing, and the gauze was partially covering the wound. There were hundreds of maggots falling from his face. She did not feel comfortable completing the wound care and Hospice RN 3 did not want to complete the wound care. The facility's NP told her that she could be fired for not completing the wound care. She felt that a doctor needed to remove them and the resident needed sedated to have the maggots removed. He was in pain and he did not want his wound touched. She did not enter the wound care order from the facility's NP into the electronic health record. She gave report and passed it on to the oncoming shift nurse. The maggots remained in the wound when she left at 6:00 p.m. During an interview, on 8/19/26 at 3:19 p.m., RN 6 indicated LPN 15 reported to her that there were maggots in Resident B's wound, and the wound was supposed to be irrigated. RN 6 had never seen a wound that bad, it was horrific. She asked the nurse from the other hall to come over as soon as possible. They tried to irrigate the wound to get all the maggots out and she didn't feel that it was right that he wasn't sent to the hospital. He was medicated a half hour before wound care. He was in excruciating pain, and it was inhumane and sad. They filled three suction containers full with gauze from wiping out the maggots from his wound. RN 14 cleaned the wound, and she and LPN 24 were trying to keep the maggots from going into other orifices because once they started flushing the maggots they started moving out of the wound. They used Dakin's soaked gauze to wipe his wound and then picked the maggots off of him and the sheets. When they turned him over there were maggots on the back of his neck. She did not know the magnitude of the situation until they started to remove the maggots, and it seemed like they were already tunneling into the wound. It was very traumatic for Resident B. He should have been sedated and at a hospital. He yelled out and the aide could hear him through the door. He yelled Please no don't, please no, I didn't mean to do it. He was pleading. The order that was received was for normal saline and Dakin's. LPN 15 refused to put the order into the computer, so RN 16 entered the order, and she put the new order in the computer for the morphine. During a follow up interview, on 8/20/26 at 4:12 p.m., RN 6 indicated they had to wait until later in the shift to complete the wound treatment to Resident B's facial wound, once everything settled down and all three nurses could get together. She wanted to complete the wound treatment sooner, but she knew she couldn't do it by herself. Once the solution hit, the maggots started to crawl everywhere. They started his wound treatment at 10:50 p.m. and it took about an hour to clean out the wound. She felt he should have been sent out, but she was doing what she was ordered to do. During a follow up interview, on 8/20/26 at 10:17 p.m., RN 14 indicated RN 6 asked her to assist with Resident B's wound care after report, around 7:00 p.m. RN 6 indicated Resident B needed to be medicated. The wound care took an hour to complete but that included clean up, fresh bedding and taking the trash out. During an interview, on 8/20/26 at 10:21 p.m., LPN 24 indicated she assisted and helped with containing the maggots, because once they started irrigating the wound, the maggots started to spread. She was unable to number how many maggots there were, not hundreds, but many. RN 14 wiped his wound with gauze and the maggots scattered. A 6/19/26 quarterly Minimum Data Set (MDS) assessment indicated he was cognitively intact. He required substantial/maximal assistance with upper-body dressing and personal hygiene, and he was dependent with toilet hygiene and lower-body dressing. He received application of ointments/medication and nonsurgical dressings (with or without topical medications) other than to his feet.Current physician ordered treatments included the following:Cleanse wound to right cheek with peroxide and cover with Vaseline gauze daily (start 7/30/26, discontinued 8/15/26), Irrigate wound bed to right cheek, cleanse with Dakin's solution and cover with Vaseline gauze and dry dressing twice daily (start date of 8/15/26 and discontinued 8/16/26), andIrrigate wound bed to right cheek with normal saline, apply gauze moistened with Dakin's solution to wound bed, cover with dry dressing twice daily (start 8/16/26).Current physician orders for medications included hydrocodone-acetaminophen (narcotic pain reliever) 5-325 mg four times daily (started 7/25/26, discontinued 8/16/26), morphine sulfate (narcotic pain reliever) solution 0.25 ml every six hours for pain/air hunger (started 8/10/26, discontinued 8/16/26), cefadroxil (antibiotic) 5 milliliters (ml) by mouth every 12 hours for facial cellulitis for 10 days (started 8/5/26, completed 8/15/26), and morphine sulfate solution 10 mg every 4 hours as needed for pain and 30 minutes prior to wound care. (started 8/15/26, discontinued on 8/16/26). A current care plan indicated he was non-complaint/resistive to care with refusing personal care and treatment to his right cheek. His interventions included educating him of possible negative outcomes related to noncompliance (3/16/26) and encouraging him to be compliant with care (3/16/26). A current 3/11/26 care plan indicated a surgical wound to his right cheek related to cancer. Interventions included monitor site for signs and symptoms of infection (i.e., increased drainage, foul odor, redness, warmth, etc.) (3/11/26), Proheal (supplement) twice daily (3/11/26), and treatment as ordered (3/11/26). A current facility policy, revised 5/4/22, titled Abuse Prevention and Reporting - Indiana, provided by the Administrator on 8/21/26 at 10:38 a.m., indicated the following: Neglect is defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. This citation relates to 3167999. 410 Indiana Administrative Code 16.2-3.1-27(a)(3)

Based on observation, interview, and record review, the facility failed to ensure urinary catheters were inflated and anchored with the correct size catheter balloon according to physician's orders for 1 of 3 residents reviewed for urinary catheters. (Resident D) Findings include:During an interview, on 7/22/26 at 10:47 a.m., Resident D indicated he had no complaints related to his urinary catheter besides having a terrible burning when he urinated, which had brought tears to his eyes. His catheter had been changed one time since he admitted to the facility. Resident D's Foley catheter tubing, accompanied by RN 25, was observed on 7/22/26 at 10:54 a.m. The catheter port indicated that the catheter was a 16 French with a 5 mL balloon. On 7/22/26 at 10:57 a.m., RN 25 reviewed Resident D's physician orders and indicated that his order was for 16 French Foley with a 10 mL balloon, and the catheter in place did not match the order. Resident D's clinical record was reviewed on 7/22/26 at 9:27 a.m. Diagnoses included chronic kidney disease, and essential (primary) hypertension. A 7/2/26 admission MDS assessment indicated he was cognitively intact and he had an indwelling catheter. His clinical record lacked a care plan for management of a urinary catheter. His physician orders included 16 French Foley catheter with a 10 mL balloon and ciprofloxacin (antibiotic) 500 mg for UTI for seven days. A nurse's note, dated 7/10/26 at 4:46 a.m. indicated Resident D's Foley catheter was changed to obtain a urinalysis with culture and sensitivity. He tolerated the catheter change without difficulty and an immediate return of clear pale-yellow urine was noted. During an interview, on 7/22/26 at 2:50 p.m., the Administrator indicated the facility did not have a policy or procedure for inserting urinary catheters. They would change them as needed or if the doctor wanted them changed more often. The expectation was that the resident's catheter size should be what the physician ordered. 410 Indiana Administrative Code (IAC) 16.2-3.1-41(b) This citation relates to Intake 3097124.

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) worked the required hours to manage the Infection Prevention and Control Program (IPCP), including infection surveillance, staff training, and antibiotic stewardship monitoring to mitigate the risk of the spread of infection. This deficient practice had the potential to affect 62 of 62 residents living in the facility. Findings include:During an interview with the Director of Nursing (DON) on 4/16/26 at 3:55 p.m., she indicated she had served as the facility's Infection Preventionist (IP) for the last five years. During an interview with the DON on 4/20/26 at 9:57 a.m., she indicated she was the person in charge of infection prevention. The ADON was her backup, when needed. The ADON was also certified in infection prevention. The ADON worked 30 hours a week. The DON worked 40 hours a week as the DON. She indicated she focused on IP during her regular workday(s) as needed. If she needed to stay over an hour or two here and there, she would. During an interview with the Administrator on 4/20/26 at 10:01 a.m., she indicated the DON was the primary IP. The DON worked approximately 60 hours per week. The DON position was a salaried position, so the Administrator was unable to provide timecards or documentation of the actual hours worked per week by the DON. The Administrator felt the DON put in 40 hours a week, on top of her hours working as IP. A current facility policy titled Infection Preventionist - Job Description, provided by the Administrator on 4/21/26 at 9:37 a.m., indicated the following: .The role of the Infection Preventionist is to oversee the infection prevention and control program for the surveillance, investigation, prevention, and control of healthcare-associated infections and other infectious diseases.Essential Duties and Responsibilities May Include But Not Limited To The Following: 1) Infection Prevention & Control - tracking and trending of infections 2) Line Listing reports 3) Vaccination Tracking 4) Antibiotic Stewardship program oversight 5) Infection Control rounding and observations 6) Performance Improvement 7) Occupational Health 8) Occupational Safety and Health Administration's (OSHA) Respiratory Protection Program oversight 9) Emergency Preparedness - Pandemic 10) Infection Control & Antibiotic Stewardship Education - Staff and Residents 11)Mandatory Reporting and Communication (may include residents, families, staff, health departments, physicians etc.) 12) Regulatory Compliance 13) Quality Assurance Committee 14) Performs other duties as assigned.To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. An untitled document, provided by the Administrator on 4/21/26 at 9:37 a.m., indicated the following: .IP Hours of Work - Designated IP hours per week can vary based on the facility and its resident population. Therefore, the amount of time required to fulfill the role must be at least part-time and should be determined by the facility assessment, conducted according to S483.71, to determine the resources it needs for its IPCP, and ensure that those resources are provided for the IPCP to be effective. Based upon the assessment, facilities should determine if the individual functioning as the IP should be dedicated solely to the IPCP.

Based on observation and interviews, the facility failed to ensure a safe environment for residents when steam tables were left on and unattended in the main dining room. This deficient practice had the potential to affect 9 cognitively impaired and independently mobile residents of 62 residents residing in the facility.Findings include:During an observation, on 4/16/26 at 10:30 a.m., a four compartment steam table in the main dining room, between D and E halls, was left unattended and on the high setting. Steam was noted coming from all four compartments. The two chains blocking off the cooking area of the dining room were down, allowing for direct access to both sides of the steam table. During an interview, on 4/16/26 at 10:36 a.m., the Dietary Manager walked into the serving area of the dining room and indicated the chains were down and should be up after each meal service. The steam tables were turned off after meal service, and staff turned them back on about an hour and twenty minutes before each meal service, so they were hot during the meal. Only dietary staff and nursing staff were permitted in the cooking area of the dining room. He had turned on the steam tables about 35-40 minutes ago when he brought up the enclosed hall carts to get ready for lunch service. A sign hanging on a pillar in the dining room, titled Mealtimes, indicated lunch meal service was at 12:30 p.m. During an observation, on 4/20/26 at 9:27 a.m., the four compartment steam table in the main dining room between D and E halls was unattended and on the high setting. Steam was noted coming from all four compartments. When the lids were removed, water was seen simmering in the holding pans. The two chains blocking off the cooking area of the dining room were down, allowing access to both sides of the steam table. On 4/20/26 at 9:30 a.m., three dietary staff members walked past the dining room pushing a three-shelf wheeled cart. The staff members did not put the chains up. On 4/20/26 at 9:30 a.m., a CNA walked by the dining room while the chains remained down. On 4/20/26 at 9:31 a.m., two dietary staff members walked past the dining room pushing a wheeled cart. The dining room chains remained down. During an interview, on 4/20/26 at 10:01 a.m., the Administrator indicated the steam tables in the dining room should be turned off when not in use. Dietary staff came up 15-20 minutes before meals to turn the steam tables back on. If the steam tables were on, the chains should be up. During a written electronic communication (e-mail), on 4/21/26 at 2:20 p.m., the Administrator indicated nine residents were cognitively impaired and independently mobile between the two halls.A current facility policy, dated 2020, Untitled, provided by the Administrator, on 4/21/26 at 3:30 p.m., indicated the following: .4. Once the steam table is in the serving location, it is plugged in to help maintain food temperatures and must be continually staffed by an employee. 5. A steam table is never left unattended in any area readily accessible to residents 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure food was served under safe and sanitary conditions regarding food handling during a meal observation for 1 of 16 residents observed in the dining room. (Resident 49)Findings include:During a lunch observation, on 4/21/26 at 12:42 p.m., the following was observed:CNA 9 assisted Resident 49 with his meal tray. CNA 9 grabbed the top hamburger bun from Resident 49's fish sandwich with her bare hands before she placed the bun on Resident 49's tray. CNA 9 picked up a small plastic container of tartar sauce and asked Resident 49 if he wanted any on his sandwich. Resident 49 declined. CNA 9 put down the small plastic container of tarter sauce, picked up the top bun again with her bare hand and placed it on top of Resident 49's sandwich before walking away from the table.During an interview, on 4/21/26 at 12:46 p.m., CNA 9 indicated she touched Resident 49's hamburger bun with her bare hands. She should not touch any food bare handed.During an interview, on 4/21/26 at 2:25 p.m., the DON indicated staff should not touch food with their bare hands.A current facility policy, dated 2009, titled Safe Food Preparation and Handling, provided by the Administrator, on 4/21/26 at 3:30 p.m., indicated the following: .1. Strict personal hygiene will be followed. Employees will avoid direct contact (i.e.) using bare hands) with ready-to-eat foods. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident was free from the use of a chemical restraint related to the use of an antipsychotic medication without clinical indication and without the development of non-pharmacological interventions for 1 of 5 residents reviewed for unnecessary medications. (Resident 21)Findings include:During an observation on 4/17/26 at 12:02 p.m., Resident 21 was in his room, asleep in bed. The room was dark and the television was playing. On 4/20/26 at 9:02 a.m., Resident 21 was lying in bed watching television. He indicated he was comfortable at the facility. The staff treated him kindly. Resident 21's clinical record was reviewed on 4/16/26 at 3:37 p.m. Diagnoses included personal history of traumatic brain injury (TBI), major depressive disorder, recurrent, psychotic disorder with hallucinations due to a known physiological condition, Alzheimer's disease with early onset, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Current physician orders included risperidone (antipsychotic) 0.25 mg give one tablet by mouth one time a day for delusional disorder (3/19/26), monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea and vomiting, lethargy, drooling, extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) due to antipsychotic medication use (5/5/25), lorazepam 0.5 mg give one tablet by mouth every morning and at bedtime for anxiety and restlessness related to generalized anxiety disorder (6/21/25), and sertraline 100 mg give one table by mouth one time a day for depression related to major depressive disorder (5/25/25). A quarterly Minimum Data Set (MDS) assessment, dated 2/25/26, indicated Resident 21 was severely cognitively impaired, had moderate depression, did not exhibit delusions, hallucinations, or behaviors, required substantial/maximal assistance for bed mobility, was dependent for toileting and showering, and was dependent for all transfers. Active diagnoses included anxiety and depression. A current care plan, initiated on 5/4/25, indicated Resident 21 used an antipsychotic medication related to depression and anxiety. The goal was Resident 21 was to remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the next review date. Interventions included to administer psychotropic medications as ordered by the physician, monitor for side effects and effectiveness every shift, consult with pharmacy - MD to consider dosage reduction when clinically appropriate at least quarterly, monitor/document/report, as needed, any adverse reactions of psychotropic medications (unsteady gait, tardive dyskinesia, extrapyramidal symptoms, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea and vomiting, behavior symptoms not usual to the person, monitor/record occurrence of behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. A Level 2 Pre-admission Screen and Resident Review (PASRR), dated 4/25/25, indicated no previous inpatient psychiatric admissions or outpatient mental health services. No history of significant mental illness, intellectual disability or developmental disability. Past psychosis included delusions and hallucinations. A Social Services note, dated 5/1/25 at 11:43 a.m., indicated Resident 21's communication issues were related to a history of traumatic brain injury (TBI). Resident 21 had difficulty making decisions. There was no evidence of an acute change in mental status from the resident's baseline. The resident was not easily distracted and did not have difficulty keeping track of the conversation. He did not exhibit disorganized or incoherent thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. There were no indicators of psychosis, and no examples of hallucinations and/or delusions within the lookback period. The resident exhibited no behavioral symptoms. He did not reject evaluation or care (e.g., bloodwork, taking medications, assistance with activities of daily living). A 5/13/25 pharmacy recommendation indicated there did not appear to be an appropriate diagnosis listed in (the electronic health record) or on the eMAR that indicated the need for risperidone. Appropriate diagnoses to support antipsychotic use included schizophrenia, schizo-affective disorder, psychotic mood disorders (including mania and depression with psychotic features), acute psychotic episodes, brief reactive disorders, schizophreniform disorder, atypical psychosis, delusional disorder, dementing disorder with behavioral symptoms, Tourette's disorder, Huntington's Disease, organic mental syndromes with associated psychotic and/or agitated features. Risperidone was not indicated for depression. Please consider discontinuation of antipsychotic therapy at this time or add a supporting diagnosis. The provider did not respond to the recommendation. A psychiatry initial consultation note, dated 5/16/25 at 1:00 p.m., indicated Resident 21 was receiving risperidone 0.5 mg daily for depression related to diagnoses of depression and anxiety. The resident was in a motor vehicle accident (MVA) resulting in a TBI and the death of his mother. He had been feeling anxious and depressed related to his situation. He denied hallucinations or delusions. He refused to get out of bed except for therapy and was self-isolating. He was on one antipsychotic, risperidone 0.5 mg daily, and admitted to the facility on the medication. The NP discontinued his escitalopram (an antidepressant) and started sertraline 50 mg daily for seven days, then increase to 100 mg daily for better control of depressive symptoms. The NP started lorazepam 0.5 mg every 12 hours as needed for 14 days for anxiety. The NP continued the risperidone 0.5 mg daily with a goal to continue to gradually reduce and then discontinue at a future visit. A psychiatry progress note, dated 6/5/25 at 1:00 p.m., indicated the resident was receiving risperidone 0.5 mg daily for depression related to depression and anxiety disorders, and sertraline 100 mg daily for depression. Resident 21's anxiety and depression had improved on sertraline and lorazepam since the last visit. No other concerns were voiced related to mood or new behaviors. A 6/17/25 pharmacy recommendation indicated the resident had a diagnosis of delusional disorder listed in a progress note; however, this was not an active diagnosis in (the electronic health record) diagnosis list. The pharmacist requested an update to the clinical record. A progress note, dated 7/7/25 at 2:13 p.m., indicated Resident 21 was receiving risperidone 0.5 mg daily for depression. A behavioral health note, dated 7/15/25 at 1:00 p.m., indicated facility staff reported no new concerns about mood or behavior. A psychiatry progress note, dated 8/7/25 at 1:00 p.m., indicated Resident 21 received risperidone 0.5 mg for delusional disorders related to depression and anxiety. Staff and the Social Services Director (SSD) reported the resident had been at baseline since the last encounter. He accepted care and medications as scheduled. There were no concerns related to mood. A 30-Day Follow-Up note, dated 8/12/25 at 11:57 a.m. indicated Resident 21 received risperidone 0.5 mg daily for delusional disorders related to depression and anxiety (7/8/25). A psychiatry progress note, dated 9/18/25 at 1:00 p.m., indicated Resident 21 received risperidone 0.6 mg daily for delusional disorders related to depression and anxiety. Staff and SSD reported Resident 21 had been baseline since last encounter. He accepted care and medications as scheduled. No concerns related to mood, oral intakes, or sleep pattern. A behavioral health progress note, dated 10/1/25 at 1:00 p.m., indicated Resident 21 had past psychiatric diagnoses of depression, anxiety, and delusions and hallucinations prior to admitting to the facility. Facility staff reported no new concerns. The behavioral health progress note did not define the delusions and hallucinations the resident had experienced prior to admission. A psychiatry progress note, dated 10/16/25 at 1:00 p.m., indicated staff and the SSD reported the resident had been at baseline since last encounter. He accepted care and medications as scheduled. No concerns related to mood, oral intakes, or sleep pattern were reported. A behavioral health progress note, dated 11/18/25, indicated Resident 21 was calm and cooperative. He smiled and told the clinician he was doing well. He denied concerns about his mood. Facility staff reported no changes in mood or behavior. A psychiatry progress note, dated 11/20/25 at 1:00 p.m., indicated Resident 21 received risperidone 0.5 mg daily. The resident was admitted to the facility with the risperidone. A psychiatry progress note, dated 12/18/25 at 1:00 p.m., indicated Resident 21 received risperidone 0.5 mg daily. Staff and the SSD reported the resident had been baseline since the last encounter. He accepted care and medications as scheduled. No concerns related to mood, oral intakes, or sleep pattern. A 1/9/26 pharmacy recommendation indicated the resident had an order for risperidone 0.5 mg. However, psychiatric progress notes indicated the resident was to receive a GDR of risperidone to 0.25 mg daily on 12/18/25. The provider responded and clarified the order was for risperidone 0.25 mg daily. A psychiatry progress note, dated 1/9/26, indicated Resident 21 was being seen for consideration of a gradual dose reduction (GDR) for risperidone 0.5 mg. Resident 21 was appropriately dressed and groomed for the day. He had no concerns related to his mood. He was pleasant and calm. Staff and the SSD reported Resident 21 had been at baseline since the last encounter. There were no concerns related to mood, oral intakes, or sleep patterns. The NP indicated to continue risperidone 0.25 daily. The GDR was contraindicated because the resident had an acute medical illness at that time. A GDR at that time could impair the resident's function and/or cause psychiatric instability and risk decompensation. There was no clinical indication for a reduction at that time. The resident had a recent GDR of medication in December 2025. The NP would re-evaluate the need to GDR the risperidone at the next GDR visit. Nursing staff were to document any new or worsening moods/behaviors and notify psychiatric services. A communication with prescriber note, dated 1/14/26 at 4:20 p.m., indicated the psychiatric NP reviewed the consultant pharmacist recommendation to consider a GDR for risperidone 0.5 mg daily. The NP declined and did not provide a rationale. A progress note, dated 2/4/26, indicated Resident 21 denied any changes or concerns. He continued to eat and sleep normally. He continued to isolate himself in his room, which was his preference. Facility staff reported no new concerns. A progress note, dated 2/27/26, indicated staff and the Social Services Director (SSD) reported Resident 21 had been baseline since the last encounter. There were no reports or concerns related to mood, oral intakes, or sleep pattern. The resident was pleasant and calm. A progress note, dated 3/4/26, indicated the NP met with Resident 21 for a routine follow-up. Resident 21 was calm, friendly, well-groomed, and in no apparent distress. He was smiling and joked with the clinician. He reported he had been doing fine and his mood was good. Facility staff reported no new concerns about mood or behavior. The NP suggested non-pharmacological interventions to include cognitive/emotion-oriented interventions (reminiscence therapy, simulated presence therapy, validation therapy), sensory stimulation interventions (aromatherapy, light therapy, massage/touch, music therapy), behavior management (distraction, redirection, and relaxation) techniques, and other psychosocial interventions such as animal-assisted therapy and exercise. The clinical record lacked documentation of the development and implementation of non-pharmacological interventions, sensory stimulation interventions, behavior management techniques, or other psychosocial interventions. A psychiatry progress note, dated 4/2/26 at 1:00 p.m., indicated Resident 21 was taking risperidone tablet 0.25 mg one time a day for delusional disorder. He was referred to psychiatric services for ongoing management of his anxiety, depression, and mood disorder. Staff reported Resident 21 had been at baseline since the last encounter. He accepted care and medications. He spent most of the time in his room, as was his choice. He was in no distress, appropriately dressed and neatly groomed. He denied concerns during the visit. No reported hallucinations or delusions. Nursing was to monitor/document any clinically significant changes in mood/behaviors (e.g., feeling scared, panic attack, irritability, pacing/fidgeting, excessive worrying, etc.) related to anxiety. Nursing was to monitor/document any clinically significant changes in mood/behaviors (e.g., sadness, anhedonia, tearfulness, hopelessness, isolation in room, feelings of guilt, etc.) related to depression. During an interview with NP 12 on 4/17/26 at 10:02 a.m., she indicated Resident 21 stayed in his room most days. Staff had never reported hallucinations, delusions, or behaviors for Resident 21. Although she did prescribe some of his medications, she did not prescribe his psychotropic medications. During an interview with CNA 10 on 4/21/26 at 11:06 a.m., she indicated she had never seen Resident 21 experiencing hallucinations or delusions. He would sometimes get angry when he was on the phone with family or if he dropped something, he could yell or cuss out of frustration. He was usually a happy person and did not refuse care. During an interview with LPN 11 on 4/21/26 at 11:08 a.m., she indicated she had never witnessed behaviors, delusions, or hallucinations from Resident 21. He did not resist or refuse care. During an interview with CNA 19 on 4/21/26 at 11:10 a.m., she indicated Resident 21 was always very sweet and respectful. He did not exhibit delusions or hallucinations. He was very calm and quiet. During an interview with psychiatric NP 13 on 4/21/26 at 11:41 a.m., she indicated she did not diagnose Resident 21 with delusional disorder. The diagnosis was part of his past psychiatric history. She was not familiar with his psychiatric history, other than what was in the hospital discharge documents. The resident was admitted to the facility with the prescription for risperidone. She had never observed him having delusions or hallucinations. She had not agreed to the last pharmacy recommendation to GDR the risperidone because the resident was not medically stable at the time of the recommendation. She had decreased his risperidone from 0.5 mg to 0.25 mg on 12/18/25. The GDR on 12/18/25 was the only GDR performed since he admitted . The next GDR should be coming up soon. During an interview with the DON on 4/21/26 at 2:40 p.m., she indicated she would have to look in Resident 21's record to find documentation of hallucinations and/or delusions. During an interview with Resident 21's representative on 4/21/26 at 2:45 p.m., she indicated she was not aware of any time in the past when Resident 21 had experienced hallucinations or delusions. During an interview with the DON on 4/21/26 at 3:01 p.m., she indicated whoever added the diagnosis of delusional disorder was an NP filling in for the regular psychiatric NP. The resident had a diagnosis of delusions and hallucinations on his 4/25/25 hospital discharge. During an interview with the DON on 4/21/26 at 3:15 p.m., she indicated she could find no documentation of behaviors, hallucinations, or delusions for Resident 21. A current facility policy, titled Psychotropic Medication - Gradual Dose Reduction, provided by the Administrator on 4/21/26 at 3:29 p.m., indicated the following: .To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions.Resident who use psychotropic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue or reduce the medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful or reduction is clinically contraindicated. The drug reduction will continue until eliminated or the clinical condition of resident worsens.The time frames and duration of attempts to taper any medication must be consistent with accepted standards of practice and depend on factors including the co-existing medication regimen, the underlying causes of symptoms, individual risk factors, and pharmacologic characteristics of the medications.Monitoring while medications are tapered will enable facility staff to determine whether a resident is experiencing side effects, changes in behavior, or withdrawal symptoms that originally prompted prescribing of the drug.The reduction procedure will help ensure the resident is maintained on the lowest possible dose of psychotropic medication, and also will help to determine if psychotropic medication is still needed, and will help to detect signs of extrapyramidal symptoms upon withdrawal of the masking effects of the neuroleptic. 410 IAC (Indiana Administrative Code) 16.2 - 3.1-3(w)

Based on observation and interview, the facility failed to provide notification of Medicare Non-Coverage (NOMNC) at the end of Medicare A-covered services for 1 of 3 residents reviewed for beneficiary notification. (Resident 7).Finding includes:On 4/15/26 at 12:37 p.m., the Skilled Nursing Facility (SNF) Beneficiary Notification Review Forms were reviewed and indicated the following:Resident 7 was admitted to Medicare Part A Skilled Services on 11/11/25. The last covered day of Part A services was 1/25/26. The facility/ provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. A NOMNC was not provided since the beneficiary initiated the discharge.The resident transferred to a local area hospital on 1/18/26 and returned to the facility on 1/23/26 under Medicare Part A services.Resident 7 had an Occupational Therapy visit on 1/23/26.A Therapy Payor Verification Form, dated 1/23/26, indicated Resident 7's payor source was Medicare Part A.Resident was discharged from Medicare Part A on 1/25/26.The SNF Notice of Medicare Non-Coverage (NOMNC) was not provided to the resident or resident's representative.During an interview, on 4/21/26 at 9:38 a.m., the Administrator indicated Resident 7 readmitted to the facility and was Medicaid pending. The NOMNC would be discussed 48 hours before the resident discharged . The facility could not find where Resident 7 was provided with a NOMNC.During an interview, on 4/22/26 at 9:57 a.m., the Financial Coordinator indicated the facility discussed during a team meeting that the resident would be discharged off Medicare Part A Services while he was at the hospital. When the resident readmitted to the facility, he would no longer be skilled service. The Financial Coordinator did not speak with the resident or his representative regarding discontinuing services. She assumed since Resident 7 did not discharge home, and stayed in the facility, he did not need a NOMNC completed.During an electronic written correspondence (e-mail), on 4/21/26 at 3:30 p.m., the Administrator indicated the facility did not have a policy regarding Beneficiary Notification and the facility followed Indiana State Regulations.410 IAC (Indiana Administrative Code) 16.2-3.1-4(f)(3)

Based on interview and record review, the facility failed to provide residents and/or their representatives with written notice of transfer/discharge and bed hold policy for 2 of 3 residents reviewed for hospitalizations (Resident 2 and Resident 70). Findings include: 1. Resident 2's clinical record was reviewed on 4/17/26 at 11:34 a.m. Diagnoses included acute respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), chronic kidney disease, and atrial fibrillation (rapid irregular heartbeat).A 12/10/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A progress note, dated 12/14/25 at 9:49 p.m., indicated the resident was sent to the hospital for altered mental status. The resident was difficult to wake up and would not stay awake. He followed commands slowly but returned to sleep. Vital signs were obtained and within normal limits. The hospital was called and given a report of the resident's condition. Two attempts to notify the resident's representative were unsuccessful. A progress note, dated 12/14/25 at 10:18 p.m., indicated the resident's representative was notified and given report at 10:10 p.m. The clinical record lacked review of the notice of transfer/discharge and bed hold policy with the resident or the resident's representative. 2. Resident 70's clinical record was reviewed on 4/20/26 at 8:48 a.m. Diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, chronic obstruction pulmonary disease, and abnormal finding of the lung field. A 1/5/26, admission, MDS indicated the resident was cognitively intact. A progress note, dated 1/29/26 at 10:50 a.m., indicated the resident was found unresponsive but breathing. The resident had been administered a new medication, lorazepam 0.5 milligrams (mg) at 7:06 a.m., for anxiety and oxycodone-acetaminophen (opiate) 7.5 mg-325 mg at 8:06 a.m. for pain. The NP was notified, and naloxone (rapid acting medication to reverse drug overdose) was given twice per order. Following the second dose of naloxone the resident was responsive to name but reached out, yelled, and was restless. The resident repeatedly attempted to remove the oxygen mask with increasing shortness of breath. The NP was notified, and an order was received to send to the hospital for evaluation. The resident's representative was present at the bedside and agreed. Paperwork, current medication list, and code status were sent with the resident. The clinical record lacked review of the notice of transfer/discharge and bed hold policy with the resident or the resident's representative. A notice of transfer/discharge form and bed hold policy form, dated 1/29/26, had a box marked that the resident was unable to sign. The form was signed by the Social Services Director. During an interview on 4/22/26 at 11:18 a.m., LPN 17 indicated when a resident was sent to the hospital, the face sheet, which included the medication list and diagnoses, a transfer form which included the resident's condition, and the code status were sent to the hospital. When the resident was alert and oriented, the transfer/discharge notice and bed hold policy were discussed and signed. If the resident was unable to sign, then the family was notified. The facility kept the transfer/discharge form and bed hold policy form. A progress note about the transfer to the hospital should include the notification of the physician, the orders received, the hospital to which the resident was transferred, the notification of the resident and/or resident representative of the resident's transfer, the transfer/discharge form, and bed hold policy. During an interview, on 4/22/26 at 11:50 a.m., LPN 18 indicated when a resident went to the hospital, an order was received from the provider. If the resident was not cognitively intact, the resident's representative was notified. The medication list, face sheet, and bed hold policy were sent with the resident. Report was given to the emergency medical technicians and to the receiving hospital. The transfer/discharge notice and bed hold policy were reviewed with the resident. If the resident was unable to sign, the notice and policy were reviewed with the resident's representative. The review of the transfer/discharge notice and the bed hold policy was documented. During an interview, on 4/22/26 at 12 p.m., the DON indicated she was unable to locate where the transfer/discharge notice and bed hold policy were reviewed with Resident 2, Resident 70, or their representatives. She indicated a notice of transfer/discharge form with the bed hold policy, dated 1/29/26, had a box marked that the resident was unable to sign for Resident 70 and was signed by the SSD. During an interview, on 4/22/26 at 12:34 p.m., the SSD indicated she had signed the notice of transfer/discharge and bed hold form for Resident 70. She was new at the time and did not remember what happened. Usually, the nurses signed the form with the residents. A current facility policy, revised 8/14/17, provided by the Administrator on 4/21/26 at 3:29 p.m., titled Notice of Transfer and Discharge, indicated the following: .Notify the resident and the resident's representative for the move in writing and in a language they understand. 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(i)410 IAC 16.2-3.1-12(a)(6)(ii)410 IAC 16.2-3.1-12(a)(6)(iii)410 IAC 16.2-3.1-12(a)(25)

Based on interview and record review, the facility failed to ensure shift to shift narcotic count and reconciliation was completed to mitigate risk of misappropriation for 2 of 3 carts reviewed for medication reconciliation. (D1 Hall and E1 Hall)Findings include: 1. During a medication storage observation of the D1 Hall medication cart, on 4/16/26 at 12:15 p.m., accompanied by LPN 14, the Shift change controlled substance inventory count sheet and the Pharmscript Controlled Drug Count Sheets were reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications:April 2026:April 5: day shift, evening shift and night shiftApril 6: evening and night shiftApril 7: evening shiftApril 8: evening shiftApril 9: evening shiftApril 10: evening shift During an interview at the time of observation, LPN 14 indicated the narcotic count sheets were incomplete due to missing shift to shift signatures. 2. During a medication storage observation of the E1 Hall medication cart, on 4/16/26 at 12:06 p.m., accompanied by QMA 15, the Pharmscript Controlled Drug Count Sheet was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications:April 2026:April 5: evening shiftApril 6: night shiftApril 7: night shiftApril 13: night shift During an interview, on 4/16/26 at 3:55 p.m., the DON indicated the controlled narcotic sheets were incomplete.A current facility policy, dated 11/2012 and revised on 11/2017, titled Narcotic/Controlled Substances- Counting, provided by the Administrator, on 4/21/26 at 3:30 p.m., indicated the following: .Always participate in counting of the controlled substances at the beginning and ending of your shift. 16. Sign name, time and date of completed count 410 IAC (Indiana Administrative Code) 16.2-3.1- 25(b)(3)

Based on interview and record review, the facility failed to ensure non-pharmacological interventions were developed and implemented for a resident prior to ordering an antipsychotic medication for insomnia for 1 of 5 residents reviewed for unnecessary medications. (Resident 3) Finding includes:Resident 3's clinical record was reviewed on 4/17/26 at 10:45 a.m. Diagnoses included post-traumatic stress disorder, bipolar disorder, anxiety disorder, and depression. Orders included amitriptyline (antidepressant) 50 mg at bedtime for depression (3/20/26 -4/6/26), amitriptyline 50 mg at bedtime related to post-traumatic stress disorder (PTSD), bipolar disorder, anxiety disorder, and depression (4/10/26), trazodone (antidepressant) 50 mg at bedtime for insomnia related to depression and insomnia (3/20/26 - 4/6/26), trazodone (antidepressant) 50 mg at bedtime for insomnia (4/10/26), quetiapine (antipsychotic) 25 mg every 24 hours as needed (PRN) for insomnia related to bipolar disorder, anxiety disorder, and depression for 14 days (3/20/26 - 4/3/26), and quetiapine 25 mg every 24 hours PRN for insomnia (4/9/26). A 2/14/26, admission, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. She indicated she had trouble falling or staying asleep for 7-11 days of the 14 days assessment period. No behaviors were marked. She indicated she had frequent moderate pain that occasionally affected sleep. She received insulin, antidepressant, anticoagulant, antibiotic, diuretic, opioid, hypoglycemic, and antiplatelet medications. A 3/25/26, significant change, MDS assessment indicated the resident was cognitively intact. She indicated she had trouble falling or staying asleep for 7-11 days of the 14 days assessment period. No behaviors were marked. She indicated she had frequent moderate pain that occasionally affected sleep. She received insulin, antidepressant, anticoagulant, antibiotic, diuretic, opioid, hypoglycemic, and antiplatelet medications. A current care plan, dated 2/11/26, indicated the resident had episodes of insomnia. Interventions included administer medications per order (2/11/26) and monitor causes for insomnia: medications, caffeine, over stimulation, depression, and anxiety (2/11/26). The clinical record lacked individualized identification of the resident's insomnia symptoms related to bipolar disorder and did not indicate non-pharmacological interventions to be implemented prior to administration of additional medications. A current care plan, dated 2/11/26, indicated the resident was at risk for mood fluctuation related to anxiety disorder, bipolar disorder, depression, and PTSD. Interventions included administer medications per order and monitor/document for side effects (2/11/26) and observe for signs and symptoms of mania or hypomania racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, and agitation or hyperactivity (2/11/26). A progress note, dated 3/20/26 at 3:30 p.m., indicated the resident had returned from the hospital. Discharge orders from the hospital on 3/20/26 included the order for quetiapine 25 mg at bedtime daily for insomnia. A progress note, dated 3/23/26 at 5:48 p.m., indicated the resident was seen by the nurse practitioner (NP) for readmission. She indicated the resident received trazodone 50 mg at bedtime for insomnia and quetiapine 25 mg every 24 hours as needed for insomnia for 14 days at bedtime. A progress note, dated 3/25/26 at 9:36 a.m., for date of service 3/24/26, indicated the resident was seen by the physician for readmission. The physician indicated the resident continued to have frequent pain management. The resident was crying because of being in pain. The resident stated her pain medicine adequately controlled her pain for now. Medications were reviewed. A progress note, dated 3/27/26 at 8:32 a.m., indicated the resident was seen by the NP for reports of left wrist pain from a recent bruise. The resident stated her pain was not well controlled and requested a pain medication increase. The plan indicated the oxycodone-acetaminophen dosage was increased from 5 mg/ 325 mg to 7.5 mg/325 mg every 6 hour as needed for pain for 48 hours then resume 5 mg/ 325 mg dosage. A progress note, dated 4/9/26 at 10:10 p.m., indicated the resident arrived at the facility from the hospital at 10:02 p.m. A progress note, dated 4/10/26 at 5:01 p.m., indicated the resident was seen by the NP for readmission. The resident denied pain or discomfort. She indicated the resident received quetiapine 25 mg as needed for insomnia at bedtime and trazodone 50 mg at bedtime for insomnia. The clinical record lacked indication of the resident's exhibition of behaviors related to bipolar disorder. A review of the medication administration record for March 2026 and April 2026 indicated the resident did not take the as needed quetiapine. A review of the pharmacy recommendations on 4/10/26 indicated the pharmacist recommended adding a stop date not exceeding 14 days from the start of therapy to the quetiapine 25 mg every 24 hours PRN. The NP indicated, on 4/20/26, to discontinue the quetiapine if not used. During an interview, on 4/20/26 at 2:32 p.m., the ADON indicated the resident had an order for the PRN quetiapine upon return from the hospital on 3/20/26 and 4/9/26. She had asked the NP to review the order. The NP had decided to keep the order. During an interview, on 4/20/26 at 4:02 p.m., NP 20 indicated the quetiapine was appropriate for 14 days as the resident had used it in the hospital while in the intensive care unit and on the medical unit. The quetiapine was a typical medication used in the hospital for insomnia. If the resident had used the medication, she would have referred the resident to the psychiatric health provider. During an interview, on 4/22/26 at 11:27 a.m., LPN 17 indicated the resident got antsy if she did not get medications when she asked for them immediately even when the medications were not yet due and if the resident felt her call light was not answered immediately. The resident sometimes said no one had been in her room for hours, but LPN 17 indicated she knew that statement was not true because she herself had been in resident's room earlier to deliver breakfast, to get her blood sugar, and to discuss when her medications were due. The resident seemed to calm when LPN 17 listened and conversed with her. LPN 17 did not remember the resident having any difficulties with sleeping. The resident took amitriptyline for her bipolar disorder. Since the resident's oxycodone was scheduled every four hours, the resident does not complain of pain anymore. During an interview, on 4/22/26 at 11:32 a.m., QMA 21 indicated she had never heard of the resident having trouble sleeping at night. The resident had been very friendly lately. The resident enjoyed interaction with others. QMA 21 had never seen the resident have any behaviors. During an interview, on 4/22/26 at 11:57 a.m., CNA 10 indicated the resident had not had any behaviors lately. The behavior she had seen in the past were the resident would wake up angry and be unpleasant. Before the resident's first stay in the hospital, the resident occasionally had difficulty with sleeping, but since then she had no problems with sleeping. During an interview, on 4/22/26 at 12:09 p.m., the DON indicated the resident had started the quetiapine in the hospital. She and NP 20 had discussed the quetiapine order. NP 20 indicated the resident had issues in the hospital and wanted to keep the quetiapine order in case the resident had those issues at the facility. NP 20 discontinued the quetiapine on 4/20/26. According to the FDA website, accessed on 4/21/26 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/020639s074lbl.pdf,Indications for usage of quetiapine are schizophrenia, bipolar I disorder with manic episodes, and bipolar disorder, depressive episodes. The indications did not include insomnia. A current facility policy, revised 2/1/18, titled Psychotropic Medication - Gradual Dosage Reduction, provided by the Administrator on 4/21/26 at 3:29 p.m., indicated the following Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standard of practice. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions when food was handled with bare hands during a meal service observation. Findings include: During a lunch service observation, on 4/17/26 at 12:37 p.m., the following was observed:Cook 16 picked up a roll with her bare hands before placing it on a resident's plate. [NAME] 16 grabbed a single scoop of mashed potatoes and place them on the food portion of the plate. A ping pong ball - size of mashed potatoes fell off the scoop and onto the handle of the stainless-steel pan. [NAME] 16 scooped up the mashed potatoes from the pan's handle with her bare hand before tossing it back into the pan of mashed potatoes.Cook 16 plated three rolls for three plates with her bare hand before using tongs.During an interview, on 4/17/26 at 1:16 p.m., [NAME] 16 indicated she could have slipped up and touched a piece of bread with her bare hands. She did not recall touching the mashed potatoes with her bare hands. Staff should not touch food with their bare hands.During an interview, on 4/17/26 at 1:19 p.m., the Dietary Manager indicated staff members should not touch food with their bare hands. During an interview, on 4/21/26 at 2:25 p.m., the DON indicated staff should not touch food with their bare hands.A current facility policy, dated 2009, titled Safe Food Preparation and Handling, provided by the Administrator on 4/21/26 at 3:30 p.m., indicated the following: .1. Strict personal hygiene will be followed. Employees will avoid direct contact (i.e.) using bare hands) with ready-to-eat foods. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on interview and record review, the facility failed to identify the risk for the development of wounds and failed to develop and implement interventions to prevent wounds for 1 of 3 residents reviewed for wounds. (Resident B) This deficient practice resulted in the resident requiring hospitalization and surgical intervention to treat a severely infected diabetic ulcer to their foot.Findings include:An anonymous report submitted to the Indiana Department of Health indicated Resident B had developed a wound to his foot the facility failed to notice and then had blamed the resident of causing it by using nail clippers to cut his skin.Resident B's clinical record was reviewed on 2/25/26 at 9:44 a.m.A nurse practitioner progress note, dated 2/16/26, for a follow up related to a urinary tract infection indicated the resident's family member approached the nurse's station demanding that someone examine the resident's left foot. The nurse practitioner and the facility nurse entered the resident's room and noted a wound to the bottom of the resident's left foot. His left forefoot had a circular necrotic hard, firm, wound with pink granular tissue and peeling skin, measuring 5 centimeters (cm) length by 4.5 cm width with no depth. A second area of darkened skin was noted along his heel. A third area on his left third toe had a darkened area along nail. A fourth area with darkened skin along the lateral nail and the dorsal foot was erythemic (red in color), cool to touch and non-tender. A duplex scan (ultrasound study) of the venous systems of his left lower extremities was completed on 2/16/26 due to swelling. The impression indicated that there was no evidence of deep venous thrombosis (blood clots). The nurse practitioner's plan was to obtain a STAT (immediate) x-ray of his left foot to rule out osteomyelitis and a STAT complete blood count (CBC) lab, and wound care per facility policy. The resident was observed sitting up in wheelchair after the treatment of his foot was completed, and he used his barefoot to propel himself in his wheelchair. He was educated to attempt to not utilize bare feet to move his wheelchair. The nurse practitioner assisted the resident with putting socks on and requested a protective boot to be placed. The duplex scan results were normal and without evidence of deep venous thrombosis. A nurse's note, dated 2/16/26 at 1:55 p.m., indicated the nurse practitioner saw the resident related to edema (swelling) and an abrasion (top layer of skin rubbed off) to his left foot. New orders were received for STAT CBC, x-ray to his left foot, doppler to left extremity, midline (intravenous line) to be placed for IV antibiotic STAT, discontinue Macrobid (antibiotic) and start Zosyn. A left heel wound assessment, dated 2/16/26, indicated he had a facility acquired abrasion that was 100% necrotic (darkened, dead tissue) area that measured 2 cm length by 1.5 cm width with no depth. A new order was received to apply skin protectant every shift. A left plantar (bottom of) foot wound assessment, dated 2/16/26, indicated he had a facility acquired abrasion that had 40% pink or red non-granulating tissue with 60% hard, firm adherent necrotic tissue that measured 5 cm length by 4.5 cm width with no depth. It appeared that the resident had been picking at the wound and cutting the surrounding tissue. A new order was received to paint the wound with povidone iodine and cover with a foam border daily. A physician's progress note, dated 2/17/26, indicated the resident was seen related to a foot wound with concerns for osteomyelitis. The x-ray results showed soft tissue swelling and bone irregularity in his great toe. He had a prior fourth and fifth toe amputation. The physician's plan was to have a Magnetic Resonance Imaging (MRI) completed to rule out osteomyelitis and a prior authorization from insurance was pending. The resident would be started on vancomycin and Zosyn for presumed osteomyelitis while awaiting MRI approval.A nurse practitioner progress note, dated 2/18/26, indicated the resident was seen for a follow up visit related to possible osteomyelitis. He was observed sitting up in his room in his wheelchair using his foot to move wheelchair and was not wearing his heel boot as ordered. He was started on IV Zosyn (antibiotic) and vancomycin and reported hearing loss. Per nursing, he was not compliant with wearing the boot and was observed propelling wheelchair with his affected foot. The nurse practitioner's plan was a pending MRI to rule out osteomyelitis. The resident was offered to go to the hospital for an evaluation and treatment, which the resident adamantly refused. Vancomycin was discontinued and Zyvox 600 mg IV every 12 hours for 14 days was added. After the assessment and discussion with the resident regarding hospitalization, his family arrived demanding that the resident to be sent to the emergency room (ER) for evaluation.The hospital's operative procedure notes, dated 2/19/26, indicated that an incision was performed on the left foot and drainage of an abscess (painful, inflamed pocket of pus) in deep tissue, abscess surrounding the tendon (connective tissue) and septic arthritis (severe joint infection), second Metatarsophalangeal Joint (a joint in the foot).During an interview, on 2/25/26 at 4:02 p.m., LPN 13 indicated Resident B's family member reported there was an area on the bottom of the resident's left foot, approximately the size of a tennis ball and a DTI to his heel. The area had black, hard, necrotic tissue and looked like the thick skin that once covered the necrotic area was torn, cut, or peeled back with either scissors or nail clippers. Resident B did not complain of pain, but there was edema to his lower extremities. LPN 13 had not seen Resident B with scissors or nail clippers. He was very mobile and used a wheelchair for mobility. He was able to transfer from his bed to his wheelchair with assistance. He wore socks, shoes, non-skid socks, or slippers. He was able to apply his shoes himself.During an interview, on 2/26/26 at 1:47 p.m., Nurse Practitioner 8 indicated, on 2/16/26, Resident B's family member approached the nurse's station and reported that something was wrong with Resident B's leg. When Nurse Practitioner 8 entered Resident B's room, his sock was off and it looked like the wound had been trimmed. Previously, the resident had picked at various scabs, but she had never witnessed him having scissors or nail clippers. He normally wore gripper socks and propelled himself with his feet, not his hands on the wheels. Nurse Practitioner 8 ordered Resident B an antibiotic, an ultrasound for his leg to rule out a deep vein thrombosis (DVT) (blood clot), an x-ray of his foot, and labs. He was offered to be sent to the hospital earlier in the day on 2/18/26 and he did not want to go. Later that day, the facility called her and the family of Resident B demanded for the resident to be sent to the hospital. Nurse Practitioner 8 sent him out due to needing an MRI for his foot and his family demanding him to go.During an interview on 2/26/26 at 3:04 p.m. CNA 5 indicated Resident B, at times, was able to put on socks and shoes. She assisted him with washing his body in the shower, but he was able to wash his private areas. He refused to shower on 2/13/26. She looked at his feet and there were no concerns, no redness, and only a scab where his toe used to be. There was nothing on the ball of his foot and no bruising or redness. Review of Resident B's clinical record indicated diagnoses included vascular dementia, hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right non-dominant side, dependence on supplemental oxygen, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, chronic respiratory failure, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD), other idiopathic peripheral autonomic neuropathy, acquired absence of other right toe(s), and acquired absence of other left toe(s). An 11/15/25, quarterly, Minimum Data Set (MDS) assessment indicated he was cognitively intact. He was at risk for the development of pressure ulcers and he had pressure reducing devices to his chair and bed. Current physician's orders included sugar free oral supplement (nutritional supplement to promote wound healing) 30 milliliters (ml) twice daily for wound care, vancomycin (antibiotic) intravenously (IV) 1000 mg (milligram)/200 ml every 12 hours for osteomyelitis (bone infection), Zyvox (antibiotic) IV 600 mg/300 ml every six hours for osteomyelitis for 14 days, Magnetic Resonance Imaging (MRI) with contrast of left foot one time only for osteomyelitis, and skin protectant to left heel every shift for wound care.Current care plans included the following:Potential for skin impairment (initiated on 4/9/22) related to vascular dementia, dependence on supplemental oxygen, major depressive disorder, gout, anemia, muscle spasms, hemiplegia and hemiparesis, diabetes mellitus, convulsions, absence of left and right toes, benign prostatic hyperplasia, morbid obesity, obstructive and reflux uropathy, and being noncompliant with care. Interventions included minimize pressure over boney prominences (4/11/22).Non-compliant/resistive to care (initiated on 2/1/24) for refusing mediations, oxygen therapy, shower/bed baths, and oral supplement.The clinical record lacked indication the resident picked at his skin or used implements to cut his skin or wounds.A Braden Scale assessment (predicts pressure injury), dated 1/10/26, indicated that he was not at risk for developing pressure injuries. A Weekly Skin Observation note, dated 2/7/26 at 1:58 a.m., indicated his skin was warm, dry, and intact and within normal limits with good skin turgor. No foot concerns were noted. A functional abilities progress note, dated 2/13/26, indicated he required partial to moderate assistance with bathing, lower body dressing and putting on and taking off footwear. A shower sheet document, dated 2/13/26, indicated that he refused his shower because he did not feel good and a full body check was completed. A nurse's note, dated 2/13/26 at 4:55 p.m., indicated that he wasn't feeling well enough to shower and signed a refusal of shower form.A late entry weekly skin observation note, dated 2/14/26 at 11:40 p.m. and written on 2/19/26 at 6:41 p.m., indicated his skin was warm, dry, flaky and within normal limits. He refused his shower and the skin assessment with the shower, so his feet were not assessed. He had calloused areas to his feet prior to this date.A current facility policy, titled Pressure Injury and Skin Condition Assessment, and provided by the DON on 2/26/26 at 3:11 p.m. indicated the following: .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.This citation relates to Intake 2749190. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to develop and implement individualized interventions to mitigate the risk of pressure injuries for a resident experiencing decreased mobility while recovering from a hip fracture for 1 of 3 residents reviewed for pressure injuries. (Resident E)Findings include:Resident E's clinical record was reviewed on 2/26/26 at 8:56 a.m. Diagnoses included chronic combined systolic (congestive) and diastolic (congestive) heart failure, end stage renal disease, dependence on renal dialysis, presence of automatic (implantable) cardiac defibrillator, encounter for other orthopedic aftercare, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, muscle wasting and atrophy, not elsewhere classified, multiple sites, and other abnormalities of gait and mobility.Current physician's orders included sugar free nutritional supplement (promotes wound healing) 30 milliliters (ml) twice daily, nutritional supplement three times daily, dialysis friendly nutritional supplement three times daily if he did not consume meals, and skin protectant every shift.A 1/27/26 admission Minimum Data Set (MDS) assessment indicated he was cognitively intact. He was at risk of developing pressure ulcers/injuries. He had a surgical wound. And he had pressure-reducing devices for his chair and bed. He had an impairment to one side of his lower extremities. He used a manual wheelchair for mobility.A current care plan indicated the potential for skin impairment (initiated on 1/25/26) related to an encounter for other orthopedic aftercare, displaced intertrochanteric fracture of right femur, abnormalities of gait and mobility, muscle wasting and atrophy. Interventions included minimize pressure over boney prominences (1/25/26).The clinical record lacked individualized interventions to prevent or mitigate the risk of pressure injuries.A shower sheet, dated 2/5/26, indicated he received a shower and a full body check was completed.A weekly skin observation note, dated 2/6/26 at 3:10 a.m., indicated his skin was warm and dry with good skin turgor. He had a right trochanter (hip) surgical incision with staples removed and wound closure strips were intact. It was noted that there were no foot concerns.A Braden Scale assessment (for pressure injury risk), dated 2/6/26, indicated he was at risk for developing pressure injuries.A shower sheet dated 2/9/26 indicated he received a shower. The form lacked documentation of a skin check.A weekly skin observation, dated 2/13/26 at 1:50 a.m., indicated an open lesion was observed on the resident's foot, a small open area to the back of his right heel. A treatment was in place. The skin concerns observed to his feet were not new.A facility acquired ulceration wound assessment, dated 2/23/26, indicated he had a DTI (serious type of pressure injury with dark, purple or maroon skin or intact blood-filled blister) to his right heel that was identified on 2/9/26. The DTI was 100% necrotic (darkened, dead tissue), hard, and measured 6 cm length by 6 cm width (the size of a large egg), with no depth. During an interview, on 2/26/26 at 12:14 p.m., the ADON indicated Resident E's DTI was initially reported by the therapy department. Therapy asked the ADON to look at it and it was an obvious DTI. On admission, Resident E had a surgical incision, which was on the same side of his body as the DTI. The resident did not have pressure relief boots implemented when the DTI was noticed. The facility standards were to turn and reposition the residents every two hours and as needed, float (raise) heels, and offload prominent areas. CNAs completed shower sheets, reported excoriation or redness, the nurse assessed the resident, and reported to the ADON. The nurses were responsible for completing weekly skin assessments.During an interview, on 2/26/26 at 3:43 p.m., Physical Therapist 5 indicated she was applying socks to Resident E's feet and noticed an area on his right heel. She compared his heels and reported it to the nurse.A current facility policy, titled Pressure Injury and Skin Condition Assessment, and provided by the DON on 2/26/26 at 3:11 p.m. indicated the following: .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.A current facility policy, titled Pressure Injury Prevention, and provided by the DON on 2/26/26 at 3:11 p.m. indicated the following: .Guidelines.2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures.11. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated.This citation relates to Intake 27491090. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from verbal abuse and intimidation by a staff member for 1 of 3 residents reviewed for abuse. (Resident C)Findings include:Resident C's clinical record was reviewed on 9/29/25 at 12:10 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, depression, atrial fibrillation, and congestive heart failure.An admission Minimum Data Set (MDS) assessment, dated 8/4/25, indicated Resident C was cognitively intact, had depression, required supervision for bed mobility, transfers, toileting, and eating. Resident C did not exhibit hallucinations, delusions, or behaviors.A current care plan, initiated on 7/30/25, indicated Resident C had a diagnosis of depression. Interventions included administering medications as ordered, encouraging socialization, and observing signs and symptoms of depression (crying, seclusion from others, isolation, decreased appetite, withdrawal).A current care plan, initiated on 9/22/25, indicated Resident C used antidepressant medication related to diagnoses of anxiety and depression. Interventions included administering medications as ordered and monitoring for side effects and effectiveness every shift, educating the resident/family/caregivers about the risks, benefits, and side effects of medications, and monitoring/documenting/reporting, as needed, adverse reactions to antidepressant therapy.A progress note, dated 9/26/25 at 1:56 p.m., indicated the Social Services Director (SSD) spoke with Resident C about the situation that occurred in the dining room. The SSD conducted a psychosocial assessment along with an abuse/neglect screening. Psychological services were scheduled to follow up with the resident on 10/1/25.Review of a facility - reported incident indicated, on 9/25/25, Resident C, was attempting to get a drink in the dining room, and was approached by Dietary Aide (DA) 3, who informed Resident C he was not allowed to get his own drink from the drink cart. An exchange of words between Resident C and DA 3 ensued and ended with DA 3 telling the resident he would knock his dumb f****ing a** out. The resident was removed from the situation, and the incident was reported to the Dietary Manager (DM).A written statement by DA 3, signed and dated 9/25/25, provided by the Administrator (ADM) on 9/29/25 at 12:30 p.m., indicated upon service to residents in the dining room, a particular resident, Resident C, approached the cooking area and began serving himself. DA 3 told the resident that he wasn't allowed to do so, and the resident began ranting at him. DA 3 may have responded in an unprofessional manner.During an interview with the Dietary Manager (DM) on 9/29/25 at 2:17 p.m., he indicated he had just arrived at the facility when DA 3 approached him about the incident. DA 3 described how Resident C was behind the counter getting himself a drink. DA 3 approached the resident and told him he could not be back there. The conversation escalated into a back-and-forth confrontation. The DM wrote up DA 3 and went to Human Resources (HR) to report the incident. The DM indicated other staff were present when the altercation took place, but nobody heard what was said. During an interview with [NAME] 2 on 9/30/25 at 10:22 a.m., he indicated he heard DA 3 talking to himself at the service window and could tell DA 3 was mad about something. [NAME] 2 was not paying attention to Resident C at that time. Later in the day, DA 3 told [NAME] 2 about Resident C getting his own drinks and passing coffee out to other residents. DA 3 just wanted to do his job.During an interview with Resident C on 9/30/25 at 10:07 a.m., he indicated DA 3 said he would knock me out. There were residents and other dietary staff present at the time of the incident. DA 3 started running his mouth and told Resident C if he did not quit talking, he was going to knock him out. Resident C walked away, but DA 3 followed him and continued to threaten him. That was not the first time DA 3 was disrespectful to Resident C.During an interview with DA 3 on 9/30/25 at 11:36 a.m., he indicated Resident C became unruly during breakfast service. He cut into the line and got his own drink. DA 3 had told him several times previously he was not allowed behind the service line. DA 3 felt Resident C was being disrespectful to the dietary staff. DA 3 indicated he might have been a little loud when addressing Resident C. He reported the incident to the DM and was suspended pending an investigation. He was later terminated. He felt Resident C's statement was respected over his own statement regarding the incident.During an interview with the Administrator on 9/30/25 at 11:55 a.m., she indicated Resident C said DA 3 cursed at him, saying I'll knock your f***ing a** out. DA 3 indicated to both the Administrator and the DM Yeah, I probably did say that. Resident C did not have a history of being dishonest. DA 3 indicated he yelled at Resident C the day before when passing him outside, in front of the facility. DA 3 and Resident C had a history outside of the facility, prior to either being affiliated with the facility.During an interview with the DM on 9/30/25 at 12:17 p.m., he indicated DA 3 was waiting in the back parking lot the morning of the incident. DA 3 asked Resident C to not get his own drinks on other occasions. None of the dietary staff saw or heard the incident.A current facility policy, titled Abuse Prevention Policy, provided by the Administrator on 9/29/25 at 11:09 a.m., indicated the following: .The abuse, neglect, or other mistreatment of residents in (facility), physically, mentally, or emotionally, is unlawful and is prohibited. Any employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Administrator or Department head. The Administrator or Department head will report abuse to the state agency per state and federal requirements.a. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.1. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of harm, saying things to frighten a resident.3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure physician orders for blood pressure and heart rate parameters were followed when medications were administered for 2 of 3 residents reviewed for blood pressure medications. (Resident B and Resident D) Findings include: 1. Resident D's clinical record was reviewed on 9/9/25 at 11:11 a.m. Diagnoses included essential hypertension, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery (plaque buildup in the artery) with unspecified angina pectoris (severe chest pain), and heart failure, unspecified. Physician orders included metoprolol tartrate (for blood pressure) 50 milligrams (mg) two times a day - hold for systolic blood pressure (SBP) less than 100 either/or heart rate (HR) less than 60 (started 4/16/25 and discontinued 8/9/25), metoprolol tartrate 50 mg two times a day - hold if SBP less than 100 or HR less than 50 (started 8/9/25), losartan potassium (for blood pressure) 100 mg daily - hold for SBP less than 110 or diastolic blood pressure (DBP) less than 60 (started 6/8/24), amlodipine besylate (for blood pressure) 10 mg daily - hold for SBP less than 100 or HR less than 60 (started 4/17/25), and hydralazine (for blood pressure) 25 mg every six hours as needed for SBP greater than 150 - administer one hour after routine blood pressure medication if SBP remains greater than 150 (started 12/5/24). An Annual Minimum Data Set (MDS) assessment, dated 5/22/25, indicated the resident was cognitively intact. The resident rejected care daily. He received opioid, diuretic, and antidepressant medications. A care plan for coronary artery disease related to lifestyle choices and smoking was initiated 5/22/24. Interventions included the following: Give all cardiac medications as ordered by the physician. Monitor and document side effect. Report adverse reactions to the physician as needed (5/22/24), Give medications for hypertension and document response to medication and any side effects (5/22/24), and Monitor blood pressure. Notify physician of any abnormal readings (5/22/24). A care plan for hypertension related to lifestyle choices and smoking was initiated on 5/22/24. Interventions included the following: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness (5/22/24) and Medications as ordered (5/22/24). A current medication administration record for September 2025 indicated the following: On 9/1/25 at 7:00 a.m., the resident's heart rate was 47, and his blood pressure was 118/53. The resident received amlodipine besylate 10 mg, metoprolol tartrate 50 mg, and losartan potassium 100 mg. The resident's heart rate and/or blood pressure were not within the ordered parameters. On 9/3/25 at 7:00 a.m., the resident's heart rate was 48. The resident received amlodipine besylate 10 mg and metoprolol tartrate 50 mg. The resident's heart rate was not within the ordered parameters. On 9/5/25 at 8:00 p.m., the resident's blood pressure was 96/53. The resident received metoprolol tartrate 50 mg. The resident's blood pressure was not within the ordered parameters. On 9/6/25 at 7:00 a.m., the resident's heart rate was 50, and his blood pressure was 93/49. The resident received amlodipine besylate 10 mg, metoprolol tartrate 50 mg, and losartan potassium 100 mg. The resident's blood pressure and/or heart rate were not within the ordered parameters. On 9/9/25 at 7:00 a.m., the resident's heart rate was 54. The resident received amlodipine besylate 10 mg. The resident's heart rate was not within the ordered parameters. During an interview, on 9/9/25 at 3:41 p.m., RN 3 indicated when a medication had blood pressure and heart rate parameters, she obtained the blood pressure and heart rate. She administered the medication if the blood pressure and heart rate met the parameters. If the medication order was unclear, she would call the physician to get further instructions. 2. Resident B's clinical record was reviewed on 9/9/25 at 12:20 p.m. Diagnoses included atherosclerotic heart disease of native coronary artery with unstable angina pectoris, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, and essential (primary) hypertension. Physician orders included midodrine 5 mg every eight hours as needed (PRN) for hypotension (low blood pressure) - administer for systolic blood pressure (SBP) less than 90 (started 3/17/25) and blood pressure monitoring three times a day for hypotension - administer PRN midodrine 5 mg for SBP less than 90. An annual Minimum Data Set (MDS) assessment, dated 8/2/25, indicated the resident was moderately cognitively impaired. No behaviors were marked. A care plan for coronary artery disease was initiated on 1/28/24. Interventions included give medications for hypertension and document response to medication and any side effects (1/28/24) and monitor blood pressure and notify physician of any abnormal readings (1/28/24). A medication administration record (MAR) for July 2025 indicated the following: On 7/1/25 at 3:00 p.m., the resident's blood pressure was 88/54. The MAR lacked an entry for the administration of midodrine on 7/1/25. On 7/11/25 at 7:00 a.m., the resident's blood pressure was 83/49. The MAR lacked an entry for the administration of midodrine on 7/11/25. On 7/19/25 at 7:00 a.m., the resident's blood pressure was 88/61. The MAR lacked an entry for the administration of midodrine on 7/19/25. On 7/24/25 at 7:00 a.m., the resident's blood pressure was 73/41. On 7/24/25 at 3:00 p.m., the resident's blood pressure was 86/54. The MAR lacked an entry for the administration of midodrine on 7/24/25. On 8/1/25 at 7:00 a.m., the resident's blood pressure was 88/57. The MAR lacked an entry for the administration of midodrine on 8/1/25. On 9/8/25 at 7:00 p.m., the resident's blood pressure was 86/54. The MAR lacked an entry for the administration of midodrine on 9/8/25. During an interview on 9/9/25 at 3:47 p.m., LPN 4 indicated when a medication required a blood pressure or heart rate to be a certain number, she obtained the blood pressure and/or heart rate and administered or held the medication as ordered. If she had questions, she notified the nurse practitioner to get more clarification. During an interview on 9/9/25 at 3:59 p.m., LPN 5 indicated, for medications that required blood pressure or heart rate monitoring, she obtained the blood pressure and heart rate and administered the medication if the readings met the ordered parameters. If the readings did not meet the parameters, then she held the medication as ordered. For any discrepancies in the order, she called the physician. It was important to pay attention to the orders. During an interview, on 9/9/25 at 4:11 p.m., the Director of Nursing (DON) indicated the staff should be following the parameters on medication orders. Multiple physicians provided care for Resident D, thus his medications had different parameters. During an interview, on 9/9/25 at 4:58 p.m., the DON indicated the physician orders should have been followed, and the medications should have been given or held according to the blood pressure and/or heart rate parameters. During an interview, on 9/9/25 at 5:01 p.m., the Administrator indicated the facility did not have a policy on following physician orders. The facility followed Federal and State guidelines. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to identify and ensure the resident environment remained free of potential hazards for 2 of 4 residents reviewed for smoking. (Resident B, Resident E)Findings include:1.During an observation, on 7/16/25 at 12:14 p.m., Resident B held her cigarettes and lighter as she walked away from the designated smoking area. Resident B indicated she smoked independently and she was headed back to her room to store her cigarettes and smoking supplies. Resident B's clinical record was reviewed on 7/17/25 at 1:44 p.m. Diagnoses included hypertension (high blood pressure), chronic obstructive pulmonary disease (progressive lung disease that makes it hard to breathe), depression, and anxiety.An admission Minimum Data Set (MDS) assessment, dated 5/1/25, indicated Resident B was cognitively intact.Resident B's clinical record lacked an order for smoking.A smoking safety risk assessment, dated 4/28/25, indicated Resident B smoked daily and used cigarettes and a lighter. She did not have a history or currently present with unsafe storage of materials. The portion of the assessment that identified all smoking materials would be locked in the facility's designated area was not complete. The assessment indicated a smoking care plan was in place.Resident B's clinical record lacked a smoking care plan.2.During an interview, on 7/17/25 at 10:15 a.m., Resident E indicated she vaped and pulled a red vape out of a black bag that was lying in bed next to her.Resident E's clinical record was reviewed on 7/17/25 at 1:44 p.m. Diagnoses included cerebral infarction (stroke), chronic obstructive pulmonary disease, and the need for assistance with personal care.A current order for Resident E indicated she could smoke as indicated for psychosocial and physical/medical necessity related to nicotine addiction (1/25/24).A quarterly Minimum Data Set assessment, dated 5/2/25, indicated Resident E had moderate cognitive impairment. She required supervision or touching assistance with eating. She required substantial/maximal assistance with oral hygiene, rolling left to right, and wheeling her wheelchair 50 feet. She was dependent for toileting, upper and lower body dressing, sitting to lying, lying to sitting, sit to stand, and chair/bed to chair transfers.Resident E's clinical record lacked a smoking care plan.A physician's progress note, dated 7/2/25, indicated Resident E was a current, some days, smoker and the tobacco type was vaping/e-cigarettes.A smoking safety risk assessment, dated 4/23/25, indicated Resident E did not currently smoke or use an electronic smoking device and she was not able to get to the designated area for smoking independently. All other questions on the assessment were unanswered.Resident E's electronic record contained her admission agreement. The agreement included a Resident and Visitor Smoking Policy Notification, which indicated there would be no smoking in any patient rooms and the authorized smoking area was the fire pit area.During an interview, on 7/17/25 at 2:54 p.m., LPN 2 indicated Resident E had a history of vaping and had not attended the supervised smoking breaks for two months. No residents were permitted to have smoking materials in their rooms.During an interview, on 7/17/25 at 3:20 p.m., Resident E indicated her family supplied her vaping devices. She vaped in her room, but not recently. She was aware it was against the rules.During an interview, on 7/17/25 at 3:54 p.m., the ADON indicated all smoking items and supplies for skilled nursing residents were kept at the front reception desk. No skilled nursing residents were permitted to keep smoking supplies in their rooms.A skilled nursing resident list of dependent and independent smokers, provided by the ADON on 7/16/25 at 10:46 AM, did not include Resident E. Resident B was identified as an independent smoker.A current policy titled Smoking Policy Acknowledgement Aperion Care Marion, undated, provided by the ADON on 7/16/25 at 10:46 a.m. indicated the following: .all residents are required to turn in all smoking materials to staff This citation relates to Complaint 1453272.3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure the Dietary Manager completed the required education to meet the qualifications for a dietary manager. This deficiency had the potential to impact 58 of 58 facility residents who received meals from the facility kitchen. Finding includes: The employee record form, completed by the facility and provided following entrance conference on 4/27/25, indicated the Dietary Manager had been employed by the facility since 2/1/25 and lacked a dietary manager certification. During an interview, on 4/30/25 at 3:00 p.m., the Dietary Manager indicated he was in the process of getting his food manager certification. During an interview, on 5/1/25 at 11:59 a.m., the Nurse Consultant indicated the Dietary Manager did not have any food service manager certifications. During an interview, on 5/1/25 at 3:08 p.m., the Dietary Manager indicated he had twenty years of food service experience but was not technically a dietary manager until he started at the facility. He was not currently certified but was getting ready to take the examination to be certified. The Corporate Dietary Consultant came to the facility about every two weeks. He had seen the dietician once since he had started the position in February 2025. He stayed in contact with the dietician through emails and phone as needed. A current dietary manager job description, signed by the Dietary Manager on 2/1/25, provided by the Administrator on 5/1/25 at 4:51 p.m., indicated the following: .Must be possess Food Service Sanitation Manager Certification 3.1-20(e)

Based on observation and interview, the facility failed to ensure food was prepared and served under safe sanitary conditions regarding food handling and hand washing. This deficient practice had the potential to affect 55 of 55 residents who received their meals from the kitchen. Findings include: During a lunch service observation, on 04/29/25 12:30 p.m. to 1:15 p.m., the following food handling and food service concerns were observed: Dietary Employee 7 (DE 7) propelled a resident forward in her wheelchair and locked the wheelchair brake. She did not perform hand hygiene before touching a set of tongs to place a lemon slice into a drink. She then touched the back of another female staff member before she lifted a container of lemon slices, with her left thumb touching the inside of the lemon slice container. Dietary Employee 8 (DE 8) grabbed a hot dog bun with his bare hands, place it on a plate, and opened it. No hand hygiene was performed. DE 8 crossed his ungloved hands, placing his hands on his waist and lower back. He went through meal tickets one by one like he was dealing cards. He scratched his left nostril with his left index finger. He then grabbed a plate, and his left thumb touched the food portion of the plate. No hand hygiene was performed. DE 8 grabbed two hot dog buns and a hamburger bun with his bare hands. He used his hands to open the hot dog/ hamburger bun on the plate. No hand hygiene was performed. DE 8's left thumb kept touching the food portion of the plate while he plated food. During an interview, on 4/29/25 at 1:20 p.m., DE 7 indicated she did not reposition a resident's wheelchair, but she did lock their brake. During an interview, on 4/29/25 at 1:24 p.m., DE 8 indicated he touched the buns with his bare hands. He also touched his hips and shirt with his bare hands. During an interview, on 4/30/25 at 3:00 p.m., the Dietary Manager indicated staff should not touch buns with their bare hands. The dietary employees should not touch any part of their clothing, glasses, or face without performing hand hygiene. 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure mail was distributed to the residents on Saturdays. This deficiency had the potential to affect 58 of 58 residents who resided in the facility. Findings include: During a Resident Council meeting, on 4/30/25 beginning at 3:35 p.m., Resident 40 indicated the facility did not deliver mail to the residents on Saturdays. The activity department staff was to deliver mail after the business office manager sorted it. The business office manager did not work weekends. Residents 41, 45, 58, 10, 28, 51, 2, 33, and 25 indicated they did not receive mail on Saturdays. During an interview, on 5/1/25 at 10:06 a.m., the Activity Director (AD) indicated the activity department delivered mail to the residents. Mail was distributed on the days that the Business Office Manager /Financial Coordinator (BOM) was at the facility. The BOM received and sorted the mail and placed it on the front desk when it was ready for distribution to the residents. During an interview, on 5/1/25 at 10:14 a.m., the BOM indicated that she sorted the facility mail. She removed anything that the facility or the resident's representative was responsible for. Once mail was sorted, she took the mail to the front desk for the activity department to distribute to the residents. Her regular work schedule was Monday through Friday. A current facility policy, updated September 2015, titled Mail Policy, provided by the Social Services Director on 5/1/25 at 4:23 p.m., indicated the following: Policy: The residents have a right to receive mail. Guidelines: The follow procedure will be followed: .3. Mail will be delivered Monday thru Saturday 3.1-3(s)(1)

Based on interview and record review, the facility failed to ensure residents and/or resident representatives received a copy of their baseline care plans on admission for 5 of 5 residents reviewed for care plans. (Resident 8, 52, 57, 61, and 264) Findings include: 1. Resident 52's clinical record was reviewed on 4/29/25 at 10:48 a.m. Diagnoses included alcoholic hepatic (liver) failure without coma, hepatic encephalopathy (disease or damage that affects the brain, leading to a change in mental state), type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified anemia, and thrombocytopenia (low platelet count in the blood which can cause prolonged bleeding). A progress note, dated 12/5/24 at 12:45 p.m., indicated the resident was admitted to the facility. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan prior to the completion of the comprehensive care plan. During an interview, on 5/1/25 at 11:04 a.m., the Social Services Director (SSD) indicated she had recently been educated that the baseline care plans were to be discussed with and given to the residents and their representatives during the admission process. She had a care plan meeting with the resident's representative 2/2025. She did not have a care plan meeting with the resident or the resident's representative 12/2024 nor provide a baseline care plan. 2. Resident 61's clinical record was reviewed on 4/29/25 at 9:12 a.m. Diagnoses included essential (primary) hypertension (high blood pressure), gastroesophageal reflux disease (stomach acid and content flow back up into the esophagus) without esophagitis (inflammation of the esophagus, Charcot's joint, right ankle, right foot, left ankle, and left foot (nerve damage, often due to diabetes, leads to weakening and collapse of bones and joints in the foot, resulting in a deformed shape), repeated falls, and cellulitis of the right lower limb and the left lower limb. Census information indicated the resident was admitted on [DATE]. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan prior to the completion of the comprehensive care plan. During an interview, on 5/1/25 at 11:04 a.m., the SSD indicated she had not provided or discussed the baseline care plan with Resident 61. 51985 3. Resident 8's clinical record was reviewed on 4/30/25 at 11:34 a.m. Diagnoses included repeated falls, hyperlipidemia, nicotine dependence, low back pain, unspecified secondary osteoarthritis (arthritis that occurs when flexible tissue at the ends of bones wear down), fibromyalgia (long-term condition that involves widespread body pain and tiredness), chronic viral hepatitis C (liver disease that results from hepatitis C virus), fracture of unspecified parts of lumbosacral spine (low back) and pelvis, subsequent encounter for fracture with routine healing, unspecified sequelae of cerebral infarction (long term effects of a stroke), dysphagia (difficulty swallowing) following cerebral infarction (stroke), irritable bowel syndrome, major depressive disorder, recurrent, unspecified, hemiplegia, unspecified affecting left nondominant side, unspecified severe protein-calorie malnutrition, and other abnormalities of gait and mobility Census information indicated the resident was admitted on [DATE]. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. During an interview, on 4/30/25 at 3:00 p.m., the SSD indicated she tries to have a care plan within the first week of a resident's admission to the facility. She recently had been given instructions regarding baseline care plans. She had not been doing baseline care plans prior to receiving this education. 4. Resident 57's clinical record was reviewed on 5/01/25 at 11:20 a.m. Diagnoses included acute respiratory failure with hypoxia (lack of adequate oxygen supply), dissection (tear) of aorta, dysphagia (difficulty swallowing) following cerebral infarction (stroke), other paralytic syndrome following cerebral infarction affecting unspecified side (loss of movement or sensation), other neuromuscular dysfunction of bladder, neurogenic bowel (lack of communication between brain and bowel causing loss of normal bowel function), unspecified systolic congestive heart failure (heart unable to pump blood adequately), myopathy (disease process that affects the skeletal muscles), kidney failure, anemia, type 2 diabetes mellitus (high blood sugar), essential (primary) hypertension (high blood pressure), unspecified injury at T 11-T 12 level of thoracic spinal cord, pressure ulcer of sacral region, muscle wasting and atrophy (shrinking in size), difficulty in walking, and other abnormalities of gait and mobility. Census information indicated the resident was admitted on [DATE]. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. 5. Resident 264's clinical record was reviewed on 5/01/25 at 12:33 p.m. Diagnoses included constipation, chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breath), malignant neoplasm of supraglottis (cancer of the upper part of the larynx, known as the voice box), gastrostomy status (tube feeding), unspecified atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), essential (primary) hypertension (high blood pressure), hyperlipidemia (high cholesterol), unsteadiness on feet, aphasia (language disorder that makes it difficult to read, write, and speak)), encounter for palliative care (receiving hospice care), and tracheostomy. Census information indicated the resident was admitted on [DATE]. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. A current facility policy, last revised 11/17/17, titled Baseline Care Plan, and provided by the DON on 5/1/25 at 4:39 p.m., indicated the following: .The resident and/or their representative shall receive a summary of the Baseline Care Plan prior to completion of the comprehensive care plan . As a best practice, the interdisciplinary team should attempt to schedule an initial meeting with the resident and/or resident representative within 5 days of admission to review the baseline plan of care and make updates or revisions as indicated based on feedback and input of the resident and/or representative prior to the development of the comprehensive care plan.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a resident with a known risk of elopement. This deficient practice resulted in the resident ambulating with his walker approximately 1.4 miles away from the facility, in a busy residential area, with temperatures exceeding 84 degrees F (Fahrenheit) for 1 of 3 residents reviewed for elopement risks (Resident B). The immediate jeopardy began on 5/30/23 when Resident B, a severely cognitively impaired resident, eloped from the facility on foot, down a 30 degree driveway decline, without staffs' knowledge. His whereabouts were unknown for approximately two hours, and he was found unsupervised in a busy residential area approximately 1.4 miles away from the facility. The low temperature on 5/30/23 was 84 degrees F and the high temperature was 89 degrees F, between the hours of 3:30 p.m. and 5:30 p.m. The Administrator, Regional [NAME] President of Operations, and the Regional Nurse Consultant were notified of the immediate jeopardy at 3:49 p.m. on 6/1/23. The immediate jeopardy was removed, and the deficient practice corrected, on 6/3/23. Findings include: Review of a facility self-reportable, dated 5/31/23, indicated Resident B had left the facility to check on his home, was located at his former residence, and returned to the facility with out incident. He was to remain on one on one supervision until placement on a secured unit was arranged. On 6/1/23 at 8:48 a.m., Resident B was observed in his room alone. He was dressed in street clothing and was ambulating in his room with his walker. He was not being provided one on one supervision. On 6/1/23 at 11:07 a.m., he was observed sitting on his walker seat near the nurses station. On 6/1/23 at 2:59 p.m., he was observed sitting on his walker seat near the nurses station. Resident B's clinical record was reviewed on 6/1/23 at 9:54 a.m. Diagnoses included cerebrovascular disease, impulse disorder, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, acute and chronic respiratory failure with hypoxia, unspecified systolic (congestive) heart failure, paroxysmal atrial fibrillation, old myocardial infarction, atherosclerotic heart disease of native coronary artery without angina pectoris, presence of coronary angioplasty implant and graft, cognitive deficits following cerebral infarction, essential (primary) hypertension, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. His orders included, clopidogrel bisulfate (blood thinner) 75 mg daily, losartan (blood pressure) 25 mg daily, insulin glargine (insulin) 13 unit subcutaneously twice daily, escitalopram (antidepressant) 5 mg daily, metoprolol succinate (blood pressure) 100 mg daily, and memantine (dementia) 10 mg in the morning, and 5 mg at bedtime. A current elopement care plan, initiated on 8/9/22, indicated he was at risk for elopement related to disorientation to place and he had impaired safety awareness. His goal was he would accept redirection within two minutes of staff intervention and his safety would be maintained through the review date. His interventions were distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book. He preferred coffee and sat by the nurses station (initiated 8/9/22, revised 6/1/23). Provide structured activities: monthly resident birthday celebrations, coffee social, musical entertainment, reorientation strategies including signs, and pictures (initiated 8/9/22, revised 6/1/23). An elopement/unauthorized leave risk assessment, dated 10/7/22, indicated he was at risk for elopement and should be placed on the Elopement Risk Protocol and an elopement care plan was indicated. A quarterly MDS (Minimum Data Set) assessment, dated 5/9/23, indicated he was severely cognitively impaired. He required limited assistance for bed mobility, dressing, toilet use, and personal hygiene. He required supervision for transfers, walking in his room and in the corridor, and locomotion on and off the unit. He used a walker. The weather for [NAME], Indiana on 5/30/23, retrieved from the website Local Conditions, at www.localconditions.com/weather-[NAME]-indiana/46952/past, indicated the low temperature was 84 degrees F and the high temperature was 89 degrees, between the hours of 3:30 p.m. and 5:30 p.m. A nurses note, dated 5/30/23 at 5:51 p.m., created on 5/31/23 at 3:41 p.m., indicated the resident left the facility to check on his former home. He was located at his former residence and was returned to the facility. He was assessed with no injuries noted. Vital signs were obtained and they were within normal limits. The NP (Nurse Practitioner) was notified and was on her way to the facility to assess him. He was offered, and accepted, four cups of fluids to drink. He was offered a supper tray and consumed 100%. He was placed on one on one supervision immediately upon return to the facility with the nursing staff. The DON, Administrator, and POA (Power of Attorney) were notified. A NP note, dated 5/30/23 at 6:10 p.m. and created on 5/31/23 at 4:57 p.m., indicated he was evaluated in the morning and was found to be in his normal, pleasantly confused state, although his behavior was easily redirectable. When he returned to the facility from checking on his house, he was flushed, slightly wheezy, and was difficult to redirect. He was fixated on returning to his house, and was somewhat unsteady on his feet. He was encouraged to drink ample fluids, although he did not want to readily drink water as offered. The ER (emergency room ) was called and his case was discussed with a doctor. His POA was notified that he would be sent to the ER for further evaluation. The POA refused for him to be sent and requested him to be given dinner and treated in-house. Instead, STAT (immediately) labs were ordered. After he returned to the facility he was alert to self, hard of hearing, anxious, difficult to redirect, constantly stated he was going home, and attempted to leave the area. He required one on one supervision. He had scattered wheezes and crackles in his lungs, mild tachycardia (elevated heart rate) and his bowel sounds were sluggish. His skin was flushed, dry, and he had poor skin turgor. A nurses note, dated 5/30/23 at 6:32 p.m. and created on 5/31/23 at 3:51 p.m. indicated the POA was made aware the NP wanted to send the resident to ER for evaluation and treatment. The POA refused to send him to the ER. The NP was notified and STAT labs were ordered. During an interview with CNA 7, on 6/1/23 at 8:50 a.m., she indicated someone had just called the nurse and told her Resident B was to be a one on one with staff, and to make sure someone was with him. She was not aware of his elopement on 5/30/23 and had just heard about it from the nurse. During and interview with LPN 13, on 6/1/23 at 8:54 a.m., she indicated she was told in report by the night shift nurse of Resident B's elopement. The resident was taken out front to sit, was left alone, and then wandered off. He was to be one on one and to keep an eye on him when he was out of his room. She didn't know he was supposed to have someone with him at all times and it was a miscommunication. The Receptionist had just told her he was supposed to be with someone at all times. During an interview with the Receptionist, on 6/1/23 at 9:00 a.m., she indicated on Tuesday (5/30/23) a little after 3:00 p.m., Resident B came up to the front desk and was looking to go outside and was talking about the weather. She asked him if he wanted to go out and he went outside. He sat outside for about 10 minutes, came back in, and he indicated it was too hot. He sat in the front foyer area for a couple seconds and then walked back towards his room. She had left him out before, but he didn't go out very often. He had never left the property when he was outside. She left at 4:30 p.m. and no one was outside when she left. During an observation, at the time of the interview, a keypad was located to the right of the exit doors (to allow for a code to be entered to unlock the doors). During an interview with Resident B's POA, on 6/1/23 at 10:28 a.m., she indicated the resident had been let out of the facility previously, in the fall of last year. The BOM (Business Office Manager) held the door for him and let him outside. He was later found in the facility's parking lot. This time, someone let him outside to sit on the front porch and didn't watch him. She was told he was gone for awhile. He walked to his previous home, where he had not lived at for over four years. It was a long way for him to walk, it was so hot out that day, and he was so frail. The facility told her he was an elopement risk and needed to be placed somewhere else. It was not typical for him to want to leave. She felt he was only an elopement risk when someone let him out the front door. During an interview with the Administrator, on 6/1/23 at 11:19 a.m., she indicated on 5/30/23, Resident B went to the end of the month birthday party, as she saw him around 3:45 p.m. walking back towards his room. She went outside to water the flowers. She heard at some point, he came back to the front of the building and the Receptionist let him out to sit on the front porch. She left the facility between 4:20 p.m. and 4:30 p.m. and he was not outside when she left. She received a phone call at 5:50 p.m. from the DON, who indicated she had received a call from the facility that a former employee called and reported Resident B was at his old neighbors house. Two employees went to pick him up and brought him back to the facility. They called the NP to come to the facility to assess him. He was very thirsty and angry because he couldn't get in his house. He drank four glasses of water. His blood pressure was slightly elevated and his temperature was normal. He was placed on one on ones and his family was notified. He was given a cool shower, he didn't want to eat a lot, but he was urinating fine and was ready to go to bed. He was going to be moving to a secured unit at another facility. There was no video available for when, or how, he left the facility. During an interview with the BOM, on 6/1/23 at 11:29 a.m., she indicated she was coming back from break between 3:45 p.m. and 4:00 p.m. She seen Resident B in the foyer and he was pushing the door to the facility closed. She noticed the Administrator was outside watering flowers and didn't think anything about him being outside. Plus, she got stopped by another resident. Last year in the fall, he was sitting up front, and she passed him when she went to the bathroom. When she came out of the bathroom, she saw him outside and he was walking towards the front of the parking lot. She called code pink over the intercom and ran out to get him. He was easily redirected back into the building. During an interview with the DON, on 6/1/23 at 11:47 a.m., she indicated she received a phone call from the QMA/Scheduler at 5:34 p.m., who told her Resident B was out of the building. He was near his prior home and they were going to go get him. She remained on the phone the entire time, until he got back to the facility. He got in the QMA/Schedulers car with some persuasion. He thought the car had been stolen. They were back at the facility at 5:51 p.m. He was placed on one on ones. She tried to piece the timeline together. He came to the birthday party at 3:00 p.m. and left the party at 3:45 p.m. The Administrator saw him walk by her office and was heading back towards his room. The Receptionist let him outside, and he came back in. She thought he may have left sometime between 3:45 p.m. and 4:30 p.m. Around 4:40 p.m., the QMA/Scheduler was looking for him and assumed he was at another activity. The Receptionist and the BOM left at 4:30 p.m. and did not see him. This was not typical for Resident B to leave. His dementia was progressing. He usually didn't go outside or come to activities. The BOM let him out last year and he was found walking in the parking lot. That's when his information was put into the elopement binder. He needed a locked unit. During an interview with Activity Assistant 21, on 6/1/23 at 12:35 p.m., she indicated Resident B was at the birthday party and left around 3:45 p.m. She noticed him sitting outside with another resident around 4:00 p.m. She left between 4:30 p.m. and 4:40 p.m. The Administrator was outside watering flowers and the Receptionist was at the desk. Review of the Elopement Binder, on 6/1/23 at 1:59 p.m., indicated a form titled Wandering/Elopement Risk, dated 10/7/22, with Resident B's, race, height, weight, eye color, and hair color. It listed his responsible party and physician, and if he had any identifying marks. He enjoyed socializing with other residents. The recommendations on approaching/reassuring him was to approach him in a calm manner. During an interview with QMA/Scheduler, on 6/1/23 at 2:41 p.m., she indicated the other QMA came over to her hall and asked if she had seen Resident B. He was last seen at 3:30 p.m. walking up front to an activity. A former employee called the facility and indicated the resident was at his old house visiting with his neighbors. She called the DON at 5:34 p.m. and told her they were on their way to pick him up. The DON remained on the phone. He appeared fine and happy, like he was taking a stroll through the neighborhood. She tried to get him in the car, and offered him some food and drink. He got in the car, they brought him back to the facility. They did a head to toe assessment and vitals every 15 minutes until the NP got there. They gave him water. The NP wanted to send him out, but the POA refused. He was placed on one on one supervision. She thought he was with his neighbors for 30 to 45 minutes. He had been confused from time to time, but normally was very with it. She had never known him to go outside like that before. During an interview with LPN 27, on 6/1/23 at 3:03 p.m., she indicated Resident B attended the birthday party and was let outside to sit on the porch. Prior to the birthday party, she heard him say he was going to go home to check on his house. As soon as they found out he was missing, she contacted the DON and the Administrator. They started to search for him around 4:40 p.m. During the search, they received a call from a former employee and found out where he was. He was brought back to the facility and they initiated one on ones. She gave him water and a supper tray. The NP did an assessment and wanted to send him out to the hospital. The family refused, so they did STAT labs on him. Staff knew he was at risk for elopement. When she completed the education, she realized she should have called the code pink over the intercom. During an interview with the Maintenance Director, on 6/1/23 at 3:58 p.m., he indicated the driveway, from the facility parking lot to the street, was a decline of 30 degrees . A current facility policy, revised on 11/15/18, titled Code Pink - Missing Resident/Elopement, provided by the Administrator on 6/1/23 at 4:00 p.m., indicated the following: .2. Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or Nurse or Director of Nursing .Be courteous in preventing the departure .Should an employee discover that a resident is missing from the facility, he or she should .Alert staff by announcing Code Pink over the paging system The Immediate Jeopardy that began on 5/30/23 was removed, and the deficient practice corrected, on 6/3/23 when the facility educated all staff regarding residents who were at risk for elopement, interventions and behavioral signs and symptoms of elopement, new protocols were developed for nursing home residents to sit outside unsupervised in designated areas, and elopement drills were conducted on all shifts. This Federal tag relates to Complaint IN00409757. 3.1-45(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's preferences were met for 1 of 2 resident's reviewed for accommodation of needs. This deficient practice resulted in psychosocial harm related to the resident's fear of the mechanical lift (Resident B). Findings include: Resident B's clinical record was reviewed on 2/6/23 at 11:04 a.m. Diagnoses included amyotrophic lateral sclerosis (ALS), anxiety disorder, peripheral vascular disease, hereditary and idiopathic neuropathy, neuralgia and neuritis, foot drop, unspecified foot, and other abnormalities of gait and mobility. A quarterly MDS (Minimum Data Set), dated 11/25/22, indicated he was cognitively intact. He required extensive assistance of two staff members for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. He had an impairment to both sides of his upper and lower extremities. He used a wheelchair. He was occasionally incontinent of bladder and frequently incontinent of bowel. He had a life expectancy of less than six months due to a chronic disease or condition. His orders included aspirin (blood thinner) 81 mg (milligram) daily, clopidogrel bisulfate (blood thinner) 75 mg daily, hydrocodone-acetaminophen (pain reliever) 10-325 mg every four hours, lorazepam (treat anxiety) 0.5 mg every four hours and mechanical lift transfers only. He had a current care plan problem of being at risk for bladder incontinence related to terminal prognosis of ALS, hospices services, medication, weakness and impaired mobility initiated on 6/10/22. His interventions included ensure the resident had an unobstructed path to the bathroom, initiated on 6/10/22. He had a current care plan of an ADL (Activities of Daily Living) self-care performance deficit including bed mobility, eating, transfers and toileting related to terminal prognosis of ALS, received hospice, PVD, neuralgia, neuropathy, history of dysphagia and foot drop, revised on 9/13/22. His interventions included total staff assistance for toilet use and he required total staff assistance for transfers, revised on 12/8/22. A hospice nurses note, dated 2/2/23, indicated he was alert and oriented. He voiced complaints of the facility nursing staff, as he was not getting his medications like they were ordered and a nurse charted he refused his medications. The nurses would not allow staff to transfer him unless they used the mechanical lift. He refused to use the lift because he was scared of falling out of it. He had only been getting up to use the bedside commode and had since stopped getting up at all. He refused to use a bedpan. He now refused all meals. His reasoning was if he did not eat, he would not have bowel movements. He said he had no need to get out of bed or use the mechanical lift. She tried to encourage him, but he was not having it. She spoke to staff who stated they were aware. The hospice nurse and nurse practitioner were also aware. During an interview with Resident B, on 2/6/23 at 1:45 p.m., he indicated he had filed a facility grievance on 1/3/23, and then again on 1/12/23, with the facility. The grievance on 1/3/23 was related to the facility food and the 1/12/23 was related to the nurse who documented he refused his medications when he did not. The entire time he had been at the facility they had pivot - transferred him. He had never used the mechanical lift. Now, they had told him he had to be a mechanical lift. He had worked in healthcare previously and had seen residents dropped from the mechanical lift and he didn't want to be dropped from it. He was 6'1 tall, and by having to use the mechanical lift, he would not be able to get up to use the bedside commode and he would have to use the bedpan. He did not want to use the bedpan, as it made him feel like he was sitting in his own feces. He had not eaten since 1/30/23. He felt if he didn't eat, then he would not have to have a bowel movement. Therapy had not screened him since he first admitted to the facility. He felt since he filed the complaint, they told him he had to be transferred with the mechanical lift. He would rather eat again. That's all he had left, but did not want to use the bedpan to have bowel movements. He preferred to sit on the commode. During an interview with the Administrator and ADON, on 2/6/23 at 2:32 p.m., the Administrator indicated the resident was very upset about the lift. It had been a great concern with the CNAs that were 5'1 tall. She was not aware he wasn't eating. He was manipulative to staff and dismissed you from his room. He enjoyed manipulating his mom against others. He had an angry side. During an interview with the hospice nurse, on 2/7/23 at 9:26 a.m., she indicated the resident refused to get out of bed the previous week, and he didn't want to use the lift. He didn't want to eat because he didn't want use the lift. He was terrified of it. He refused to use to use the bedpan, which was why he was not eating. He had ALS and weakness, but he could use his legs enough to stand. The facility put a mechanical lift transfer in place. One day they were pivot transferring him, then there was a big uproar, and now they were to use the mechanical lift. CNAs had indicated they didn't mind transferring him. There was a certain nurse who complained about transferring him and had never transferred him. He did not care for her at all, and had dismissed her from his room. If he was not in the mood, he would say ok you can go. Not rude, just he was ok, he was done, and you could go. During an interview with LPN 5, on 2/7/23 at 11:47 a.m., she indicated the resident could not stand well, he towered over the aides, and was not safe. The facility was a no-lift facility. There was a short pregnant aide who worked at the facility and she didn't want to transfer him. She, herself, had not transferred him. She assumed it was the DON who had changed him to a mechanical lift transfer. The DON had told her to put the order in the computer system for him to be transferred with the mechanical lift. During an interview with CNA 35, on 2/7/23 at 1:29 p.m., she indicated the resident had never been mean to her. Certain things irritated him, such as if you couldn't transfer him how he liked to be transferred and if you didn't knock on his door before you entered his room. He didn't liked to be bothered. She had been pregnant and physically could not transfer him. He started to decline, and she went to the DON and told her that he wasn't safe to transfer. They had to use the mechanical lift since his knees would collapse and he was completely dead weight. His family and hospice would transfer him without the use of a lift. During an interview with the hospice CNA, on 2/7/23 at 1:43 p.m., she indicated she took care of him every Monday, Wednesday, and Friday. At first, she didn't know how to take him, since he would get short of breath and did not like to talk a lot. She felt he was just misunderstood. She was 5'4 tall, and when she transferred him, he would grab around her shoulder/neck area and she would put her hands under his armpits. He was not really able use his legs. He was upset about using the mechanical lift. He was terrified of it and he felt LPN 5 was picking on him. She had talked to the aides and they still wanted to transfer him, but LPN 5 threatened them she would call the State and they would lose their jobs. He had stopped eating and he was weak. Yesterday was his eighth day of not eating. He felt if he didn't eat, he would not have to have a bowel movement. He so badly didn't want to have a bowel movement while in the bed and have someone to clean him up. He wanted to keep his dignity. During an interview with the DON, on 2/7/23 at 2:01 p.m., she indicated when the resident first admitted they transferred him with two people, but he had progressed so much. He wanted the staff to bear hug him and they would slam him down on the commode because he was so much taller than them. They were a non-lift facility. Safety came first for him and the staff. Hospice and the family would get him up. Staff felt it wasn't safe anymore to pivot transfer him. She had tried to talk with him, he didn't want to hear it. He said he did not want to be a mechanical lift transfer. The staff needed to be safe and consistent. Hospice and family had left him on the commode, and the facility staff had no choice but to lift him into bed. During a follow up interview with Resident B, on 1/8/23 at 11:50 a.m., he indicated his last bowel movement was 1/31/23 and the last time he ate was 1/30/23. His family did not bring food in for him. He would have the same results, he would still have a bowel movement, whether he ate food from the facility or from his family. He had not used the lift since he had been at the facility. He wanted to keep his last bit of dignity, he wanted them to sit him on the commode and put him back in bed. All they needed to do was tell him he didn't have to use the lift and he would go back to eating. He was so afraid to use the lift. During an interview with CNA 39, on 2/9/23 at 8:49 a.m., she indicated the resident had been refusing everything. They offered him a meal tray, but he wouldn't take it. She knew he had not eaten breakfast or lunch. They normally transferred him with one CNA holding the commode, and the other CNA would bear hug him. If you lifted him high enough, he would lock his legs and then pivot to the commode. She had no problems transferring him. He refused the bedpan, he indicated it was a dignity issue for him. The commode also got him out of bed and he was safe to sit on the commode by himself. During an interview with CNA 31, 2/9/23 at 8:58 a.m., she indicated the resident transferred with two CNAs to the commode. He was scared of the lift. She had no problems with transferring him. She would straighten him up and he locked his legs backward and was able bear some weight. One CNA would bear hug him and other CNA would pull his pants down and they would place him on the commode. He did not want to be transferred with the lift, which was why he had refused to eat. They had forced him to be a straight mechanical lift, and he was scared of it. He would rather use the commode than the bedpan. She did not have any problems with pivot transferring him, she actually preferred to transfer him that way. It also helped him stretch out because he was in the bed all day. During a follow up interview with the hospice CNA, on 2/9/23 at 9:10 a.m., she indicated the resident had not had any bowel movements for her lately. His last bowel movement was 1/30/23. Every time she was at the facility she got him up on the commode. He had not eaten at all and she could tell his body was weakening. A current, 1/19/18 revised, facility policy, titled Transfers - Manual Gait Belt and Mechanical Lifts, provided by the Administrator, on 2/17/23 at 3:06 p.m., indicated the following: Guidelines .5. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories .2 = 2 person transfer with gait belt (ONLY when use of mechanical lift is not possible) This Federal tag relates to complaint IN00399248. 3.1-3(a)

Based on record review and interview, the facility failed to provide adequate education and preparation prior to discharge. This deficient practice resulted in the resident (Resident E) being discharged to a location unprepared for his arrival, and consequently being moved out of state temporarily, while appropriate placement was sought. Using the reasonable person concept, this alleged deficient practice would cause prolonged anxiety and fear. Findings include: The clinical record for Resident E was reviewed on 2/7/23 at 10:00 a.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, depressive disorder. The resident was assessed as being moderately cognitively impaired. Review of a progress noted, dated 11/23/22 at 9:31 a.m., indicated the resident was spoken to about smoking in the facility. He denied smoking in the facility. The clinical record had no other documentation of Resident E being suspected of, or actual smoking, in the facility. There was no record of, or care plan for, the resident displaying aggressive behaviors. The clinical record lacked a care plan for smoking for the resident. Review of a Social Service progress note, dated 11/28/22 at 12:30 p.m., indicated the Social Service Director (SSD) informed the family of Resident E about his discharge the same day. The resident had been discharged from therapy. They were also notified the resident had cursed at the administrator several times the same day. The resident's family indicated the resident was exhibiting behaviors because he wanted to leave and come home. The SSD indicated the resident had not displayed this type of behavior before. He was overall very pleasant and calm to me. The SSD indicated the resident's behavior that day was very different from his normal. During an interview, on 2/7/23 at 9:45 a.m., the Executive Director (ED) indicated Resident E was supposed to have discharged on [DATE] to a family member's home. The family member did not pick the resident up, and he had remained in the facility until 11/28/22. On 11/28/23, the ED and the resident had a verbal exchange related to the resident's smoking privileges. The exchange became heated and verbal abuse was alleged. The ED informed the resident to pack his belongings, he would be discharged , and the facility would provide transportation to the resident's home in the facility van. The ED instructed staff to pack the resident's belongings. The ED and Activity Aide 3 then transported the resident to a family member's home, via the facility van. During an interview, on 2/8/23 at 12:00 p.m., Resident E's family member indicated he had been speaking with the ED about Resident E's upcoming discharge. He had come home after work on 11/25/22 to discuss the discharge. He was unable to get off work when expected, and had been unable to come to the facility as planned. He had been waiting for information about home health, and education on how to care for Resident E. He had questions about his home being ready for Resident E such as bathroom set up for shower support, railings for level changes, etc. No home evaluation was performed. On 11/28/23, while he was at work, he received a phone call from another family member, telling him the resident had called her and stated he was in the facility van on his way to his house. He had to leave work in an attempt to arrive before the facility van. He called the police to complain about the facility just dropping the resident off without proper notification and preparation. Had his other family member not called him, he would not have been able to be there when the van arrived. The police arrived, determined it was a civil matter, and left the area before the facility van arrived. The resident had to be taken out of state to the home of another family member while family attempted to find in-state nursing home placement. During a phone interview, on 2/8/23 at 6:16 p.m., Resident E's sister indicated the facility had called her and told her the resident needed to be removed from the facility. She was told there was nowhere to go and he would go to a homeless shelter the day before Thanksgiving. The facility wanted him out of there and were going to put in referrals. She asked them to try the [NAME] area. A half-hour later, they said he needed picked up, or he was going to a homeless shelter. On 11/28/22, Resident E called and stated the ED had him in the van to drop him off. This was the first she knew of him discharging from the facility. He had been eating dinner when they came and got him. He went to Missouri for a week, came back and was now in another facility. During this interview, the resident was present and indicated the facility tried to say he was smoking in his room, which he denied. They had taken his smoking away, then gave it back. He had been sitting there waiting to go smoke, when the ED told him he couldn't go smoke. He felt he was being picked on. The resident and the ED were cussing each other out the day before discharge. The ED called him a little b_ _ _ _ _d. The ED told him that she was gonna take him to the homeless shelter almost every day over three to four days. While he was eating dinner, some girl carrying his coat and phone, came and got him. They had packed up his stuff and loaded it in the van before he got back to his room. He didn't feel he was treated fairly by the facility. During an interview, on 2/9/23 at 8:38 a.m., PTA 7 indicated she could find no documentation of a home evaluation being done for Resident E. Home evaluations were usually done prior to discharge. PTA 7 called the Therapy Director and indicated no home evaluation had been billed for Resident E. Review of the physical therapy and occupational therapy discharge notes indicated the therapy department believed the resident to be remaining in the facility. PTA 7 indicated she remembered the resident's facility discharge being sudden. He had been discharged from physical therapy on 11/23/22, and occupational therapy on 11/15/22. Review of a current policy, dated 3/22/17, titled Notice of Transfer and Discharge and provided by the ED on 2/9/23 at 9:48 a.m., indicated the following: .Guidelines: Prior to discharge or transfer, the facility will: Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. No further information was provided prior to exit. This federal tag relates to Complaint IN00400281. 3.1-12 (a) (21) 3.1-12 (a) (22)

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for 3 of 5 residents reviewed for pressure ulcers (Resident 14, 26 and 4). This deficient practice resulted in Resident 14 sustaining an unstageable pressure ulcer to her right heel, Resident 26 sustaining four DTI's (Deep Tissue Injury) pressure ulcers to his right heel, right lateral ankle and two to his left lateral ankle and Resident 4 sustaining an unstageable pressure ulcer to his coccyx and to his right heel. Findings include: 1. During an observation on 7/7/22 at 10:57 a.m., Resident 14 was sitting in a wheel-chair in her room, her feet were on the floor and she was wearing non-skid socks and slip on shoes. On 7/8/22 at 9:21 a.m., she was sitting in a wheel-chair in her room, her feet were on the floor and she was wearing non-skid socks and slip on shoes. During an observation of a preventative treatment to the resident's bilateral heels on 7/8/22 at 10:04 a.m., as the Wound Nurse removed the sock from the resident's right foot, she jumped in her seat and pulled her right foot back and indicated her heel was sore. The heel had an open wound of non-blanchable red tissue, the size was the diameter of a golf ball visible wound edges were the resident's normal skin tone. The resident indicated the area had started about a month ago. During an interview with the Wound Nurse while the skin barrier treatment was applied, she indicated the resident had not had an open wound on her heel since she had admitted to the facility, and she did not recall a picture, dated 6/24/22, of an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead tissue, yellow, tan, gray, green or brown) and/or eschar (dead tissue, tan, brown or black) pressure ulcer to the resident's heel in the resident's clinical record. The resident's clinical record was reviewed on 7/6/22 at 3:27 p.m. She had admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/15/22 admission MDS (Minimum Data Set) assessment indicted the resident had severe cognitive impairment. She was at risk for the development of pressure ulcers and did not have any pressure ulcers. She required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and supervision with eating. A current care plan, dated 5/10/22, indicated she had limited mobility related to revision of total left hip arthroplasty status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, monitor/document/report as needed any signs or symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown or fall related injury, date initiated was 5/10/22. A current care plan, dated 5/10/22 and revised on 5/20/22, indicated she had the potential of impairment to skin integrity related to impaired mobility status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal, with a revised date of 7/5/22 and a target date of 8/10/22, indicated she would not develop alteration in skin integrity. Interventions included, but were not limited to, assess/record changes in skin status, avoid shearing: use lift sheet for repositioning, minimize pressure over bony prominences, report pertinent changes in skin status to physician, all dated 5/10/22. The clinical record did not include a care plan related to a pressure ulcer to her right heel. An Admission Observation assessment, dated 5/9/22 at 6:53 p.m., indicated a surgical incision to left hip with a dressing that was not to be removed until a follow up appointment. A Weekly Skin Observation assessment, dated 5/16/22 at 6:53 p.m., indicated her skin was intact and no foot concerns had been noted. A Braden Observation assessment, dated 5/23/22 at 6:53 p.m., indicated a score of 15 for skin-breakdown. The scoring and category of risk for skin-breakdown indicated the following, a score of 15-18 indicated at risk, a score of 13-14 indicated moderate risk, a score of 10-12 indicated high risk and a score of 9 or below indicated very high risk. A Weekly Skin Observation assessment, dated 5/23/22 at 6:53 p.m., indicated no foot concerns had been noted. A Braden Observation assessment, dated 5/30/22 at 3:23 a.m., indicated a score of 17. A Weekly Skin Observation assessment, dated 5/30/22 at 6:53 p.m., indicated her skin was intact and no foot concerns had been noted. A Skilled Charting assessment, dated 6/6/22 at 1:52. p.m., indicated no changes in skin integrity. A Skilled Charting assessment, dated 6/15/22 at 2:10 p.m., indicated no wound or skin concerns. A Skilled Charting assessment, dated 6/19/22 at 4:12 p.m., indicated no wound or skin concerns. A Skin & Wound Evaluation assessment, dated as opened on 6/24/22 at 10:48 a.m., the assessment had not been locked and remained open. The section of assessment labeled as wound measurements indicated a length of 2.8 cm (centimeters) and a width of 1.5 cm and depth was listed as not applicable. The assessment did not identify the type of wound or the location of wound and did not indicate a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The Skin & Wound tab of the clinical record included a picture of heel, dated 6/24/22 with wound evaluation signed with the Wound Nurse's signature. The picture indicated eschar covered 50% of the wound bed, the size was consistent with the diameter of a golf ball. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A Weekly Skin Observation assessment, dated 6/27/22 at 6:53 p.m., indicated right heel pressure ulcer. A Weekly Skin Observation assessment, dated 7/4/22 at 6:53 p.m., indicated scabs to bilateral heels. During an interview, on 7/8/22 at 2:26 p.m., the Wound Nurse indicated the picture was of the resident's right heel and showed the area had already formed a scab, 6/24/22 was the first time she had known about the area and she had not done a wound assessments after 6/24/22. During an interview, on 7/8/22 at 2:41 p.m., RN 7 indicated the protocol for a wound included, but was not limited to, notify if the DON and Wound Nurse/ADON and put the information in the physician's communication book. 2. During an observation on 7/5/22 at 3:30 p.m., Resident 26 was lying in bed, feet visible through bottom of sheet, heels were resting on the mattress. During wound observations, accompanied by LPN 14 on 7/7/22 at 2:32 p.m., Resident 26 was lying in bed, a pillow was between his knees, his left lateral ankle was lying on the mattress and his right heel was lying on the mattress, the following was observed: a. Right heel pressure ulcer: LPN 14 removed the resident's slipper sock from his right foot and removed a bordered dressing from his right heel. The nurse measured the wound at a length of 3.0 cm and a width of 1.0 cm, the wound was purple, intact skin that presented as a DTI (Deep Tissue Injury) (intact or non-intact skin localized area of persistent non-blanchable red, maroon or purple discoloration). The wound was cleansed and a skin barrier was applied. b. Right lateral ankle pressure ulcer: no dressing covered this wound that presented as a stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer). The nurse measured the wound at a length of 1.5 cm, a width of 1.5 cm and a depth of 0.1 cm. The tissue in the wound bed was cream colored, red tissue at wound edges. The wound was cleansed, skin barrier applied to the area surrounding the wound and a protective dressing was placed over the wound. c. Left lateral ankle pressure ulcer (area 1): red/purple, non-blanchable area, nurse measured wound at a length of 2.0 cm, a width 1.0 cm and no depth. The wound was cleansed and a skin barrier was applied. d. Left lateral ankle pressure ulcer (area 2, distal from area 1): red/purple, non-blanchable area, nurse measured wound at a length of 1.0 cm, a width of 1.0 cm and no depth. The wound was cleansed and a skin barrier was applied. The resident was repositioned with two pillows under the bends of his knees, a pillow case was rolled and folded and placed between his knees, a pillow was placed to off-load his heels but the pillow flattened and his heels were resting on the mattress. His clinical record was reviewed on 7/6/22 at 2:58 p.m. He had admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Apply skin prep to bilateral heel every shift for prevention, the order date was 6/22/22. b. Float right heel and ankle every shift, the order date was 6/22/22. c. Skin prep to bilateral heels, float heels when in bed every shift for prevention, the order date was 7/3/22. A 6/22/22 significant change MDS assessment indicated he was rarely/never understood. He was at risk for the development of pressure ulcers, had two unstageable deep tissue wounds and neither were present upon admission. He required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A current care plan, dated 5/29/22 and revised on 5/31/22, indicated he had limited physical mobility related to a fall with right hip fracture and [CONDITION(S)]. The goal, with a revised date of 7/1/22 and a target date of 9/23/22, indicated he would remain from of complication related to immobility, including contractures, thrombus formation, skin-breakdown and fall related injury through the next review date. Interventions included, but were not limited to, monitor/document/report as needed any signs or symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown and fall related injury, dated 5/29/22. A current care plan, dated 5/29/22 and revised on 7/1/22, indicated he had potential for impairment to skin integrity related to impaired mobility, fall with right hip fracture, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal, with a revised date of 7/1/22 and a target date of 9/23/22, indicated he would not develop further alteration in skin integrity. Interventions included, but were not limited to, assess/record changes in skin status, minimize pressure over bony prominences and report pertinent changes in skin status to physician, all dated 5/29/22, avoid shearing: use lift sheet for repositioning and turn and reposition every 2-3 hours as tolerated, both dated 5/31/22. A current care plan, dated 7/1/22, indicated he had two DTI's to right heel and ankle. The goal, with a revised date of 7/1/22 and a target date of 9/23/22, indicated the pressure ulcers would show signs of healing and remain free from infection through review date. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, monitor/document/report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size and stage and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and drainage, all dated 7/1/22. A Braden Observation assessment, dated 5/28/22 at 3:37 p.m., indicated his score was 8, at very high risk for skin-breakdown. A Weekly Skin Observation assessment, dated 6/4/22 at 3:37 p.m., indicated skin intact, no concerns, no foot concerns noted. A Weekly Skin Observation assessment, dated 6/11/22 at 7:37 p.m., indicated skin intact, no concerns, no foot concerns noted. A Braden Observation assessment, dated 6/14/22 at 2:37 p.m., indicated his score was 11, at high risk. A Weekly Skin Observation assessment, dated 6/18/22 at 7:37 p.m., indicated skin intact, skin concern observed to feet was not new. An IDT (Interdisciplinary Team) note, dated 6/22/22 at 2:00 p.m., indicated the IDT discussed the new DTI's to his right heel and ankle. A Skin & Wound Evaluation assessment, dated as opened on 6/24/22 at 3:15 p.m. and a locked date was 6/28/22 at 3:20 p.m., indicated his right heel had a DTI pressure ulcer that developed at the facility measured 2.2 cm in length, 1.6 cm in width and no depth. A Skin & Wound Evaluation assessment, dated as opened on 6/24/22 at 3:07 p.m. and a locked date was 6/28/22 at 3:22 p.m., indicated right lateral ankle had a DTI pressure ulcer that developed at the facility measured 1.6 cm in length, 1.6 cm in width and no depth. A Skin & Wound Evaluation assessment, dated as opened on 7/5/22 at 8:20 p.m. with errors and no lock date, indicated DTI pressure ulcer to his right heel, acquired in-house, measured 0.9 cm in length, 0.5 cm in width and no depth. A Skin & Wound Evaluation assessment, dated as opened on 7/5/22 at 8:18 p.m. with errors and no lock date, indicated DTI pressure ulcer to right lateral ankle, acquired in-house, measured 2.3 cm in length, 1.6 cm in width and no depth. During an interview, on 7/7/22 at 3:10 p.m., LPN 14 indicated he tried to keep the resident positioned so he didn't have skin to skin contact and so that his heels would be off-loaded, and tried to educate other staff on how to do this and why it was necessary. 3. On 7/7/22 at 1:19 p.m., Resident 4 was observed sitting in his wheelchair, in his room, covered with a blanket, his eyes were closed. He had blue protective boots to both feet and pillows under his calves. On 7/8/22 at 8:53 a.m., he was in his wheelchair in his room and staff assisted him with eating. During a wound care observation with LPN 36, a CNA, DON, and LPN 39 present, on 7/8/22 at 10:26 a.m., he was in bed, he had blue protective boots on both feet and his feet were elevated on pillows. LPN 36 assisted him to roll over onto his left side and removed his brief. [MEDICATION(S)] ointment was observed on his buttocks. LPN 36 measured the open area to his coccyx, and it measured 0.5 cm (centimeters) x 0.2 cm. An observation of his right heel, there was discoloration to the right side and the back of his heel, LPN 39 indicated that was a blister that had reabsorbed and just a few days ago his heel was open with granulated tissue where the blister was and she could not believe it was closed and it felt like baby skin now. The DON indicated he was up in his chair for meals and then laid back down, he had been laying down more after having oral surgery. Observation of his wheelchair there was a foam pressure reducing cushion with Dycem (non-slip material) on top, the cushion cover was ripped and exposed the foam underneath. She indicated a new cushion was on order. On 7/8/22 at 2:22 p.m., he was in bed. Resident 4's clinical record was reviewed on 7/6/22 at 3:46 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His orders included, but were not limited to, the following: a. Skin Inspection/Nursing Weekly Assessment on Friday night shift dated 1/1/21. b. Proheal Sugar Free Critical Care (supplement) 30 ml (milliliters) two times daily for wound healing related to pressure-induced deep tissue damage to left heel dated 4/18/22. c. Heel protectors on in bed. Remove to assess left heel pressure area and skin integrity every shift for prophylaxis dated 4/26/22. d. Low air loss mattress as preventative dated 6/24/22. e. Remedy [MEDICATION(S)] paste 0.4-20.5 % (Menthol-[MEDICATION(S)]) (protectant paste) apply to coccyx topically every shift for wound care and apply to affected areas topically every eight hours as needed for wound care, three times daily, dated 6/24/22. f. Skin prep to bilateral heels every shift for preventative dated 7/8/22. A significant change MDS (Minimum Data Set), dated 4/19/22, indicated he was rarely or never understood. He required total assistance of two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. He was at risk for developing pressure ulcers. He had an unstageable pressure ulcer that was present upon admission/entry or re-entry. He had a pressure reducing device to his chair and bed. He had a nutrition or hydration intervention to manage skin problems. He received pressure ulcer care. He had a care plan that indicated he was at risk for further impairment to skin integrity related to incontinence, decreased mobility, impaired cognition related to dementia and TBI (Traumatic Brain Injury), dependence on staff for bed mobility and transfers, [CONDITION(S)], incontinence, thickened liquids and requires staff assistance to obtain fluids, right heel DTI (Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.) and an unstageable (Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without [CONDITION(S)] or fluctuance) on an ischemic limb or the heel(s) should not be removed.) sacral pressure ulcer injury initiated on 9/16/19 and revised on 6/29/22. His goal was he would not develop further alteration in skin integrity. His intervention initiated, on 9/16/19, was assess/record changes in skin status. His interventions initiated, on 12/10/19, included administer/monitor effectiveness of medications as ordered, avoid skin-to-skin contact, report pertinent changes in skin status to physician, minimize pressure over bony prominences, monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician, treatment as ordered, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. His intervention initiated, on 12/17/19, was keep skin clean and dry. Use lotion on dry skin and protective skin barrier cream as ordered. Interventions initiated, on 4/18/22, was encourage good nutrition and hydration to promote healthier skin, heel protectors at all times, provide diet as ordered and monitor nutritional status and dietary needs and supplement(s) as ordered for wound healing. He had an at risk for complications related to DTI to his right heel and an unstageable sacral wound initiated on 6/18/22 and revised on 6/27/22. His goal was his pressure ulcer would show signs of healing and remain free from infection through review date. His interventions initiated on 4/13/22 included, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly and prn, measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, and report improvements and declines to the physician, educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Document alternative methods, inform the resident/family/caregivers of any new area of skin breakdown. Heel protectors at all times initiated on 4/15/22. Low air loss mattress to bed initiated on 6/27/22. A pressure ulcer assessment, dated 4/19/22, indicated he was at moderate risk for the development of a pressure ulcer. A pressure ulcer assessment, dated 6/21/22, indicated he was at high risk for the development of a pressure ulcer. His skin and wound evaluations indicated, but was not limited to, the following: a. On 6/24/22, he had a new unstageable pressure ulcer to his coccyx that was facility acquired and measured 0.6 cm x 1.5 cm x 0.5 cm. On 7/5/22, he had a new unstageable pressure ulcer to his coccyx that was facility acquired and measured 0.4 cm x 1.1 cm x 0.5 cm. b. On 6/17/22, he had a new unstageable pressure ulcer to his right heel that was facility acquired and measured 19.7 cm x 6.2 cm x 4.1 cm. On 6/24/22, he had a new unstageable pressure ulcer to his right heel that was facility acquired and measured 9.3 cm x 4.0 cm x 3.0 cm. On 7/5/22, he had a new unstageable pressure ulcer to his right heel that was facility acquired and measured 0.9 cm x 1.6 cm x 0.8 cm. An IDT note, dated 4/13/22 at 10:55 a.m., indicated his new DTI pressure injury to left heel was reviewed. Treatment and preventative orders in place. A nurses note, dated 6/16/22 at 1:17 p.m., indicated his right heel was assessed. An open like blister area was noted. Old serosanguinous (yellowish with small amount of blood) drainage noted to his sock. Skin was bright pink in color. No s/s of infection noted. No current drainage noted. The nurse practitioner was aware. A new order was received to wash area with soap and water, pat dry, apply xeroform, cover with nonstick pad, and wrap with kerlix daily. An IDT note, dated 6/17/22 at 4:42 p.m., indicated he was noted to have new pressure ulcer injury to right heel. A nurses note, dated 6/22/22 at 1:34 p.m., indicated he had new unstageable pressure area to coccyx. The nurse practitioner was updated, and a new order was received for [MEDICATION(S)] cream to coccyx every shift and as needed. During an interview with RN 32, on 7/11/22 at 11:05 a.m., he indicated Resident 4 did not move around at all. He had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He was completely dependent on staff. He was nonverbal and unable to use a call bell. A current facility policy, titled Skin Condition Assessment and Monitoring - Pressure and Non-Pressure, provided by the DON, on 7/11/22 at 1:30 p.m., indicated the following: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: Pressure .will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record . Residents identified will have a weekly skin assessment by a licensed nurse .A wound assessment will be initiated and documented in the resident chart when pressure .conditions are identified by licensed nurse .Wound Assessment/Measurement: . The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure care and services were provided to a resident with critical laboratory values and residents were transported to the emergency room timely during a medical crisis for 2 of 3 residents reviewed for emergency transport (Residents C and L). This practice resulted in Residents C and L being admitted to the hospital critical care unit. Findings include: 1. Review of Resident C's clinical record was completed on 9/1/20 at 8:33 a.m. [DIAGNOSES REDACTED]. A 4/2/20, quarterly, Minimum Data Set assessment indicated she was rarely/never understood and rarely/never understood others. She required extensive assistance for ADLs and mobility. Review of progress notes and assessment notes indicated the following: On 3/31/20, she continued to pocket food and medications in her mouth. On 4/3/20 at 2:20 a.m., a new order was received to change her diet from mechanical soft to pureed, and to provide oral care after each meal. Her medications were to be crushed and placed in applesauce. A 4/3/20 dietary note indicated her weight was down 8.3% in 30 days, which was a significant weight loss. She consumed 25-100% at most meals. Her fluid needs were 2376-2574 mL daily. Her oral intakes were hoped to improve with the downgrade in her diet. Review of meal intake documentation indicated she consumed 51-75% of breakfast on 4/8/20, and did not consume any food again until 4/10/20, when she ate 26-50% of breakfast and lunch, and less than 25% of supper. She consumed between zero and 25% of her meals from breakfast on 4/11/20 through breakfast on 4/14/20. She then consumed between 26-50% of lunch on 4/14/20, and then between zero and 25% through 4/15/20, when she was transferred to the hospital. Review of fluid intake documentation indicated the following daily intakes: On 4/8/20, she accepted 900 mL of fluids. On 4/9/20, she accepted 720 mL of fluids. On 4/10/20, she accepted 890 mL of fluids. On 4/11/20, she accepted 290 mL of fluids. On 4/12/20, she accepted 120 mL of fluids. On 4/13/20, she accepted 1300 mL of fluids. On 4/14/20, she accepted 720 mL of fluids. On 4/15/20, she accepted 250 mL of fluids, through 12:59 p.m. On 4/13/20, a care plan meeting was held, with her family present. The therapy department felt she was experiencing a decline. Her family requested lab studies to evaluate for a urinary tract infection [MEDICAL CONDITION] and dehydration; they were concerned about her fluid intake. The DON informed the family staff assisted her with meals and drinking water throughout the day, and informed her family she was currently receiving Glucerna. On 4/14/20 at 1:00 p.m., the Nurse Practitioner (NP) examined the resident per family request, as she had not been herself and was not responding to them. Nursing reported a decreased appetite, and she was not willing to drink much fluid and was pocketing food. Exam revealed dry mucous membranes in her mouth. A urinalysis with culture was ordered due to altered mental status, oral fluids were to be offered often for malaise. Dehydration was suspected, and she was to continue with speech therapy and oral care three times daily, due to dysphagia and food pocketing. A basic metabolic panel (BMP) was ordered for evaluation of her [MEDICAL CONDITION]. Review of a 4/15/20 BMP result indicated it was collected on 4/15/20 at 6:55 a.m. Her sodium was critical, at 166 milliequivalents (mEq) per liter (L) (normal was 137-146 mEq/L). The results were called to LPN 17 at the facility at 10:20 a.m. Her BUN was 113 milligrams (mg) per deciliter (dL) (normal was 7-25 mg/dL) and her creatinine was 5.4 mg/dL (normal was 0.5-1.10 mg/dL). Her glomerular filtration rate (GFR) was 9 milliliters (mL) per minute (min.) (normal was over 60 mL/min). There was no documentation in the clinical record of the medical provider being immediately notified of the critical laboratory results. Her blood pressure at 8:45 a.m. was documented as 100/70. On 4/15/20 at 12:09 p.m., an order was received from the NP for a STAT electrolyte panel. Review of a 4/15/20 electrolyte panel indicated at 1:45 p.m., her sodium remained critically high ([MEDICAL CONDITION]) at 163 mEq/L and her potassium was high ([MEDICAL CONDITION]) at 6.0 mEq/L (normal was 3.4-5.2 mEq/L). Review of a 4/15/20 at 4:19 p.m., NP note indicated a telehealth visit was completed for a change in condition, when the nurse called to inform the NP of critical lab results. Nursing reported she was pocketing all food and pills, refusing to drink and was very lethargic. She had a critically high sodium. Due to dehydration, her diuretic was to be stopped; due to [MEDICAL CONDITION] and acute kidney injury related to dehydration, intravenous fluids were ordered. She had worsening dementia, as she was pocketing food and medication, had no desire to drink fluids, and was minimally responsive. The DON was to call her representative to set up a meeting to discuss hospice services due to the expected continuation of decline, and to decide on PEG tube for nutrition vs. hospice. Review of a 4/15/20 4:45 p.m., progress note, indicated she was unresponsive to verbal stimuli, but did respond to painful stimuli. Critical labs had been called back, and her sodium was 163. Her temperature was 98.5, pulse 95, respiration 12, and blood pressure was 132/78. The doctor was notified and orders received to start IV fluids. The resident's representative was made aware and attempted to talk to the resident; she did make facial movement but did not respond verbally. The representative wanted her sent to the emergency room (ER) for evaluation, and an order was received to send her. Review of a 4/15/20 ER report indicated she arrived at 5:39 p.m. for treatment of [REDACTED]. Review of a hospital History and Physical, dated 4/15/20, indicated she had severe dehydration and appeared very dry with tenting of the skin and dry mucous membranes. She had a significant worsening of her GFR in three weeks, from 44 to 9, likely due to dehydration. During an interview, on 9/1/20 at 1:53 p.m., the DON indicated Resident C's family had complained to her the resident wasn't feeling well and wasn't herself, on the day prior during window visit. It was the DON's first day at the facility, and she assessed her and then contacted the NP. She had not been eating, nor drinking, well that day. The NP indicated she had been declining, and had been speaking to family about hospice. The DON asked for orders for IV fluids, but her family wanted her sent out, so they did. They did not call 911, since she wasn't coding, and used a non-emergent transport service. The nurse who had accepted the call with the critical results no longer worked at the facility, so she was not available for an interview. During an interview, on 9/2/20 at 9:25 a.m. the DON indicated the expectation would be to assess the resident and notify the physician of critical lab results and changes in condition. During an interview, on 9/2/20 at 9:27 a.m., the private ambulance company dispatcher indicated the run sheet on 4/15/20 showed a pick up was scheduled for the resident at 5:15 p.m. and arrived at the facility at 5:18 p.m. During an interview, on 9/2/20 at 9:58 a.m., the DON indicated she had accepted the call with the results of the electrolyte panel. She immediately called the NP, and her family happened to be there for a visit; they wanted her sent to ER.There had been a number of interim DONs at the facility between the time of the annual survey and her start of employment on 4/15/20. 2. Review of Resident L's clinical record was reviewed on 9/2/20 at 8:42 a.m. [DIAGNOSES REDACTED]. She had a history of [REDACTED]. diff.) infection. A 5/29/20, annual, MDS assessment indicated she was cognitively intact and required extensive assistance with ADLs and mobility. She had been in quarantine or isolation precautions for active infectious disease during the assessment period. Review of progress notes and assessments indicated the following: A 6/15/20 NP note indicated she had reviewed the resident's urine culture, which showed a UTI with multiple resistance. She was started on IV antibiotics, and was to be transferred to the ER if no improvement or her vital signs became unstable. A 6/17/20 infection note indicated at 1:15 p.m., she had increased confusion. A 6/17/20 at 10:05 a.m. NP note indicated she had been pocketing her medications in her mouth, and had minimal conversation. She was to be sent to the ER for concern [MEDICAL CONDITION]. A 6/17/20 at 4:22 p.m. eINTERACT Transfer Form indicated she was transported to the ER for abdominal pain. She had a pressure area to her sacrum and a deep tissue injury (DTI) to her left heel, with the center a clear fluid filled blister. She was being treated with an antibiotic via a PICC line for a UTI. She was not as alert, had spoken softly during the day, and was not taking in food or fluids per her usual. She had +3 [MEDICAL CONDITION] to her left arm and +2 [MEDICAL CONDITION] to her right arm. Her medications needed to be crushed due to her change in condition, as she usually took her pills whole. The transfer sheet listed the vital signs completed at 7:41 a.m., which included, but was not limited to, a blood pressure of 115/63 and pulse of 73. Her temperature was last taken at 1:15 a.m., and was 98.2 degrees Fahrenheit. There were no other vital signs documented after 7:41 a.m. A 6/17/20 progress note indicated she was sent to the ER at 5:05 p.m. via a private ambulance transportation company. Review of an ER report, dated 6/17/20 indicated the resident arrived by private ambulance at 5:23 p.m. Her blood pressure was 78/65, pulse 101, and temperature was 98.3 rectally. She had 3+ [MEDICAL CONDITION] to her bilateral hands. Her PICC line to her right upper arm was observed to be intact and patent, but leaking and oozing. A triple lumen [MEDICATION NAME] central line was placed in the ER. At 6:04 p.m., her labs included, but were not limited to, her BUN was 37 mg/dL, creatinine was 2.2 mg/dL, sodium was 132 mEq/L, potassium was 5.4 mEq/L, and GFR was 22 mL/minute. She was admitted to the critical care department with, but not limited to, [MEDICAL CONDITION] with septic shock, acute kidney failure, UTI, and left lower lobe pneumonia. A 6/17/20 hospital History and Physical document indicated a family member had called the facility the night before and was told the resident was unresponsive, and had not been eating or drinking well. Her BUN and creatinine was elevated, and she had no history of [MEDICAL CONDITION]. She was having very little urine output, despite IV fluid boluses. She had a history of [REDACTED]. It was suspected her low blood pressure was partly caused by dehydration, as well [MEDICAL CONDITION]. She had a deep tissue injury to her right heel and an unstageable, necrotic pressure wound to her sacrum; a referral was made to the wound clinic, as her sacral wound may have required debridement. During an interview, on 9/2/20 at 2:48 p.m., the DON indicated the resident was not sent to the ER immediately following the NP's exam and orders at 10:05 a.m., as an IV was to be started and IV antibiotics were to be given- she wasn't just supposed to be sent to the ER. Her representative was requesting she be sent to the hospital and the facility transfer record indicated she went to the ER at 4:30 p.m. During a phone interview, on 9/2/20 at 2:54 p.m., the private ambulance company dispatcher indicated the run sheet on 6/17/20 showed they arrived at the facility at 4:57 p.m., to transport the resident. The ambulance staff was on station when the call was received, so they would have left the station almost immediately after the call was received to schedule the transport. Review of a current facility policy, titled Physician-Family Notification-Change in Condition, revised 11/13/18 and provided by the DON on 9/2/20 at 9:18 a.m., indicated the following: .The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner .(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) . This Federal tag relates to Complaints IN 719, IN 061 and IN 106. 3.1-37(a) 3.1-37(b)

Based on observation, interview, and record review, the facility failed to provide interventions to prevent the development of pressure ulcers, provide treatment for [REDACTED]. This deficient practice resulted in Resident 17 developing an unstageable (full thickness skin or tissue loss with unknown depth) pressure ulcer which was not discovered by the facility. Findings include: 1. During an interview, on 3/2/20 at 9:34 a.m., Resident 17 was seated in her recliner in her room, with a blanket over her legs. She indicated she had some wounds to her lower legs. On 3/6/20 at 8:05 a.m., the resident was seated in her recliner, with a blanket rolled under her left lower leg, near the ankle. Resident 17's clinical record was reviewed on 3/3/20 at 3:06 p.m. [DIAGNOSES REDACTED]. Orders included, but were not limited to, sugar free protein supplement three times daily, [MEDICATION NAME] (insulin) 42 units daily, [MEDICATION NAME] (insulin) per sliding scale four times daily, elastic bandage wraps to bilateral legs twice daily for stasis [MEDICAL CONDITION], and oil [MEDICATION NAME] non-adherent wound dressings to bilateral lower extremities in the evening. A 1/14/20, quarterly Minimum Data Set (MDS) assessment indicated she was cognitively intact. She required extensive assistance with bed mobility, transfers, and ADLs. She was at risk for pressure injuries, and had an unhealed stage 2 pressure injury. She had a current, 2/20/20, care plan problem of a pressure ulcer of the left posterior calf related to immobility. Interventions included, but were not limited to, treatment as ordered, avoid positioning on posterior calf, and footboard to wheelchair. She had a current, 3/14/19 care plan problem of potential for impairment to skin integrity related to aging/disease process, decreased mobility, impaired mobility, incontinence, and fungal [MEDICAL CONDITION]. She had a current, 12/4/19, care plan problem of venous/stasis ulcers of the bilateral lower extremities. Review of a 12/22/19 Braden Skin Risk Assessment indicated she was at moderate risk for developing a pressure ulcer. The clinical record lacked any other skin risk assessments in the clinical record. Review of a 2/20/20 Nurse Practitioner (NP) progress note indicated the resident had a wound to her left posterior thigh. The wound was to be treated with [MEDICATION NAME] iodine and a foam bandage. She was to be followed by the wound nurse, and be provided with off-loading of the area and protein supplements. She had a pending appointment at the [MEDICAL CONDITION] (chronic swelling, usually in the arms and legs) clinic. Review of a 2/20/20 wound assessment indicated she had an in-house acquired, unstageable pressure ulcer to her left posterior calf. The wound measured 2.0 centimeters (cm) length (L) x 2.5 cm width (W) x no depth. It was 100 % covered with necrotic tissue/eschar (hardened dead tissue). The assessment indicated the wound was being treated with [MEDICATION NAME] iodine painting every shift and covered with a foam dressing with each left leg wrap daily. The order for the [MEDICATION NAME] iodine and foam pad was not implemented in the clinical record. Review of a 2/27/20 wound assessment indicated the pressure ulcer to her left posterior calf remained unstageable, measured 2.0 cm L x 2.5 cm W x no depth, and was 100 % covered with necrotic tissue/eschar. The assessment indicated the wound being treated with [MEDICATION NAME] iodine painting every shift. The order for the [MEDICATION NAME] iodine was not implemented in the clinical record. During an interview, on 3/4/20 at 9:35 a.m., Resident 17 indicated the Wound Nurse had done the treatment with [MEDICATION NAME] iodine when the wound was found, but it hadn't been done again. They had left it open at first, but that was uncomfortable, so she has had them put two ABD (gauze pads are used to absorb discharges from abdominal and other heavily draining ) pads on it for cushion. They change the wraps to her legs twice daily, usually around 5:00 a.m. and anytime after 8:00 p.m. They thought the pressure area was caused from the recliner, because it's right where the wound area met the leg rest. She was supposed to get some kind of board for her wheelchair legs, but hadn't gotten it yet. During a interview, on 3/4/20 at 9:55 a.m., the Wound Nurse indicated she had already completed her wound rounds for the week earlier that morning. The resident usually had her treatment done between 5:30 a.m. and 6:30 a.m. and late at night. She received a [MEDICATION NAME] iodine paint to her left leg and wraps bilaterally daily. During an interview, on 3/4/20 at 9:58 a.m., the Wound Nurse indicated she had not yet completed the resident's assessment or treatment for [REDACTED]. During the wound observation, on 3/4/20 at 11:20 a.m., accompanied by the Wound Nurse, she indicated the following: The resident had elastic wraps to her bilateral lower legs, with petroleum dressings sticking out of the top, to her shins. The wound was 2.0 cm L x 2.5 cm W, and had softened and opened, but had lots of drainage. She lowered the wrap on the resident's left lower leg and lifted the leg to make the back of her calf visible. A wound, slightly larger than a quarter, was observed to the back of her calf. The edges were attached from 12 o'clock to 3 o'clock (if the wound was the face of a clock), to a solid, dark brown/black piece of tissue covering the wound bed. The skin surrounding the wound was intact, with a purple discoloration at the edges. She wasn't able to determine if there was tunneling, due to the eschar cap. The wound nurse indicated there had not been a treatment in place, other than off-loading, because she already had her lower legs wrapped daily. The Wound Nurse indicated the [MEDICATION NAME] iodine and foam hadn't been continued, because the resident was scared it would hurt. The resident indicated during the observation, she had minimal pain at the time, but had more at night, which was why she had them add abdominal (ABD) pads under the wraps to cushion the area. She would see if the NP would order a treatment to help debride it. Review of a 3/4/20 wound assessment indicated the pressure ulcer to her left posterior calf remained unstageable, measured 2.0 cm L x 2.5 cm W x no depth, and was improving, but still covered 100% with eschar. There was moderate serous drainage, and the eschar had softened. There were no signs or symptoms of infection and no odor. The edges were well-defined, and she had no pain. A treatment was ordered for medical grade honey and [MEDICATION NAME] gel with foam dressing to be changed every Tuesday and Friday morning, and as needed. Review of 3/5/20 NP progress note indicated the resident reported pain to her posterior left thigh. She denied fever, nausea, vomiting or chills. The wound to her posterior thigh presented with eschar and slough to the surrounding edges, and a moderate discharge with odor. She had an infection of the wound to her left posterior thigh and was to start [MEDICATION NAME] (antibiotic) twice daily for seven days. She was to continue wound care with the wound nurse, continue off loading the area, and protein supplements. During an interview, on 3/5/20 at 9:02 a.m., the resident indicated the facility staff took the pedals off of her wheelchair the day before, which seemed to help the pain when she was up. She never did get the foot board for the wheelchair, they kept talking about it, but never got one. There was nothing added to her recliner, and nothing to her legs other than the two ABD pads under the wraps. She stayed in her recliner throughout the day, after getting up out of bed around 5:30 or so in the morning. She would get up in her wheelchair late in the afternoon or early evening, depending on what activities were going on, and stayed up for supper. During an interview, on 3/5/20 at 9:29 a.m., the NP indicated she had discovered the pressure wound while doing wound rounds with the Wound Nurse. The resident was complaining of pain to the back of her leg while she assessed her lower legs, and the wound was found. She was supposed to be having [MEDICATION NAME] iodine applied to the area, with a foam dressing. She was not aware the treatment was not being completed, and had not seen the wound yet for the week. Wound rounds were usually completed on Thursdays, but the Wound Nurse had completed them the day before for some reason, and she had not been made aware. The NP did not usually come in on Wednesdays. Review of a 3/9/20 at 12:21 p.m. progress note indicated the resident had complained of severe pain to her left lower extremity. A muscle relaxer had been administered, but was not effective. A doppler study and blood work was ordered, and the resident was referred to the wound clinic. She received a one time additional dose of [MEDICATION NAME] for the pain. During an interview, on 3/10/20 at 12:48 p.m., the resident indicated she had not refused the [MEDICATION NAME] treatment, the nurses just hadn't ever done it. 2. During a wound observation with LPN (Licensed Practical Nurse) 28, on 3/5/20 at 10:39 a.m., Resident 38's second toe on her right foot was swollen twice the size of her second toe on her left foot and slightly purple below the knuckle. A cranberry sized opened area was observed to the second toe on her right foot with a dark pink wound bed to the knuckle area. During an interview, on 3/5/20 at 10:58 a.m., LPN 28 indicated the resident's second toe of the right foot had a wound approximately the size of a dime with minimal slough noted at the bottom right base of the wound site. She indicated the resident's entire toe was reddened and swollen. During an interview, on 3/5/20 at 3:24 p.m., LPN 28 indicated the wound on the resident's second toe of the right foot was a pressure ulcer rather than a skin tear. During an interview, on 3/5/20 at 10:39 a.m., Certified Nurse's Aide (CNA) 20 indicated the resident's family bought the resident some new slippers. An observation of the slippers indicated a hard/firm seam to the area lining up with her toe. CNA 20 indicated the wound had been present the entire month she worked at the facility. The resident was observed wearing new thinner slippers without a seam at the toe. Resident 38's clinical record was reviewed on 3/5/20 at 11:00 a.m. [DIAGNOSES REDACTED]. Medications included, but were not limited to, aspirin 81 milligram (mg) once daily, [MEDICATION NAME] 40 mg once daily, [MEDICATION NAME] (blood pressure) 5 mg once daily, glimepiride (diabetic) 8 mg once daily, [MEDICATION NAME] (depression) 25 mg once daily, Pro-Stat Sugar Free (supplement) 30 milliliters (ml) twice daily, [MEDICATION NAME] (pain) 50 mg every four hours as needed, and Xeroform Oil [MEDICATION NAME] (wound) every two days for open wound on bilateral second toes. A quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired. She required extensive assistance for bed mobility, transfers, dressing, and toileting. The MDS indicated the resident was at risk for pressure ulcers and no pressure ulcers were noted. Skin interventions included, but were not limited to, an application of dressings to the feet. A current care plan for a skin tear, dated 2/15/20, indicated the resident had a skin tear to the right second toe. Interventions included, but were not limited to, the resident needed footwear on while up and awake. The clinical record lacked a care plan for pressure ulcers or impaired skin integrity. Review of a physician progress notes [REDACTED]. The note indicated the resident's wound was still open with no eschar or slough. Review of a weekly skin sheet, dated 2/15/20 at 3:23p.m., indicated the skin tear to the resident's second toe on the right foot measured 1 centimeter (cm) x 1 cm x 0.3 cm, the wound was worsening, and no new skin concerns were noted that required physician notification. Review of the clinical record indicated a lack of physician notification on 2/15/20 for the resident's worsened pressure ulcer. Review of a weekly skin sheet, dated 2/20/20 at 10:40 a.m., indicated the skin tear to the second toe on the right foot was improved and measured 0.8 cm x 1 cm x 0.3 cm. Review of a weekly skin sheet, dated 2/27/20 at 1:41 p.m., indicated the skin tear to the resident's second toe on the resident's right foot measured 0.8 cm x 1 cm x 0.3 cm. Review of a weekly skin sheet, dated 3/4/20 at 8:08 a.m., indicated the resident had an open lesion to the second toe on the right foot. The open lesion measured 0.8 cm x 0.8 cm x 0.2 cm and had no signs or symptoms of infection noted. Review of a Braden Assessment, dated 1/24/20 at 8:19 p.m., indicated the resident was not at risk for pressure ulcers. During an interview, on 3/5/20 at 4:07 p.m., the Director of Nursing (DON) indicated the clinical record lacked care plans for a pressure ulcer or impaired skin integrity. During an interview, on 3/10/20 at 9:40 a.m., the DON indicated any change in the appearance or documentation that referenced a worsened wound should have been reported to the physician immediately. She indicated the Wound Nurse is not certified. 3. During a wound observation on 3/5/20 at 2:35 p.m., LPN 28 indicated the Resident 41 had a stage three pressure ulcers to the Achilles region of the right foot which measured 5.7 cm x 2.1 cm x 0.2 cm. LPN 28 described the wound as an open wound with scant slough along the edge of the wound and granulation surrounded the entire wound. The resident's wound had serosanguinous drainage. During the observation, the resident did not have a wound located on the right heel. Resident 41's clinical record was reviewed on 3/03/20 at 4:10 p.m. [DIAGNOSES REDACTED]. Medications included, but were not limited to, [MEDICATION NAME] (antipsychotic) 5 mg daily, [MEDICATION NAME] 15 mg daily, sodium chloride (supplement) 1 gram twice daily, Promod Liquid (supplement) 30 ml three times daily, [MEDICATION NAME] 20 mg (diuretic) twice daily, [MEDICATION NAME] acid (supplement) 500 mg daily, zinc sulfate (supplement) 225 mg once daily, and calcium alginate (wound) every shift. A quarterly MDS, dated [DATE], indicated the resident was not cognitively impaired. The resident required supervision for bed mobility and transfers. He is independent with locomotion on and off the unit. The resident was at risk for pressure ulcers and had stage 3 pressure ulcer present on admission. Skin interventions included nutrition to manage skin problems and an application of dressings to the feet. The clinical record indicated the wound was documented as being on the right heel rather than the right foot Achilles region. The clinical record lacked care plans for pressure ulcers and impaired skin integrity. Review of a weekly skin assessment, dated 2/6/20 at 6:39 a.m., indicated the stage three pressure ulcer to the resident's right heel measured 3.8 cm x 1.3 cm x 0.1 cm. Review of a weekly skin assessment, dated 2/15/20 at 3:00 p.m., indicated the resident's stage three pressure ulcer to the right heel measured 3.6 cm x 1.2 cm x 0.1 cm. The documentation indicated the physician was last notified on 2/13/20 and the family was last updated on 2/15/20. Review of a weekly skin assessment, dated 2/20/20 at 10:03 a.m., indicated the resident's stage three pressure ulcer to the right heel measured 3.6 cm x 1.1 cm x 0.1 cm. Review of a weekly skin assessment, dated 2/27/20 at 9:03 a.m., indicated the resident's stage three pressure ulcer to the right heel measured 3.6 cm x 1.1 cm x 0.01 cm. The skin assessment indicated the wound improved, edges were rolled, and tissue was 95 percent granulation with 5 percent [MEDICATION NAME]. Review of a weekly skin assessment, dated 3/4/20 at 7:28 a.m., indicated the resident's stage three pressure ulcer to the right heel measured 3.6 cm x 1.1 cm x 0.01 cm with moderate serosanguinous drainage. The assessment indicated wound status improved with 10 percent granulation and 90 percent slough. Review of a Braden Assessment, dated 3/06/20 at 4:16 p.m., indicated the resident was at risk for pressure ulcers with a score of eighteen. During an interview, on 3/5/20 at 3:14 p.m., LPN 28 indicated the clinical record lacked a pressure ulcer or skin integrity care plans. LPN 28 indicated the wound measurements were significantly larger on her assessment dated [DATE] compared to the wound measurements documented by RN 9 on the skin assessment dated [DATE]. During an interview, on 3/5/20 at 4:19 p.m., the DON indicated Resident 41's clinical record lacked care plans for impaired skin integrity and pressure ulcers. 4. Resident 19's clinical record was reviewed on 3/4/20 at 9:29 a.m. [DIAGNOSES REDACTED]. Her physicians orders included, but were not limited, prostat sugar free liquid (Amino Acids-Protein Hydolys) 30 ml (milliliter) twice daily, vitamin C 500 mg (milligram) daily for wound healing, zinc sulfate 220 mg daily for wound healing, skin inspection/nursing weekly assessment every nightshift every Monday complete weekly skin observation and wash and pack with CA (Calcium Alginate) rope and cover with dry dressing daily every day shift for wound care. A quarterly MDS (Minimum Data Set), dated 1/22/20, indicated the resident was severely cognitively impaired. She required extensive assistance with bed mobility, dressing, toilet use, personal hygiene. She was totally dependent with two staff members for transferring. She was at risk for developing pressure ulcers/injuries, she had one Stage 2 pressure ulcer that was present upon admission to the facility. She had a pressure reducing device for bed. She received pressure ulcer/injury care. She had a focus care plan, initiated on 9/26/19, indicated she had an open wound under her abdominal fold as well as a large hernia. Her goal was for her wound to heal without complications. Interventions were monitor site for signs and symptoms of infection (ie; increased drainage, foul odor, redness, warmth, etc) initiated on 9/26/2019 and treatment as ordered initiated 9/26/2019. A Braden (pressure ulcer risk assessment) observation indicated the following: a. 9/23/19, she was at risk for pressure ulcer development. b.10/21/19, she was at risk for pressure ulcer development. c. 1/21/20, she was at moderate risk for pressure ulcer development. d. 3/6/20, she was at high risk for pressure ulcer development. A skin and wound evaluation, dated 10/1/19, indicated the resident had an open lesion to her lower right abdomen, it was present on admission and measured 0.8 cm (centimeter) x 1.7 cm x 0.6 cm, there was granulation tissue, light amount of serous exudate, wound edge appeared flush with wound bed or as a sloping edge, surrounding tissue was normal in color, area was improving, no infection was suspected to area. Area looks good and wound edges were clean and normal skin color. The resident was educated on the importance of attending physical and occupational therapy to promote strengthening and to take the pressure off of her body from lying in bed. On 11/8/19 the [MEDICAL CONDITION] measurements were 1.0 cm x 0.7 cm x 1.9 cm. The skin-pressure/diabetic/venous/arterial wound report indicated the following: a. The resident admitted with a stage 2 pressure ulcer. b. On 12/16/19 the measurements were 2.0 cm x 2.0 cm x 2.0 cm. c. On 12/27/20 the measurements were 2.0 cm x 2 cm x 1.5 cm. d. On 1/9/20 the measurements were 0.3 cm x 0.3 cm x <0.1 cm. e. On 1/23/20 the measurements were 0.5 cm x 0.5 cm x 0.1 cm, the wound was unchanged, there was 100% granulation tissue, there was no drainage, the treatment was collagen powder and foam. f. On 2/6/20 the measurements were 0.4 cm x 0.4 cm x 0.1 cm. g. On 2/20/20 the measurements were 1.0 cm x 0.8 cm x 0.5 cm, the wound was improving with 100% granulation tissue, there was small bloody drainage. h. On 2/27/20 the measurements were 0.8 cm X 0.8 cm X 0.4 cm. i. On 3/4/20 she was admitted with a wound to her right abdominal fold and was a stage 2 pressure injury measuring 0.8 cm X 0.8 cm X 0.4 cm, the wound status was unchanged, tissue type was 100% granulation, there was bloody drainage, wound edges were well defined. Interventions were nutrition or hydration intervention to manage skin problems, supplements, predisposing risk factors were immobility and diabetes. A skin - other skin condition report dated 3/6/20 indicated the resident had pressure, to her lower abdomen measuring 2.0 cm x 0.7 cm x 0.4 cm, it was worsening, area measured larger than prior measurements. The treatment was wash and pack with calcium alginate rope and cover with dry dressing daily, the resident had complaints of pain, [MEDICATION NAME] was given and no change was needed to her care plan. During an observation of Resident 19's abdominal wound, on 3/5/20 at 10:54 a.m. with LPN 71 and QMA 79. QMA 79 was holding the resident's large abdominal hernia up, under the hernia located in the middle of the residents abdomen in the resident abdominal fold. Serous drainage was visible on the old dressing. The area was nickel size, with granulation tissue and depth visible. LPN 71 cleansed wound with wound spray and 4 x 4 gauze pad, cut a 1 inch of calcium alginate rope and packed the wound with the rope using a cotton tipped applicator. LPN 71 indicated the wound was pressure related due to the resident's hernia was lying on top of it and it was a stage 3. During a wound measurement observation with the Interim DON and QMA 79 on 3/06/20 at 12:01p.m., the wound measured 2 cm x 0.7 cm x 0.4 cm, the DON indicated she thought the wound was a stage 2, after reviewing the NPUAP (National Pressure Ulcer Advisory Panel) pressure injury staging definitions on Point Click Care, she indicated it would be a stage 3. NPUAP pressure injury staging definition on Point Click Care indicated the following: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Review of a current facility policy, titled Skin Condition Assessment & Monitoring - Pressure and Non-Pressure, dated 6/8/18 and provided by the Interim DON on 3/5/20 at 12:21 p.m., indicated the following: .Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented .A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified .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 .Wound Assessment/Measurement: .2. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. Physician and responsible party notification will be documented in the clinical record. These changes include, but are not limited to: a. new onset of purulent drainage b. new onset of odor .6. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care .7. Physician ordered treatments shall be initiated by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses notes. 3.1-40(a)(1) 3.1-40(a)(2)

[NAME] Based on record review and interview, the facility failed to adequately monitor and document blood sugars for 1 of 3 residents reviewed for insulin (Resident C). This resulted in the resident receiving a large amount of rapid-acting insulin, without documented indication, and without monitoring or assessment following the insulin administration and Resident C died the next morning after the administration. B. Based on record review and interview, the facility failed to assess and monitor a gangrenous foot ulcer for 1 of 5 residents reviewed for skin condition monitoring. (Resident C). The immediate jeopardy began on [DATE], when a large dose of Humalog (rapid acting) insulin was given to Resident C, without documentation of resident blood sugar result prior to administration, assessment, or physician notification, other than an order. The resident received Basaglar (long acting) insulin within hours of the Humalog, without monitoring or assessment. The resident was found unresponsive the following morning, and subsequently died (Resident C). The Administrator, DON, and ADON, were notified of the immediate jeopardy on [DATE] at 2:21 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of no actual harmwith potential for more than minimal harm that is not immediate jeopardy. Findings include: [NAME] Resident C's closed clinical record was reviewed on [DATE] at 12:45 p.m. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. She had an order for [REDACTED]. The record lacked a plan fo care for diabetes. There was one blood sugar reading in the clinical record, on [DATE], for 42 milligrams per deciliter (mg/dL). Review of the resident's (MONTH) 2019 Medication Administration Record [REDACTED] The clinical record lacked a follow up blood sugar reading or assessment, following administration of the Humalog insulin. Review of a [DATE] progress note indicated at 7:33 a.m. the resident was found in her wheelchair, with her head completely back. She was unresponsive, with a blood sugar of 42 mg/dL at the time. [MEDICATION NAME] was given intramuscularly, vital signs were attempted, but pulses were not able to be palpated; her skin was cool to the touch. Due to a full code status, 911 was called, and help obtained from the other hall to assist in moving her to the bed. Once she was placed in the bed, copious amounts of old dark blood was pouring from her mouth and nose. The Crash Cart was brought to the bedside. Neither pulses, nor breath sounds were able to be auscultated, and the resident's mouth tissue was very pale, and her eyes were fixed. Emergency Medical Services arrived, and agreed to not start CPR, as no respirations or pulses were noted. Review of a [DATE] Code Blue Note indicated the last time the resident was seen was on [DATE] at 5:30 a.m., sitting in her wheelchair, per report from the night shift nurse at the beginning of the day shift. During an interview, on [DATE] at 1:41 p.m., RN 13 indicated glucose readings would be documented in the computer (in the electronic clinical record). During an interview, on [DATE] at 1:46 p.m., RN 13 indicated she had been on duty the day Resident C had died . Her shift started at 6 a.m., and the night shift nurse had observed the resident sitting in her wheel chair at 5:30 a.m. RN 13 had not observed her until it was time to do her blood sugar, between 7:10 a.m. and 7:15 a.m. When she entered the resident's room, the resident was seated in her wheelchair, with her head totally back. RN 13 knew the resident was a brittle diabetic, and her blood sugar was around 41 mg/dL, so she had gotten the [MEDICATION NAME] injection, and as she was administering the injection, she realized the resident was dying, or had died . She needed assistance to transfer the resident into bed, so she called 911, and then went to find help. When staff transferred her into the bed, black and dark brown liquid came out of her mouth, like old blood. Maybe 10 minutes had passed; the resident was cold to touch, but not rigid. By the time EMS had arrived, it was confirmed she was dead, and beyond CPR. During an interview, on [DATE] at 9:10 a.m., the DON indicated the facility had not been double-checking new orders at the time of the resident's admission. During an interview, on [DATE] at 12:34 p.m., Nurse Practitioner 15 indicated she did not recall getting a call or giving the order for Humalog, due to the quantity of calls she received. She did not have a record of the call. During an interview, on [DATE] at 12:46 p.m., RN 13 indicated she thought the resident's blood sugar had been over 500 mg/dL, when she had notified the Nurse Practitioner and received the Humalog order. The elevated blood glucose had been noted during a routine check, and the way the resident's orders were entered into the clinical record didn't allow for staff to enter the amounts. She had not rechecked the resident's glucose herself, since she had gotten the order late, but she was sure the oncoming nurse would have rechecked it, and would have offered her juice throughout the night. Review of a current facility policy titled Physician Orders-Entering and Processing, dated [DATE] and revised on [DATE], indicated the following: .6. Verbal and Telephone orders will be documented as such in the Electronic Medical Record Review of a current, undated, facility policy, titled Documentation Procedures and Guidelines, provided by the ADON on [DATE] at 9:54 a.m., indicated the following: Purpose: 1. To reflect the quality of care provided to each resident. 2. To document the resident's progress toward care plan goals, interventions and responses to treatment. 3. To serve as the basis for monitoring activities, education programs, risk management, and other management statistics .General Guidelines .3. Any change in condition, will require a written evaluation .Documentation: 1. Each health care professional shall be responsible for making their own prompt, factual, concise, entries that are complete, appropriate, and readable .3. Entries will be made whenever there is a change in the resident's condition. The entry will include interventions and appropriate notifications made in a timely manner .7. Verbal and telephone communication with all parties concerning the care and treatment of [REDACTED]. The immediate jeopardy that began on (MONTH) 21, 2019, was removed on (MONTH) 1, 2019, when the facility began inservicing staff on the facility's policy on adequate monitoring and documentation of blood sugars and required clinical documentation, assessment, physician notification of change in condition and accurate monitoring of those residents receiving insulin, but non-compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the inservicing had not been completed for all staff and monitoring to ensure staff was following the plan was completed. B. Review of Resident C's closed clinical record was reviewed on [DATE] at 12:45 p.m. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. She had a [DATE] order to leave the bandage in place on her left foot. A [DATE] re-admission note indicated she was alert and oriented to person, place, and time. She had a dressing in place to her left foot. A [DATE] progress note indicated she required limited assistance with ADLs and mobility. Review of a [DATE] discharge orders/summary, from the long term care facility the resident transferred from, indicated she had a surgical wound to her second toe of her left foot, and a necrotic third toe. The facility had been treating her foot with physician ordered daily gauze wraps to her left foot and toes. There was no treatment order in the clinical record for the treatment of [REDACTED]. There were no assessments of the wound in the clinical record. She had an [DATE] care plan problem of left toe amputation, revised on [DATE]. The intervention was to keep the incision site clean and dry. Review of a [DATE] readmission assessment indicated the resident had returned to the facility from the hospital, following a toe amputation due to gangrene and [MEDICAL CONDITION]. There was no indication in the clinical record of when the resident had left the facility for the surgery. Her last assessment was completed on [DATE]. During an interview, on [DATE] at 9:10 a.m., the DON indicated the facility had not been double-checking new orders at the time of the resident's admission. Review of a current, undated, facility policy, titled Documentation Procedures and Guidelines, provided by the ADON on [DATE] at 9:54 a.m., indicated the following: Purpose: 1. To reflect the quality of care provided to each resident. 2. To document the resident's progress toward care plan goals, interventions and responses to treatment. 3. To serve as the basis for monitoring activities, education programs, risk management, and other management statistics .General Guidelines .Documentation: 1. Each health care professional shall be responsible for making their own prompt, factual, concise, entries that are complete, appropriate, and readable This Federal Tag relates to Complaint IN 471. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to provide competent resident care by failure to use a gait belt during a transfer and failure to have a post surgical stump protector in place for 1 of 1 residents reviewed got accidents. This deficient practice resulted in the resident requiring surgery to repair the open wound. (Resident C) Findings include: The clinical record for Resident C was reviewed on 4/24/19 at 10:38 a.m. [DIAGNOSES REDACTED]. Resident C was admitted to the facility on [DATE]. A current care plan, dated 4/20/19, indicated the resident had limited physical mobility. An intervention was implemented on 4/20/19 which indicated the resident was non-weight bearing on his lower left extremity. Review of a hospital Discharge Disposition, dated 4/19/19, indicated the resident was to be non-weight bearing on the left leg and to keep the Rooke (rigid protector for [MEDICAL CONDITION] to prevent dehiscence in the event of a fall) in place at all times. The Rooke could be removed during knee range of motion exercises. The discharge summary also indicated to change the dressing to the wound after two days. The dressing was changed on discharge (4/19/19). A fall risk assessment, dated 4/19/19, indicated the resident scored an 8, which indicated he was not a fall risk. A 72- new admission progress note, dated 4/21/19 at 6:08 a.m., indicated the resident was unable to walk. He was limited assistance with personal hygiene and required one person physical assistance. A progress note, dated 4/21/19 at 10:49 a.m., indicated the resident was being sent to the emergency room after his wound dehisced after hitting it while getting into the shower. Review of a facility reported indecent, dated 4/21/19 at 10:30 a.m., provided by the Administrator on 4/24/19 at 9:20 a.m., indicated the Administrator was contacted by a family member of Resident C. She voiced a concern related to the wound re-opening during a fall in the shower. An investigation was initiated by the Administrator and included the following: a. An interview statement by CNA 2, dated 4/23/19, indicated LPN 3 stated to the aides the resident requested a shower. The resident had his right prosthetic leg, grabbed his walker and walked to the shower. CNA 2 was being assisted by CNA 4. A CNA was on each side of the walker when the resident's foot or walker got caught on the rubber piece across the shower floor. The resident leaned forward with his head resting on the wall. CNA 2 grabbed him from behind to keep him from going down. The CNAs then lowered the resident to the toilet seat riser. CNA 4 then noticed blood dripping after they sat him down. The CNA then yelled for the nurse and LPN 3 came to assess the resident. CNA 2 indicated the resident did not fall, but stated when he had his head against the wall, he hit the leg stump on the raised shower seat bracket. She indicated they were not using a gait belt during the transfer. b. An interview statement by CNA 4, dated 4/23/19 at 11:55 a.m., indicated they were not using a gait belt during the transfer. c. An interview statement by CNA 4, dated 4/24/19, indicated the incident occurred on 4/21/19. Both herself and CNA 2 went into the residents' room to assist with a shower. The resident wanted to shower himself, but they stayed with him. The resident indicated he needed to use the bathroom first and they assisted him to the bathroom and told him to put his light on when he was finished. He put his call light on and they went back in to help with his shower. The shower seat was down and there was not enough room for all of them, so they lifted up the shower seat. He used his walker and prosthetic leg to hop into the shower. His walker got caught and he almost fell , but they grabbed him and helped him sit down on the shower chair when they noticed his stump was bleeding. CNA 4 left to get the nurse at that time. During an interview 4/24/19 at 11:52 a.m., CNA 4 indicated she put a bag over the dressing before the shower and the dressing was clean and dry. The resident was not left alone during his shower, but they did leave the room when he was using the bathroom. During a family interview on 4/24/19 at 11:57 a.m., she said they asked him how he wanted to take a shower. He had his prosthetic leg on as he was hopping to the shower, he lost his balance and staff grabbed him. He slipped again and that was when he hit his stump on the strip that divided the shower. She indicated he should have not been asked how he wanted to transfer and they should of used a gait belt. He had a second surgery the day before (4/23/19) to repair the wound and was in a lot of pain. She indicated the resident had the Rooke in his room since admission. During an interview on 4/24/19 at 2:34 p.m., CNA 2 indicated the nurse said the resident had asked for a shower. He had initially said he wanted to do it by himself, but they did help him. Both CNA 2 and CNA 4 were on each side of his walker and they were going into the bathroom, he turned his walker and either his foot or walker got stuck. She grabbed his waist, then set him right on the shower seat. The other aide saw his leg wound was dripping blood. LPN 3 came and took the gauze off. The resident became light headed so they moved him back to bed. He did not want to call his wife because she was going to be very angry. She felt like he hit the base of the shower seat. She stated he leaned forward and when they had him, he did not slip again. She normally used a gait belt, but he was adamant about it and she felt he would have moved himself if she had left him. During an interview on 4/24/19 at 2:58 p.m., the interim Director of Nursing (DON) indicated the previous management cleaned out their desks in the middle of the night and left. She does not believe they were double checking the orders. The resident was sent to the hospital before she had a chance to review his orders. She indicated this all happened on the weekend and they would have caught the error when they reviewed the orders on Monday. When they have an admission and there are two nurses' present, they do not make sure the orders are put into the computer correctly. She did come in to do his dressing change on Saturday (4/20/19). The nurse who entered the orders into the computer, did not enter a date for the next dressing change. The physician orders [REDACTED]. Review of the (MONTH) Treatment Administration Record (TAR), the dressing was changed on 4/20/19 and 4/21/19. Review of a facility policy, dated 11/28/12, titled,Fall Prevention Program was provided by the Administrator on 4/24/19 at 5:15 p.m. The policy indicated the following: Purpose: To assure the safety for all residents in the facility implementation of appropriate interventions to provide necessary supervision and assistive devices Guidelines: .Use and implementation of professional standards of practice Care plan incorporates: .Preventative measures Standards: .The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. A second facility policy, dated 8/22/17, titled Physician Orders-Entering and Processing was provided by the Administrator on 4/24/19 at 5:15 p.m. The policy indicated the following: Guidelines: .3. Notify the resident's physician (if not the prescribing physician), for verification if applicable . 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify a resident's physician of a significant change in condition for 1 of 4 residents reviewed for quality of care. This deficient practice resulted in the resident having a low blood pressure and the staff member not notifying the physician or providing treatment for [REDACTED]. (Resident E) Findings include: The clinical record for Resident E was reviewed on [DATE] at 2:58 p.m. [DIAGNOSES REDACTED]. The 5-day Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact, required two person assistance for bed mobility, transfers, dressing and hygiene. The resident had an active discharge plan to return to the community. He was admitted to the facility on [DATE] and expired [DATE]. A health care plan, dated [DATE], indicated the resident was a Do Not Resuscitate (DNR). Interventions included, but were not limited to, notify physician of changes and administer medications as ordered. Another health care plan, dated [DATE], indicated the resident had [MEDICAL CONDITION]. Interventions included, but were not limited to, monitor for difficulty of breathing and remind resident to not push beyond endurance. A new admission progress note, dated [DATE] at 2:48 a.m., indicated the most recent vital signs were completed on [DATE] at 6:48 p.m. and included a blood pressure of ,[DATE] and pulse 94. The resident was on 3 liters of oxygen with a saturation of 92%. No new vital signs were obtained. The 72-hour admission progress note, dated [DATE] at 10:48 a.m., indicted the most recent vital signs were completed on [DATE] at 6:48 p.m. and included a blood pressure of ,[DATE] and pulse 94. No new vital signs were obtained. The resident had shortness of breath with exertion, sitting or at rest. Lung sounds were diminished and he had a productive cough. He was receiving 2 liters of oxygen. A progress note, dated [DATE] at 4:30 p.m., indicated the resident was noted to have been wheezing while lying in bed. He had refused to wear his [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) machine. The Nurse Practitioner was notified and ordered breathing treatments twice daily, started an antibiotic and ordered a chest x-ray. An order was put into the computer on [DATE] at 5:13 p.m. for [MEDICATION NAME] (antibiotic for bacterial infections). He was to be given 500 mg on the first day, then 250 mg for an additional four days for pneumonia. The 72-hour admission progress note, dated [DATE] at 6:48 p.m., indicted the most recent vital signs were completed on [DATE] at 6:48 p.m. and included a blood pressure of ,[DATE] and pulse 94. No new vital signs were obtained. The 72-hour admission progress note, dated [DATE] at 2:48 a.m., indicted the most recent vital signs were completed on [DATE] at 6:48 p.m. and included a blood pressure of ,[DATE] and pulse 94. He was receiving 2 liters of oxygen. A progress note, dated [DATE] at 9:27 a.m., indicated the resident had a blood pressure of ,[DATE] at 8:38 a.m. and a pulse of 68 at 8:40 a.m. The resident was unresponsive and/or vegetative state and he had shortness of breath on exertion. A progress note, dated [DATE] at 12:45 p.m., indicated the nurse went to check on other residents when the x-ray technician arrived and came out of Resident E's room and said he was not breathing. The nurse and a second nurse checked the residents code status and verified he had no vital signs. The clinical record lacked notification to the physician of the blood pressure obtained on [DATE]. During a telephone interview on [DATE] at 3:02 p.m., LPN 4 indicated she was unsure if the resident was unresponsive as she documented and hoped if he had a blood pressure that low she would have notified the physician, but if nothing was charted, then she probably did not. She indicated she would have held the resident's blood pressure medication as well. The facility did have a policy on parameters outside normal ranges, but it varied for each resident. She indicated a blood pressure of ,[DATE] would have concerned her. Review of a current, dated [DATE], facility policy titled Vital Signs Monitoring, provided by the DON on [DATE] at 4:35 p.m., indicated the following: Guidelines: The following are guideline for normal parameters. Physician should be notified of abnormal .based on baseline results, clinical judgement and condition of the resident Blood pressure ,[DATE] mm HG This Federal Tag relates to complaints IN 201 and IN 392. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to provide Intravenous Fluids (IV) as ordered by the physician for 1 of 4 residents reviewed for medication and/or fluid administration (Resident B). This deficient practice resulted in hospitalization for dehydration. Findings include: The closed clinical record for Resident B was reviewed on [DATE] 10:23 a.m. The resident [DIAGNOSES REDACTED]., malformation of coronary vessels and heart failure. A quarterly Minimum Data Set assessment, dated [DATE], indicated the resident was severely cognitively impaired. The resident was admitted to the facility on [DATE] and expired [DATE]. A current care plan titled, Potential for infection R/T (related to): Midline IV cath. Interventions included, but were not limited to, administer IV fluids as ordered. A change of condition text, dated [DATE] at 10:13 a.m., indicated the resident was experiencing a change of condition. The concern indicated Food and/or fluid intake (decreased or unable to eat and/or drink .) A physician acute visit, dated [DATE] at 10:16 a.m, indicated .pt (patient) is lethargic and difficult to arouse, non-verbal at baseline .no PO (by mouth) intake at this time The [DIAGNOSES REDACTED]. The plan of care included to place a midline catheter (intravenous catheter) and to start IV fluids of normal saline at 100 mL per hour. If no improvement within 48 hours, send to the emergency room . A IV catheter insertion record, dated [DATE] at 7:45 p.m., indicated a midline catheter was placed in the right, upper arm without difficulty. The record indicated an X-ray was not indicated to verify placement and the line could be used immediately. A progress note, dated [DATE] at 3:36 p.m., indicated the resident was taken by ambulance to an acute care hospital related to a decline in daily living. Review of a delivery receipt, dated [DATE] at 5:17 p.m., indicated 3 bags of 1000 mL IV sodium chloride 0.9 % were delivered for infusion. Review of the Medication Administration Record [REDACTED]. The order was dated [DATE] at 3:10 p.m. and discontinued [DATE] at 11:48 a.m. There was no documentation to indicate the fluids had been administered. On [DATE] at 9:00 a.m., LPN 1 indicated the fluid was in place on the MAR indicated [REDACTED] The resident returned to the facility on [DATE] at 11:52 a.m. with hospice care. Resident B was pronounced deceased on [DATE] at 9:15 a.m. in the facility. During an interview on [DATE] at 2:46 p.m., the Administrator indicated he could only find a charge for the IV pump. He did not find where the resident was charged for any IV fluids. During an interview [DATE] at 9:21 a.m., LPN 1 indicated she was not in the facility when the midline was inserted. She was leaving and did overhear the physician order [REDACTED]. She called for the midline to be placed and then her shift was done. She returned to work the following day at 6:00 a.m. and the IV fluids were infusing. She did not hang any bags as he went to the hospital before it was due to be changed. The nurse who was on duty had not worked for the facility for about six weeks. On [DATE] at 10:01 a.m., the Director of Nursing indicated she did not find any charge slips from the Emergency Drug Kit for IV fluids for Resident B. Review of a current policy, titled Continuous Infusion of Medications and Solution, dated [DATE] and revised [DATE] was provided by the Administrator on [DATE] at 12:22 p.m., indicated the following: .Considerations: 1. Infusion therapy must be administered as ordered to maintain response in the patient Guidance: .3. The nurse will monitor the vascular access site at least every 2 hours and prn (as needed) for signs and symptoms of complications. .5. Flow rate and condition of the vascular access site will be documented at least every shift Procedure: .26. Documentation in the medical record includes, but is not limited to: 26.1 Date and time .26.5 Site assessment 26.6 Complications This Federal tag relates to complaint IN 202 3XXX,[DATE](a)(2)

Based on record review and interview, the facility failed to ensure 1 resident in a sample of 4 was free from a significant medication error resulting in the resident experiencing a change in mental status which required IV fluids and lab tests being done. (Resident B) Findings include: The clinical record of Resident B was reviewed on 6/23/2016 at 7:44 a.m. [DIAGNOSES REDACTED]. Review of a nursing note, dated 6/13/2016 at 3:52 a.m., indicated Resident B was started on [MEDICATION NAME] (muscle relaxant) 800 mg three times a day for muscle spasms. Review of a nursing note, dated 6/13/2016 and the MAR (medication administration record) for June 2016, indicated Resident B received one dose of [MEDICATION NAME] on 6/13 and another dose on 6/14/2016. Review of a nursing note, dated 6/14/2016 at 2:07 p.m., indicated the order for [MEDICATION NAME] was discontinued by the NP (nurse practitioner). Review of the nursing note, dated 6/15/2016 at 3:20 a.m., indicated the following: guest (sic) continues to show signs of confusion. Guest is oriented to place and time. Guest is having episodes of fright and asking where everyone is and thinks she is by herself. This nurse continues to remind guest that she is in a medical facility where there is staff 24 hours. guest (sic) states she is hearing daughter when daughter is not present. she (sic) is also seeing moving ceiling tiles, and having visuals of daughter in the walls. daughter (sic) staying in room with guest for the night. daughter (sic) stated that guest explained to daughter that she is afraid of this nurse poisoning her and out to get guest Review of a nursing note, dated 6/15/2016 at 7:08 a.m., indicated the following: Spoke with (name of physician) regarding guest's continued increased confusion with visual and tactile hallucinations reported by staff and daughter. Order for CBC, Renal Panel and Doppler to right knee. (Name of surgeon) has been in contact with (name of physician) regarding guest. (name of physician) to come in to assess guest .Daughter at bedside and discussed medication review; new medication [MEDICATION NAME] was discontinued 6/14 and guest started on [MEDICATION NAME] yesterday for pain control as opposed to [MEDICATION NAME]. Daughter indicated that confusion was better today than last night. Guest in bed resting quietly with no complaints at this time. Review of a nursing note, dated 6/15/2016 at 7:59 p.m., indicated Resident B was seen by the physician due to recent episodes of confusion. The physician ordered labs, a peripheral IV placement and normal saline to be given at 75 ml per hour intravenously over 48 hours. During an interview on 6/23/2016 at 3:40 p.m., the Administrator indicated a nurse had given medication to Resident B without an order from the physician or the NP. She wrote a nursing note indicating she gave [MEDICATION NAME] after she wrote an order for [REDACTED]. During an interview on 6/23/2016 at 3:53 p.m., the DON (Director of Nursing) indicated the NP contacted her and informed her a nurse had written an order and given medication without speaking to the NP or the physician. On 6/13 she wrote the order to start the medication on 6/14 and gave the resident a dose at that time. On 6/14 she (Resident B) got the second dose and started having some confusion. The medication was discontinued after the second dose. We reached out to the NP on 6/14 to get the medication discontinued. The DON indicated Resident B was assessed by the physician, labs were ordered, IV fluids were administered and Resident B discharged to home on 6/17/2016. She (Resident B) started clearing up and got better. She discharged to home. The DON indicated nursing staff should never write an order for [REDACTED]. During an interview on 6/24/2016 at 7:23 a.m., LPN #2 indicated nurses must obtain an order from the physician or the NP before administering any medication or treatment. LPN #2 indicated nurses should never borrow medication from one resident to give to another resident. During an interview on 6/24/2016 at 7:36 a.m., RN #3 indicated the nurse must communicate with the physician any medical concerns and follow the physician orders. RN #3 indicated using a resident's medication for another resident was not allowed. If you run out of a medication before it is refilled you can usually get it from the EDK (emergency drug kit). You shouldn't use medications from someone else. This federal tag relates to Complaint IN 838. 3.1-25(b)(7) 3.1-25(b)(9) 3.1-48(c)(2)

A. Based on observation, interview and record review, the facility failed to prevent the development of a pressure ulcer, resulting in a stage 2 pressure ulcer which progressed to a stage 4 ulcer for 1 of 3 residents reviewed (Resident G). B. The facility also failed to ensure a resident with multiple pressure areas received proper skin treatments in accordance with his plan of care for 1 of 3 residents reviewed (Resident I). This deficient practice resulted in Immediate Jeopardy. This Immediate Jeopardy began on 3/22/14 when the facility failed to identify a resident with a stage 2 pressure area to her coccyx, which quickly progressed to a stage 4 ulcer. The Administrator, Director of Nursing and the Corporate Nurse were notified of the immediate jeopardy on 4/4/14. The Immediate Jeopardy was removed on 4/7/14 but the noncompliance remained at the lower scope and severity with no actual harm but potential for more than minimal harm that is not immediate jeopardy when the facility developed and had implemented a systematic plan of correction but had not fully implemented the plan. Findings include: A. 1. The clinical record of Resident (G) was reviewed on 4/3/14 at 2:00 p.m. [DIAGNOSES REDACTED]. Resident (G) was admitted to the facility on [DATE]. Resident (G) was observed briefly on 4/3/14 at 1:45 p.m. She was observed to have a healing left black eye and was found to have just returned to the facility still wearing a hospital gown. She was in a low bed with a low air-loss mattress. Bed alarms were in place. During an interview at that time, Resident (G) was unable to recall how she got the black eye. LPN #1 entered the room and indicated the resident had just returned from the hospital and was a little confused. During record review, an initial nursing admission assessment, dated 3/7/14 at 5:51 a.m., indicated Resident (G) was alert and oriented to self. She had no recent history of nutrition concerns, hydration concerns or weight loss, but had a [DIAGNOSES REDACTED]. She was dependent on staff for bathing, eating and toileting. She had occasional pain related to a right humerus fracture of her right arm. The full body skin inspection indicated a surgical incision with 18 staples to her right should and an upper forearm bruise. She was at risk for developing pressure ulcers. The initial skin interventions included a pressure reducing mattress, chair or wheelchair cushion and incontinence management. A change of condition Situation, Background, Assessment and Recommendation (SBAR) report, dated 3/16/14 at 10:30 p.m., indicated Resident (G) was observed to have an open area, stage 2 pressure ulcer on her coccyx. The area measured 3.0 cm x 1.0 cm x 0.3 cm. No tunneling or undermining was noted. The area was without drainage and non-granulating. The Nurse Practitioner (NP) was notified and a new order for DuoDerm treatments every 3 days and as needed was received. A pressure evaluation record, dated 3/16/14, indicated a stage 2 pressure area to the coccyx. The wound measured 3.0 cm x 1.0 cm x 0.3 cm. A SBAR report, dated 3/27/14 at 11:00 a.m., 11 days later, indicated a CNA reported during care she observed an open area on the coccyx. During the assessment, 3 wounds were observed. The first wound was noted at the top of the sacral. The wound measured 2.1 cm x 2.2 cm x 1.5 cm with undermining from 6-12 o'clock with 4.3 cm in depth. The wound had moderate amounts of yellow drainage and a foul odor was noted. The wound bed contained 90% slough and the edges were rolled under. The second wound was noted also at the top of the sacral, but slightly to the left side, under the first wound. The wound measured 1.0 cm x 1.0 cm with no drainage and 100% eschar to the wound bed. The area was not opened. The third wound was noted at the top/middle of the buttocks, just beside the second wound. The wound measured 1.3 cm x 1.0 cm x 0.1 cm. A small amount of clear drainage was noted and the wound bed was noted to have had [MEDICATION NAME] tissue. The physician and family were notified of the wounds. A new order was received for [MEDICATION NAME] (antibiotic) 500 mg daily for 7 days, [MEDICATION NAME] (antibiotic) 1 gram intravenous, twice daily for 10 days, [MEDICATION NAME] (pain medication) 5/325, 1 every 4 hours as needed for moderate pain and two for severe pain. The wounds were cultured and a low air-loss mattress was ordered. The pressure evaluation records, dated 3/27/14, indicated the same measurements, color and drainage as above. The first wound was listed as a stage 3 pressure ulcer. The second wound was listed as unstageable. The third wound was listed as a stage 2 pressure ulcer. The physician order [REDACTED]. The dressing was to be changed daily and as needed. The second wound was to be cleaned with normal saline, [MEDICATION NAME] to the peri-wound and TheraHoney towards the wound bed and covered with a thick foam dressing. The dressing was to be changed daily. The third wound was to be cleaned with normal saline and [MEDICATION NAME] to the entire area then covered with foam dressing. The dressing was to be changed daily. An SBAR, dated 3/28/14 at 1:30 p.m., indicated the physician was notified Resident (G) had been medicated with the strongest pain medication ordered and continued to scream and cry during and after treatment. The physician declined additional pain medication indicating he would review the pain medication later. Resident (G) was admitted to the hospital on [DATE] for a large decubitus ulcer on the coccyx full-thickness grade 4. She was given [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) during her admission. The hospital records indicated her physical activity after discharge could gradually resume but, she was currently on bed rest related to a fractured right humerus and large coccyx decubitus ulcer. Physical therapy would be difficult secondary to dementia. Resident (G) was discharged from the hospital and returned to the facility on [DATE]. The wound care instructions included packing the decubitus ulcer with [MEDICATION NAME] gauze and then cover with a 4 x 4 dressing soaked in Dakin's (antiseptic solution). The wound was then to be covered with [MEDICATION NAME]. An oral antibiotic was ordered for 10 days. A health care plan problem, dated 3/8/14, indicated the resident had the potential for impaired skin integrity related to impaired mobility, cognitive deficits and incontinence. The interventions for the problem included, but were not limited to, observe skin integrity during am/pm care, evaluate skin weekly and encourage repositioning. Another health care plan problem, dated 3/8/14, indicated Resident (G) had a self-care deficit related to a fractured right humerus. The problem indicated she was an extensive transfer, ambulation, locomotion, hygiene, bathing and dressing. She was dependent on staff for toilet use. The interventions included, but were not limited to, two person for transfer and bathing and one person assist for dressing, toilet use and personal hygiene. A current health care plan problem, dated 3/27/14, indicated an actual pressure ulcer. The interventions for the problem included, but were not limited to, pain medication prior to wound care, assess pressure ulcer weekly by licensed nurse and reposition every one hour in bed. No care plan was produced for the initial 3/16/14 pressure ulcer. The most recent Minimum Data Set (MDS) assessment indicated Resident (G) was severely cognitively impaired. Resident (G)'s active [DIAGNOSES REDACTED]. Her current swallowing and nutritional status indicated no symptoms of a swallowing disorder. Resident (G) had no recent weight loss in the past 6 months. Her skin condition indicated no risk of developing a pressure ulcer and no history of an unhealed pressure ulcer. She had a current surgical wound and skin tear. Resident (G) received the following Activities of Daily Living (ADL) assistance; transfer-total dependence with two person physical assist, ambulation-did not occur, dressing, eating, toilet use and person hygiene-extensive assist with one person physical assist. Resident (G) was frequently incontinent of urine and continent of bowel. The pressure evaluation records, dated 4/3/14, indicated a stage 3 coccyx wound. The wound measured 4.6 cm x 2.2 cm x 1.0 depth. The wound bed contained 100% eschar, light serosanguineous drainage that was malodorous. The treatment stated "tx-hosp-[MEDICATION NAME], gauze, Dakin's solution. No tunneling or undermining was listed. During observation of wound care on 4/3/14 at 2:45 p.m., RN #2 and an unidentified CNA, rolled Resident (G) onto her left side for treatment. RN #2 removed the old, undated, timed or initialed dressing and exposed a large open area with tendon and/or bone exposed. The most recent pressure evaluation dated 4/3/14, indicated a stage 3 pressure ulcer. The area was left open and the DoN was asked to come and observe the area. On 4/3/14 at 2:50 p.m., the DoN observed the pressure wound and indicated the wound was a stage 4. She proceeded to measure the wound. The wound measured 4.6 cm x 2.5 cm and the depth varied around the bone. The wound had undermining from 7-5 o'clock. The wound bed contained 75% slough and had heavy, serosanguineous drainage. The wound edges were rolled under. The resident continued to cry and complain of pain. The DoN asked RN #2 if the resident had been pre-medicated with pain medication, RN #2 stated "no". The treatment was then put on hold until pain medication had been given with some relief. On 4/3/14 at 3:45 p.m. RN #2 indicated Resident (G) was ready for her treatment. LPN #3 indicated Resident (G) had been given her oral pain relief medication. Resident (G) was rolled onto her left side by an unidentified CNA. RN #2 indicated for LPN #3 to remove the [MEDICATION NAME] from the bottle and cut a strip. LPN #3 removed approximately 18 inches from the bottle, crumpled the dressing in her right hand then poured the Dakin's solution into her hand and over the dressing. RN #2 then took the soaked dressing and applied it directly into the wound. The wound was then covered with a dry 4 x 4 gauze and secured with [MEDICATION NAME]. The dressing was not dated, timed or initialed by RN #2. RN #2 removed her donned gloves and washed in her hands in the bathroom for 7 seconds. On 4/5/14 at 9:45 a.m., Resident (G)'s chart was reviewed for physician orders. The discharge instructions indicated the decubitus ulcer should have been packed with [MEDICATION NAME] dressing then covered with 4 x 4 gauze that had been soaked in Dakin's solution and covered with [MEDICATION NAME]. On 4/5/14 at 10:45 a.m., the Corporate Nurse was provided the information related to the observed dressing change on 4/4/14. During an interview on 4/3/14 at 2:35 p.m., the Director of Nursing (DoN) indicated Resident (G) was very debilitated. She indicated when the pressure ulcer was noted on 3/27/14, the physician ordered for the resident to be sent to the hospital for an X-ray and a surgical consult. During an interview on 4/4/14 at 5:10 p.m., the Corporate Nurse indicated no pressure evaluation sheets were available after the 3/16/14 assessment during the time to the sheets dated 3/27/14. No measurement, depth of tunneling or assessment of the wound/skin area were documented for eleven days. She indicated they did not have staff initial, date or time the dressing change. B.1. The clinical record for Resident (I) was reviewed on 4/4/14 at 9:10 a.m. [DIAGNOSES REDACTED]. Resident (I) was admitted to the facility on [DATE]. During record review, a nursing admission assessment, dated 3/29/14 at 4:40 p.m., indicated Resident (I) returned from the hospital. He was listed in a comatose state with 3+ bilateral [MEDICAL CONDITION] to upper and lower extremities. He had a urinary catheter in place. The full body inspection indicated 3 non-pressure areas that measured 2.5 cm x 1.0 cm, 4.0 x 2.5 cm and 4.0 cm x 4.5 cm. Resident (I) was also noted to have a stage 3 wound to his coccyx and sacrum and a undetermined wound to his ischium. No measurements were noted. Review of the pressure evaluation record, dated 4/2/14, indicated Resident (I) had a right clavicle, stage 2 wound that measured 1.0 cm x 1.0 cm. The wound was noted to have scant, serous drainage. Another wound report indicated a left clavicle, stage 2 wound that measured 1.5 cm x 1.5 cm. The wound had scant, serous drainage. Resident (I) was also noted to have a right lower buttock, stage 2 wound that measured 1.0 cm x 1.5 cm x 0.1 cm. The wound had scant, serous drainage. Another wound report indicated a sacral, stage 3 wound that measured 4.5 x 2.5 x 0.1 cm. The wound had scant, serous drainage. The wound bed contained 100% slough with the edges rolled under. Resident (I) was noted to have a left heel wound that was Unable to Determine (UTD). The wound measured 4.0 cm x 3.0 cm with no depth. The wound contained 100 % eschar. Another wound report indicated a left lateral thigh /buttocks wound. The wound was a stage 3 and measured 5.0 cm x 5.5 cm x 3.0 cm with light, purulent drainage. The wound bed contained 95% slough and 5% eschar. The edges were rolled under. A current health care plan problem, dated 4/2/14, indicated an actual pressure ulcer. The interventions for the problem included, but were not limited to, check dressing every shift, assess pressure ulcers weekly by licensed nurse and notify MD if the ulcers fail to heal every 2 weeks. The most recent Minimum Data Set (MDS) assessment, dated 3/14/14, indicated Resident (I) was severely cognitively impaired. His skin condition indicated he was at risk for developing pressure ulcers and had more than 1 unhealed pressure ulcer. The MDS indicated Resident (I) had 5 stage 1 pressure ulcers, 3 stage 3 pressure ulcers and 2 stage 3 pressure ulcers. Five of five pressure ulcers that were greater than a stage 2, indicated Resident (I) was admitted with. Resident (I) received the following Activities of Daily Living (ADL) assistance; transfer-did not occur, ambulation-did not occur, dressing-total dependent with 2 person physical assist, eating, toilet use and person hygiene-extensive assist with one person physical assist. Resident (I) was always incontinent of bowel and had a urinary catheter. Resident (I) was initially admitted to the facility on [DATE]. He was discharged to the hospital on [DATE] and returned on 3/21/14. He was again admitted to the hospital on [DATE] and returned on 3/29/14. During observation of wound care on 4/4/14 at 9:00 a.m., RN #2 and LPN #4 attempted to roll Resident (I) on his right side for treatment. They were unable to position him completely and an unidentified CNA came to assist. Resident (I) was rolled onto his right side. A soiled dressing was removed from his left sacral wound. The dressing did not have any initials, date or time of change. The wound measured 4.9 cm x 5.2 cm x 1.4 cm depth. The large area to the left was open and approximately the size of a golf ball. RN #2 applied [MEDICATION NAME] to the outer entire area. She then applied TheraHoney to the outer edges of the wound. The wound was covered with [MEDICATION NAME] and secured with [MEDICATION NAME]. Following the dressing change, RN #2 washed her hands for less than 10 seconds. During observation of wound care on 4/4/14 10:20 a.m., RN # washed her hands for 10 seconds then donned gloves. She removed Resident (I)'s inflated boot from his left foot. No dressing was covering the wound. RN #2 measured the wound on the left heel. The wound measured 2.8 cm x 3.6 cm with no depth. She applied [MEDICATION NAME] then heel prep. [MEDICATION NAME] was placed over the wound and the foam was then covered with Kerlix. RN #2 washed her hands after completing the treatment for 8 seconds, then washed them again at 10:35 a.m. for 8 seconds. Resident (I) was fatigued and RN #2 decided to wait for the next dressing change. During observation of wound care on 4/4/14 at 2:10 p.m., RN #2 and a unidentified CNA rolled the resident to his left side. An area to the right lower buttocks did not require treatment per RN #2. The sacral wound measured 2.9 cm x 4.3 cm with no depth. The wound was cleaned with wound cleaner and [MEDICATION NAME] was applied to the outer edges. [MEDICATION NAME] was applied to the wound bed and the area was covered with foam. No dressing was noted to either the left or right clavicle. RN #2 indicated she would check on it later because she could not find any wounds. During review of the Treatment Administration Record (TAR)'s report, the March 2014 record indicated a wound #8 was on his left lower buttocks. The treatment was "to apply calmo to area every shift and as needed when soiled." Resident (I) received no treatment on 3/22, 3/23 and 3/30. The April TAR's indicated he did not receive treatment on 4/2 and 4/3. The March TAR's indicated a wound #7 on his lower back/middle. The treatment was "to clean with wound cleanser, apply Duodenum then cover with thick foam dressing. Change every 3 days." Resident (I) did not receive treatment on 3/30. The wound was not listed on the April TAR's. The March TAR's indicated a wound #6 to his left lower back/sacral. The treatment was "to clean with wound cleanser, apply DuoDerm, cover with thick foam dressing. Change every 3 days." Resident (I) was out to the hospital and last received a treatment March 24, 2014. The April TAR's indicated a similar sacral wound to be cleaned with normal saline, apply calmo to peri-wound edges, apply TheraHoney to wound bed only, cover with thick foam dressing and change daily and as needed. That order was not received until 4/2/14. The treatment was done on 4/2 and 4/3/14. The March TAR's indicated a wound #5 to his left top buttocks/sacral. The treatment was to "clean with wound cleaner, apply DuoDerm, cover with thick dressing and change daily and as needed." Resident (I) did not receive those treatments from 3/15-3/21 while he was in the hospital. He also did not receive those treatments from 3/25-3/29 while he was in the hospital. The treatments were not given 3/22-3/24/14 following his return or 3/30-3/31 following his return to the facility. The order was dated 3/15/14 and the only treatment given was on 3/24/14. The TAR's for April only indicated a sacral wound. The March TAR's indicated a wound #4 to his left top buttocks/sacral. The treatment was to "clean with wound cleanser, apply DuoDerm, cover with thick foam dressing and change every 3 days." The last documented treatment was 3/24/14. The order was dated 3/15/14 and the only treatment given was on 3/24/14. The TAR's for April only indicated a sacral wound. The March TAR's indicated a wound #3 to his top middle of buttocks/sacral. The order and treatment dates listed were the same as wound #4. The TAR's for April only indicated a sacral wound. The March TAR's indicated a wound #2. No location was noted. The wound was to be cleaned with normal saline, calmo applied to the peri-wound only, TheraHoney applied to the wound bed only and covered with a thick foam dressing. The treatment was ordered daily. The treatment was not done 3/22, 3/23 or 3/30/14. The April TAR's indicated wound #2. The same order was listed. Resident (I) did not receive treatment on 4/2 or 4/3/14. The March TAR's indicated a wound #1 to his left hip/buttock. The treatment was to "clean with normal saline, apply calmo to peri-wound, apply TheraHoney to wound bed and cover with thick foam dressing." The treatment was ordered daily. The treatment was not done on 3/22, 3/23 or 3/30/14. Resident (I) also had a left and right clavicle wound. The treatment was to "clean with wound cleanser, place DuoDerm [MEDICAL CONDITION]." The treatment was ordered every 3 days. Resident (I) readmitted on [DATE] and the treatment was not done until 4/2/14. The March TAR's indicated treatment to the left heel. The treatment included skin prep, [MEDICATION NAME] and to cover with a thick foam dressing and wrap with Kerlix. The treatment was ordered daily. The treatment was not done on 3/22, 3/23 or 3/31. The March TAR's indicated skin prep daily to bilateral feet. The treatment was not done on 3/22, 3/23 or 3/30/14. 2. Review of a current facility policy for "Skin Integrity Standard", provided by the Corporate Nurse on 4/5/14 at 10:45 a.m., included, but was not limited to the following: "Practice: Residents identified to be at risk for skin breakdown (pressure ulcers) ... Procedure: All new admissions will have a skin risk assessment (Braden or Norton Scale) and an initial head to toe skin assessment by Licensed Nurse and/or designated wound nurse as soon as possible within the first two hours of admission but no later than 24 hours of resident admission. New admission residents will have a weekly for three weeks... Care plan implementation of a preventative program... Communication by CNA to licensed nurse... Weekly "head to toe" assessment of all residents... If skin integrity issues are identified post-admission to the facility the following documented information is required: 1. Wound Specifics: a. Location of wound... b. Size of the wound... h. Stage of the wound... 5. Incident Report completed for in house acquired State III and/or IV. *DON/Designee completes weekly random skin assessments. *Verification of Pressure Logs will be completed by DON/Designee... *The DNS/DON/Designee monitors and trends acquired pressure ulcers to determine potential patterns related to occurrence. This trend information is reported at the QA&A Meeting." Review of a current facility policy for "Hand Washing", provided by the Corporate Nurse on 4/5/14 at 10:45 a.m., included, but was not limited to, the following: "...Purpose Medical asepsis to control infection. General Instructions Wash hands before and after resident contact. Wash hands when soiled. Procedure 7. Rub hands briskly using sufficient lather and friction for ten to fifteen seconds, pay special attention to area between fingers." 3. The Immediate Jeopardy that began on 3/22/14 was removed on 4/7/14 when the facility implemented a systematic plan that included the following actions: 1.) Total head to toe skin assessments on all 45 residents. The assessments were completed on 4/5/14. 2). Training of licensed nurses and CNA's related to, skin integrity standard, measuring wounds, wound appearance, staging of wounds and documentation of weekly skin assessments. The in-service included hand washing and dressing changes. CNA's were also trained to notify the nurse of any skin condition noted while providing care. The in-servicing included 24 staff members. 3). DoN/designee will monitor skin assessments and measurements be completed on admission through admission audits 5 x weekly. Monitor that skin measurements are completed weekly. Perform random observation of dressing change weekly x 2 weeks with 3 nurses, 2 nurses weekly x 2 weeks then 1 weekly thereafter. 4). Licensed staff to date and initial dressing changes and the DoN/designee will monitor for compliance until all staff have been trained. The in-service was completed on 4/7/14. The noncompliance remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all the licensed nursing staff had not yet demonstrated the ability to follow physician orders [REDACTED]. This federal tag relates to Complaint IN 653. 3.1-40(a)(1)(2)

Based on interview and record review, the facility failed to administer intravenous antibiotics as ordered by the physician, resulting in a significant medication error for 1 of 8 residents reviewed for medication administration. (Resident F) This deficient practice resulted in Immediate Jeopardy. This Immediate Jeopardy began on 2/14/14 when facility staff failed to identify and order intravenous antibiotic ordered by the physician. The Administrator, Director of Nursing and Corporate Nurse were notified of the immediate jeopardy on 4/4/14. The Immediate Jeopardy was removed on 4/7/14 but the noncompliance remained at the lower scope and severity with no actual harm but potential for more than minimal harm that is not immediate jeopardy when the facility developed and had implemented a systematic plan of correction but had not completed it. Findings include: The clinical record for Resident (F) was reviewed on 4/3/14 at 11:40 a.m. [DIAGNOSES REDACTED]. The physician order, dated 1/27/14, indicated a discharge order from an infectious disease consult for the following medications to be started on admission to the facility on [DATE]: "[MEDICATION NAME] (antibiotic) 500 mg by mouth every 6 hours, [MEDICATION NAME] (antibiotic) 2 gram intravenously every 12 hours and [MEDICATION NAME] (antibiotic) per pharmacy for brain abscess." The order indicated to keep the trough range between 19-20 mcg/ml. The antibiotic stop date was to be determined. A pharmacist dosing recommendations fax sheet, dated 3/17/14 at 9:35 a.m., requested a physician's signature. The physician signature line stated "per original order signed by...". The dosing recommendation was 1000mg [MEDICATION NAME] every 8 hours. The pharmacist signed the recommendation on 3/16/14. Review of the March Medication Administration Record [REDACTED]. The original order stated to start medication 2/14/14. A current health care plan problem/need, dated 2/15/14, indicated a potential for infection related to a Peripherally Inserted Center Catheter (PICC) line. The interventions for plan included, but were not limited to, administer IV fluid/medication as ordered and measure external catheter length on admission, with each dressing change and as needed. The most recent Minimum Data Set (MDS) assessment indicated Resident (F) was cognitively intact. Resident (F) was independent with all Activities of Daily Living (ADL). Resident (F)'s current [DIAGNOSES REDACTED]. During an interview on 4/3/14 at 11:40 a.m., the Director of Nursing (DoN) stated Resident (F) was out of the building today for brain surgery. During an interview on 4/3/14 at 12:00 p.m. with the DoN, a copy of the physician order [REDACTED]. She then stated the resident did not get his antibiotic until after she realized it had not been ordered. She stated both the physician and consulting infectious disease specialist were notified. She indicated the infectious disease specialist was not happy the resident failed to receive the doses of antibiotic. As of 4/5/14, Resident (F) had not returned to the facility following surgery. The Immediate Jeopardy that began on 2/14/14 was removed on 4/7/14 when the facility implemented a systematic plan that included the following actions: 1). The facility reviewed all residents admitted on /and or after 2/1/14 for the accuracy of the medication and/or antibiotic orders. The assessment was completed on 4/5/14. 2). The in-service included ensuring medication and/or antibiotics are delivered timely and completely. The DoN/designee will monitor compliance through Admission audits which will be completed within 72 hours of admission. The in-servicing included 24 staff members. This federal tag relates to Complaint IN 653. 3.1-25(b)(9)