Every finding on record at Arlington Place Health Campus

Based on interview and record review, the facility failed to notify the resident representative of a change in condition which included a decline in the resident's appetite and a new medication ordered to help with the resident's poor appetite, as well as a lack of documentation of any notification for this in the resident's clinical record. (Resident C) Finding include: The clinical record of Resident C was reviewed on 8-20-26 at 2:40 p.m. Her diagnoses included, but were not limited to hypertensive heart and kidney disease, chronic congestive heart failure, stage 3 chronic kidney disease, type 2 diabetes with chronic kidney disease and unspecified dementia. Her most recent Minimum Data Set assessment, dated 7-17-26, indicated she was severely cognitively impaired, was non-ambulatory and required the use of a walker or wheelchair for mobility and was able to feed herself after her meal was set up for her. A nursing progress note, dated 7-23-26 at 9:18 a.m., indicated a notation had been entered into the medical provider's book to notify the medical provider Resident C has not been eating. A nursing progress note, dated 7-25-26 at 10:08 a.m., indicated, resident started on Remeron [an antidepressant medication with a side effect of increased appetite] r/t [related to] poor appetite. Neither nursing progress note reflected Resident C's representative had been notified of the decreased appetite or the new medication order. In an interview with the Director of Nursing Services (DNS) on 8-21-26 at 11:33 a.m., the DNS indicated the order was written by the nurse practitioner, but the clinical record did not reflect any notification of the new order to Resident C's representative. On 8-20-26 at 11:37 a.m., the Executive Director provided a copy of a policy dated 5-10-24, and entitled, Notification of Change in Condition. This policy indicated its purpose is, To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known, notify the resident's legal representative when .2. A significant change in the resident's physical, mental or psychosocial status 3. A need to alter treatment significantly .Documentation of notification or notification attempts should be recorded in the resident Electronic health record. This Federal tag relates to Intake 3157978. 3.1-5(a)(2)3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure food temperatures were at an appetizing temperature and kept at safe holding temperatures. This had the potential to affect 70 of 70 residents that eat the food prepared and served from the kitchen.Findings include:An interview was conducted with Resident D on 5/28/26 at 10:29 a.m. She indicated breakfast, lunch and dinner meals were always served cold.An observation was made of the main kitchen with the DM 11 on 5/28/26 at 12:26 p.m., Dietary Manager (DM) 11 utilizing a thermometer had taken the food temperatures of the prepared food to be served. The smoked sausage had tempted 123 degrees Fahrenheit. DM 11 indicated the smoked sausage needed to be reheated. He preferred all food to be held at 150 degrees Fahrenheit, but the regulation stated food temperatures were to be held at 135 degrees Fahrenheit.During a dining observation on 5/28/26 at 11:57 a.m., Residents' N, O, P were sitting in the dining room waiting for the lunch meal. They indicated the food that was supposed to be hot, was served cold at every meal in the dining room.An interview was conducted with Resident M on 5/28/26 at 12:38 p.m. She indicated resident council discussed food temperature concerns at every meeting. The food that was suppose to be hot, was normally served cold.A hot and cold holding policy was provided by the Director of Nursing Services (DNS) on 5/28/26 at 3:41 p.m. It indicated, Purpose. The purpose of this policy is to: Give guidelines to holding temperatures.Procedure.Hot food in the steam table should be at least 135 or higher degrees Fahrenheit and arrive approximately at greater than or equal to 120 degrees Fahrenheit when the resident is served.This citation is related to Intake 3002975. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to timely complete self-medication assessments for a resident who had medication at bedside and a resident that self administered her insulin medications 2 of 3 residents medication administration. (Resident F and Resident D) Findings include: 1. The clinical record for Resident F was reviewed on 5/28/26 at 11:00 a.m. The resident's diagnosis included, but was not limited to, depression (serious mood disorder). A Quarterly Minimum Data Set (MDS) Assessment, completed 5/7/26, indicated the resident was moderately cognitively impaired. A care plan, last reviewed 5/20/26, indicated Resident F presented with a diagnosis of depression. The goal was for the resident to remain free of the symptoms of depression. The interventions included to administer medications as ordered by the physician. On 5/28/26 at 11:58 a.m., Resident F was observed in his room, sitting in his bed. The bedside table was next to the bed. A medication cup containing 4 pills was observed on the bedside table. Resident F indicated the nurse had left the medication for him to take. Resident F did not know what the medications were. During an interview on 5/28/26 at 12:00 p.m., Licensed Practical Nurse (LPN) 5 indicated the medication cup contained Resident F's morning medications. LPN 5 was unsure if Resident F had a self-medication assessment completed. During an interview on 5/28/26 at 3:30 p.m., the Director of Nursing Services (DNS) indicated Resident F did not have a self-medication assessment completed in his clinical record. 2. The clinical record for Resident D was reviewed on 5/28/26 at 9:40 a.m. The diagnoses included but were not limited to: diabetes mellitus (ineffectively utilizes the insulin made in the body either can not produce enough insulin or does not use the insulin the body makes) A physician order, dated 3/16/26, indicated Resident D was to receive a sliding scale of fast-acting lispro insulin. The sliding scale was the following: blood sugar reading of 151 – 200 = 2 units of insulin, blood sugar reading of 201 – 250 = 4 units of insulin, blood sugar reading of 251 – 300 = 6 units of insulin, blood sugar reading of 301 – 350 = 8 units of insulin, blood sugar reading of 351 – 400 = 10 units of insulin, blood sugar reading greater than 400 call the medical provider A physician order, dated 3/16/26, indicated Resident D was to receive 20 units of fast-acting lispro insulin three times a day. The staff was to hold the lispro if blood sugar was less than 110. A physician order, dated 3/16/26, indicated Resident D was to receive 40 units of long-acting lantus insulin with breakfast. The May 2026 Medication/Treatment Administration Record (MAR/TAR) indicated the resident had self- administered her insulin medications on 5/2/26, 5/8/26, 5/14/26, and 5/19/26. The resident's clinical record did not include a self-medication assessment that was conducted, medical provider orders, or a care plan developed indicating resident was able to self-medicate her insulin medications. An interview was conducted with the Director of Nursing Services (DNS) on 5/29/26 at 10:45 a.m. She indicated Resident D chose the dosage amount and self-administered her insulin medications. The medical provider was aware. The staff did not conduct a self-medication assessment for Resident D. A Guidelines for Self-Medication of Medications policy was provided by the DNS 5/28/26 at 3:41 p.m. It indicated, Purpose Statement. The purpose of this policy is to: To ensure the safe administration of medication for residents who request to self- medicate or when self- medication is a part of their plan of care. Policy Guidelines for Self Administering of medications. Residents requesting to self- medicate or has self-medication as a part of their plan of care shall be assessed using the observation Trilogy- Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication. The order should include the type of medication(s) the resident is able to self- medicate.e.: all oral meds, oral meds with the exception of., nebulizer treatment only, all medications including injection, oral, inhalers, drops, etc.6. A Self-Medication plan of care will be initiated and updated as indicated. 7. The Assessment will be reviewed quarterly, and PRN with change of condition. 8. The assessment will be documented in the EHR. This citation is related to 3002975. 410 IAC (Indiana Administrative Code) 16.3.1-11

Based on interview and record review, the facility failed to ensure the resident representative for a cognitively impaired resident was informed in advance of the risks and benefits of medications for 1 of 5 residents reviewed for informed consent. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 12/4/25 at 10:27 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, and severe protein-calorie malnutrition.A Minimum Data Set (MDS) assessment, dated 10/10/25, indicated the resident was severely impaired cognitively.A physician's order, dated 10/4/25 and discontinued 10/8/25, indicated to administer olanzapine (an antipsychotic medication) 2.5 milligrams twice per day.A physician's order, dated 10/7/25, indicated to administer Trazodone (an antidepressant medication which could be used as an off-label treatment for insomnia) 25 milligrams at bedtime for insomnia.A facility psychotropic medication informed consent observation, dated 10/8/25, indicated Resident 3 was educated on the risks, benefits, alternative treatment options, and any applicable black box warnings.During an interview, on 12/4/25 at 12:23 p.m., CNA 8 indicated Resident 3 was confused. She would not be able to understand the side effects of medications.During an interview, on 12/4/25 at 12:24 p.m., Licensed Practical Nurse (LPN) 7 indicated Resident 3 could not understand the side effects of her medications. She was confused.During an interview, on 12/5/25 at 11:25 a.m., the Director of Nursing (DON) indicated Resident 3 had impaired cognition and staff would need to educate the family to obtain informed consent.During an interview, on 12/8/25 at 9:48 a.m., Clinical Support Nurse 1 indicated staff should educate families to obtain informed consent for residents with a low cognitive status.A current facility policy, titled Psychotropic medication use and gradual dose reduction guidelines, dated as last revised 3/10/25 and received from Clinical Support Nurse 1 on 12/8/25 at 10:00 a.m., indicated .A consent shall be obtained upon admission for ordered psychotropic medications to ensure appropriate indications for use and that the Resident/Responsible party is educated on the risks, benefits, alternative treatment options and applicable black box warnings.3.1-3(n)(2)

Based on interview and record review, the facility failed to ensure the resident representative for a cognitively impaired resident was notified of a significant weight loss for 1 of 3 residents reviewed for notification of change. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 12/4/25 at 10:27 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, and severe protein-calorie malnutrition.A Minimum Data Set (MDS) assessment, dated 10/10/25, indicated Resident 3 was severely impaired cognitively.A facility weight log indicated the following:On 10/4/25, the resident weighed 149 pounds on admission.On 11/14/25, the resident weighed 131.8 pounds.On 11/18/25, the resident weighed 130.3 pounds.Resident 3 had a significant weight loss of 11% from 10/4/25 to 11/14/25.There was no documentation in the clinical record to indicate the resident's representative was notified of the significant weight loss.During an interview, on 12/5/25 at 11:25 a.m., the Director of Nursing (DON) indicated Resident 3 had impaired cognition and the family would need notification.During an interview, on 12/8/25 at 9:48 a.m., Clinical Support Nurse 1 indicated staff would need to notify the family of a significant weight loss.A current facility policy, titled Notification of Change in Condition, dated as last reviewed on 12/17/24 and received from the Clinical Support Nurse 1 on 12/8/25 at 10:00 a.m., indicated .To ensure appropriate individuals are notified of change in condition. The Facility must inform the resident, consultant with the resident's physician and if known notify the resident's legal representative when.A significant change in the resident's physical, mental or psychosocial status.The resident representative/provider should be notified of change in condition or diagnostic testing results in a timely manner.Documentation of notification or notification attempts should be recorded in the resident Electronic health record.3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a bed hold policy was provided to the resident and resident's representative at the time of discharge for 1 of 2 resident reviewed for hospitalization. (Resident 81)Findings include:The clinical record for Resident 81 was reviewed on 12/3/25 at 10:25 a.m. The diagnoses included, but were not limited to, hyperlipidemia, obesity, and acute respiratory failure.A nursing progress note, dated 9/18/25 at 12:35 p.m., indicated Resident 81 was found unresponsive and the staff called 911. The resident was transported to the hospital.There was no documentation the bed hold policy was provided to Resident 81 or Resident 81's representative.A clinical discharge observation form, completed on 9/30/25, did not indicate whether the bed hold policy was provided to the resident and the resident's representative.During an interview, on 12/8/25 at 9:48 a.m., Clinical Support 1 indicated staff should provide the bed hold policy to the resident and resident's representative at the time of discharge.A current facility policy, titled Bed Hold Notification, dated as last reviewed on 1/8/25 and received from Clinical Support 1 on 12/8/25 at 10:00 a.m., indicated .Residents and Responsible Parties have a right to be notified verbally and in writing on reserve bed payment policy per the state plan when someone goes out to the hospital.Before transferring a resident a resident to a hospital or allowing a resident to go on a therapeutic leave, the Nursing designee or other designated staff member should provide written information to the resident and a family member or legal representative of the bed hold and admission policies.3.1-12(a)(25)(A)3.1-12(a)(25)(B)

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed after the addition of mental health diagnoses and psychotropic medications for 2 of 4 residents reviewed for PASARR. (Resident 7 and 11)Findings include:1. The clinical record for Resident 7 was reviewed on 12/3/25 at 11:25 a.m. The diagnoses included, but were not limited to, hypertensive chronic kidney disease, atrial fibrillation, a wedge compression fracture of the second lumbar vertebra, major depressive disorder, chronic obstructive pulmonary disease, and dementia without behavioral disturbance. A PASARR level I screening, dated 5/9/24, indicated Resident 7 was not prescribed any mental health medications and did not have any mental health or dementia diagnoses. A physician's order, dated 8/2/24 and discontinued 9/23/24, indicated to administer escitalopram oxalate (an antidepressant medication) 5 milligrams (mg) once a day for depression. On 9/23/24, the escitalopram oxalate order was changed to 10 mg at bedtime for depression. A physician's order, dated 1/19/25 and discontinued 7/15/25, indicated to give bupropion (an antidepressant medication) 75 mg. On 7/15/25 and discontinued 11/12/25, the bupropion order was changed to indicated to 32.5 mg. A physician's progress note, dated 9/18/25 at 11:31 a.m., indicated Resident 7 was being followed for diagnoses of Alzheimer's disease, depression, and anxiety. A care plan, dated 10/13/25, indicated Resident 7 was at risk for developing adverse effects from the use of anti-depressant medications and the resident presented with a diagnosis of depression. During an interview, on 12/1/25 at 2:34 pm., Resident 7 indicated she could not even remember if she had eaten breakfast and she was depressed. During an interview, on 12/4/25 at 10:57 a.m., the Minimum Data Set (MDS) support nurse indicated a new PASARR should be completed with a new diagnosis or a psychotropic medication, such as escitalopram oxalate or bupropion. During an interview, on 12/5/25 at 10:05 a.m., the Social Services Director indicated he had not realized no diagnoses were listed on Resident 7's PASARR or new medications had been added. He would have completed a new PASARR for diagnoses or medications. 2. The clinical record for Resident 11 was reviewed on 12/2/25 at 2:38 p.m. The diagnoses include, but were not limited to, depression, hypertension, and chronic obstructive pulmonary disease. A PASARR level I screening, dated 9/17/25, indicated a level II was not required. Resident 11 had no suspected mental illness, intellectual disability, or related condition and no mental health medications were prescribed. A physician's order, dated 8/4/25, indicated to administer fluoxetine (an antidepressant medication) 20 milligrams once a day for depression. The PASARR was inaccurate and did not list the fluoxetine or the diagnosis of depression. During an interview, on 12/4/25 at 10:07 a.m., the MDS support nurse indicated typically the mental health medications and diagnosis would be listed on the PASARR A current facility policy, titled Indiana PASRR, undated and received from Clinical Support Nurse 1 on 12/8/25 at 10:00 a.m., indicated .Change in status and Level 2 follow up. Social Services ensure paperwork is submitted. They will print out the outcome letter and upload to Matrix file.Change in status.PASRR Level 1 Complete for change in status. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure medication carts were free of loose pills and debris, narcotic medications with compromised packaging were destroyed, as needed (PRN) controlled drug use records contained documented of approval by a licensed nurse prior to administration and a pharmacy label for a narcotic medication matched the physician's order for 3 of 4 medication carts reviewed for medication storage and labeling. (100-hall cart 1, 100-hall cart 2 and 200-hall cart 2)Findings include:1. The 100-hall medication cart one (1) was observed on 12/4/25 at 9:12 a.m., and had the following:a. Drawer 2, contained two (2) loose pills and powdered debris collected in the bottom of the drawer against the back wall.b. Drawer 6, the narcotic box, contained a narcotic pill pack of oxycodone 5 milligram (mg) 1/2 tablets. The medication card had not been used for administration and contained 30, 1/2 tablets. Pocket 12 was observed to be compromised and was secured closed with a piece of clear tape; the 1/2 tablet was present in the package.c. Drawer 6, the narcotic box, also contained a narcotic pill pack of oxycodone 5 mg 1/2 tablets. The medication card contained 5 remaining 1/2 tablets. Pockets 11 and 12 were observed with clear tape; the 1/2 tablets were not present in the package.d. A controlled drug use record, with a pharmacy label indicated oxycodone/acetaminophen 5-325 mg with instructions to give 1 tablet by mouth, every 8 hours as needed (PRN) contained 3 out of 6 administrations of the medication by a QMA without a nurse signature or documented nurse approval in the clinical record.e. A controlled drug use record, with a pharmacy label indicated alprazolam 0.5 mg with instructions to give 1/2 tablet (0.25mg) by mouth, three times daily as needed (PRN), for anxiety, contained 4 out of 4 administrations of the medication by a QMA without a nurse signature or documented nurse approval in the clinical record. The pharmacy label on the controlled drug use record did not match the physician's order in the clinical record.The physician's order indicated alprazolam 0.25 mg tablet with instructions to administer 0.25 mg, three times a day.During an interview, on 12/5/25 at 10:45 a.m., LPN 3 reviewed the pharmacy label and indicated the pharmacy label did not match the physician order and the medication needed a change of order or change of directions sticker on the packaging.2. The 200-hall medication cart 2 was observed on 12/4/25 at 8:48 a.m., and had the following:a. Drawer 1, contained one (1) loose pill and powdered debris collected in the bottom of the drawer against the back wall of the drawer.b. Drawer 2 contained one (1) loose pill and powdered debris collected in the bottom of the drawer against the back wall of the drawer.c. Drawer 3, contained one (1) loose pill and powdered debris collected in the bottom of the drawer against the back wall of the drawer.d. Drawer 4, contained two (2) loose pills and powdered debris collected in the bottom of the drawer against the back wall of the drawer.3. The 200-hall medication cart 1 was observed on 12/5/25 at 2:12 p.m., and had the following:a. Drawer 1, contained a 1/2 of a loose pill.b. Drawer 2, contained powdered debris collected in the bottom of the drawer against the back wall of the drawer.c. Drawer 3, contained powdered debris collected in the bottom of the drawer against the back wall of the drawer.d. A controlled drug use record, with a pharmacy label indicated oxycodone/acetaminophen 5-325 mg with instructions to give 1 tablet by mouth, every 4 hours as needed for pain, contained 1 out of 1 administration of the medication by a QMA without a nurse signature or documented nurse approval in the clinical record.During an interview, on 12/4/25 at 9:01 a.m., Licensed Practical Nurse (LPN) 2 indicated pharmacy audits were completed on the medication carts monthly, but nurses were also responsible for checking the carts for loose pills, expired medications, damaged packaging, and keeping the carts clean.During an interview, on 12/5/25 at 2:50 p.m., Unit Manager 5 observed the powder debris at the bottom of the drawers in the 200-hall medication cart and indicated the cart drawers should be wiped out better. She indicated she and another nurse reviewed the carts between the pharmacy cart audits.During an interview, on 12/4/25 at 9:28 a.m., LPN 3 indicated she believed a nurse would need to sign for an as needed (PRN) medication when a QMA was administering the medication.During an interview, on 12/4/25 at 9:38 a.m., Unit Manager 4 indicated she was not sure if damaged narcotic medication packaging could be secured with tape.During an interview, on 12/5/25 at 12:09 p.m., QMA 9 indicated if a resident requested medication as needed, she would ask the nurse for approval prior to administering the medication and document the approval in the record.During an interview, on 12/5/25 at 10:05 a.m., the Director of Nursing (DON) indicated some of the QMAs had a nurse sign the controlled drug record and some of the QMAs documented the nurse approval in the clinical record. Pharmacy labels on a medication would not necessarily need to match the physician's order, nor would the nurse need to place a change of order or change of directions label on the medication, if the nurses were checking the 5 rights of administration prior to administering the medication.During an interview, on 12/5/25 at 11:34 a.m., the DON indicated the QMAs were not consistent with documenting if a nurse approved the administration.A document, titled Qualified Medication Aide Scope of Practice, undated and received from the DON on 12/4/25 at 9:45 a.m., indicated .Administer previously ordered pro re nata [(PRN)] medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following.Obtain permission to administer the medication each time.Ensure that the resident's record is cosigned by the licensed nurse who gave permission by the end of the nurse's shift, or if the nurse was on call, by the end of the nurse's next tour of duty.A current facility policy, titled Storage of medications, dated as last revised 11/18 and received from Clinical Support Nurse on 12/5/25 at 12:23 p.m., indicated .Medications and biologicals are stored safely, securely, and properly.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal.Medication storage areas are kept clean.Medication storage conditions are monitored by pharmacy designee and corrective action taken if problems are identified.A current facility policy, titled Administration procedures for all medications, dated as last revised 11/18 and received from the DON on 12/5/25 at 11:37 a.m., indicated .To administer medications in a safe and effective manner.Prior to removing the medication from the container.Check the label against the order on the MAR.A current facility policy, titled Medication Labels, dated as last revised 11/18 and received from the DON on 12/5/25 at 11:36 a.m., indicated .Medications are labeled in accordance with facility requirements and state and federal laws.If the physician's directions for use change or the label is inaccurate, the medication administration personnel may place a [ change of order-check chart] label on the container indicating there is a change in directions for use, take care not to cover important label information.3.1-25(b)(8)3.1-25(g)(1)3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precaution signs were posted for residents who required enhanced barrier precaution isolation for 3 of 8 residents reviewed for infection control. (Resident 5, 86 and 87)Findings include: 1. During an observation, on 12/1/25 at 10:18 a.m., Resident 5 had a wound vacuum (a device used to speed up closure by optimizing the wound bed for healing). Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 11:16 a.m., Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 12:02 p.m., Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 2:20 p.m., Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.The clinical record for Resident 5 was reviewed on 12/4/25 at 2:44 p.m. The diagnoses included, but were not limited to, type 1 diabetes, gas gangrene, and chronic ulcer of the left heel.Resident 5 had a physician's order for a wound vacuum. A physician's order for enhanced barrier precautions was not located at the time of the record review.2. During an observation, on 12/1/25 at 10:26 a.m., Resident 86 had a peripherally inserted central catheter (PICC) line (a type of catheter inserted through a peripheral vein used when intravenous treatment was required over a long period of time). Resident 86 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 11:16 a.m., Resident 86 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 12:02 p.m., Resident 86 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 2:20 p.m., Resident 86 did not have an enhanced barrier precaution sign posted in or on the outside of the room.The clinical record for Resident 86 was reviewed on 12/4/25 at 2:45 p.m. The diagnoses included, but were not limited to, chronic lung disease, respiratory failure, and a history of a stroke.Resident 86 had a physician's order for a PICC line. A physician's order for enhanced barrier precautions was not located at the time of the record review.3. During an observation, on 12/1/25 at 12:42 p.m., Resident 87 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 2:20 p.m., Resident 87 did not have an enhanced barrier precaution sign posted in or on the outside of the room.The clinical record for Resident 87 was reviewed on12/4/25 at 2:47 p.m. The diagnoses included, but were not limited to chronic lung disease, inflammatory bowel disease and hypothyroidism.Resident 87 had a physician's order for a catheter. A physician's order for enhanced barrier precautions was not located at the time of the record review.During an interview, on 12/1/25 at 2:29 p.m., the Infection Preventionist indicated the residents should have had an enhanced barrier precaution sign. They did not post the signs in the rooms; signs were placed outside the room. She was not sure why the residents did not have a sign up and they should have. The signs were missing and not posted. A current facility policy, titled Infection Prevention and Control Program, dated as last reviewed 11/19/25 and received upon entrance, indicated .Education and competency assessment to ensure staff follow the IPCP's standards, policies, and procedures. Therefore, staff must be informed and competent. Knowledge and skills pertaining to the IPCP's standards, policies and procedures are needed by all staff to follow proper infection control practices (e.g., hand hygiene and appropriate use of personal protective equipment) .3.1-18(j)

Based on interview and record review, the facility failed to ensure consents were documented accurately prior to administering a Covid vaccine for 1 of 5 residents reviewed for immunizations. (Resident 51)Findings include: The clinical record for Resident 51 was reviewed on 12/4/25 at 2:15 p.m. The diagnoses included, but were not limited to, acute cystitis without hematuria, anoxic brain damage, elevated white blood cell count, pulmonary fibrosis, dementia, type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, and aphasia.A Brief Interview for Mental Status (BIMS) assessment, dated 11/6/25, indicated Resident 51 had severe cognitive impairment.A COVID vaccination consent form, dated 1/11/24 at 4:20 p.m., indicated Resident 51's representative refused the COVID vaccination.A COVID vaccination consent form, dated 11/5/25, indicated Resident 51's representative had not signed the consent form for Resident 51 to receive the vaccine. It indicated the Moderna COVID vaccination was given on 11/7/25, in the left arm.A physician's order, dated 11/7/25, indicated the resident received a COVID vaccine and to monitor for side effects three (3) times a day until 11/9/25.During an interview, on 12/4/25 at 12:45 p.m., Resident 51's representative indicated she did not remember any discussion about the resident getting a covid vaccine. She found a band-aid on his arm during a visit and was told he received a shot. She was unaware what shot he had received. She never received any written education on the covid vaccination prior to administration. During an interview, on 12/8/25 at 9:48 a.m., the Infection Preventionist (IP) indicated she had used paper forms instead of the computerized consents to try to keep up with the large number of residents who needed flu and COVID shots this season so everyone who wanted a vaccine would get it.During an interview, on 12/8/25 at 9:50 a.m., the Director of Nursing (DON) indicated consents were required prior to giving a vaccine and the IP must have missed checking the yes box when the resident's representative was there.A current facility policy, titled Guidelines for Influenza, Pneumococcal, and COVID-19, dated 12/17/24 and provided by the DON on 12/8/25 at 10:40 a.m., indicated .each resident/resident representative will be provided with information regarding the risk and benefits of .COVID-19 immunization .each resident/resident representative will sign an informed consent form indicating the acceptance/refusal of immunization 3.1-18(b)(5)

Based on observation, interview, and record review, the facility failed to ensure beard coverings were worn by the dietary staff with facial hair. This has a potential to affect 42 of 42 residents that receive food prepared in the kitchen. Findings include: An observation was made of the Kitchen with the Director of Food Services on 10/15/24 at 11:44 a.m. During the tour, [NAME] 5 was observed at the food preparation area preparing the lunch meal. [NAME] 5 had facial hair on his lip and chin with no beard covering. An interview was conducted with the Director of Food Services on 10/15/24 at 11:55 a.m. He indicated [NAME] 5 should be wearing a beard covering. A [NAME] and Mustache policy was provided by the Administrator on 10/17/24 at 11:30 a.m. It indicated, .Policy. [NAME] and mustache hair must be covered while in kitchen food product areas. Facial hair restraints are required in any production area. Purpose. Beards and mustache must be covered while in kitchen food product areas. Facial hair restraints are required in any food production area. Facial hair is not exempt from the hair restraining standard . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to timely inform a resident and the State Ombudsman Agency of a facility-initiated discharge due to payment coverage, that was initiated following a resident being discharged to an acute care hospital for a medical change of condition, for 1 of 4 residents reviewed for transfer and discharge rights (Resident C). Findings include: The clinical record for Resident C was reviewed on 10/16/24 at 3:05 p.m. The diagnoses included, but were not limited to, pressure ulcer of left and right buttocks. He was discharged to an acute care hospital due to a change of condition on 2/8/24. A Social Services Comprehensive Note, dated 12/22/23, indicated Resident C anticipated remaining in the facility long-term. A nursing progress note, dated 2/8/24 at 4:30 p.m., indicated Resident C remained hypotensive (low blood pressure) and his temperature had decreased. He was showing signs and symptoms of sepsis. Emergency Medical Services were called. A nursing progress note, dated 2/8/24 at 5:18 p.m., indicated Emergency Medical Services had arrived and Resident C was transported to an acute care hospital. The clinical record contained a Notice of Transfer or Discharge, dated 2/8/24, which indicated Resident C was being transferred to another health facility. The reason for transfer or discharge was that the transfer or discharge was necessary to meet the resident's welfare and the resident's needs could not be met in the facility. A copy of the facility bed hold policy was sent with Resident C upon transfer. The clinical record did not contain any further Notice of Transfer or discharge date d after 2/8/24. A Discharge Return Anticipated Minimum Data Set (MDS) assessment, completed 2/8/24, indicated Resident C was discharged to an acute care hospital. His short-term memory was intact and there was no active discharge plan in place to return to the community. An acute care hospital in-patient palliative care note, dated 2/14/24, indicated Resident C was admitted to the acute care hospital on 2/8/24. The social determinants of health were Resident C had to find a new extended care facility as the one he had been residing at was no longer covered in network with his insurance. The facility electronic health record did not contain information or documentation that Resident C had been informed that he would not be residing at the facility due to insurance coverage or issued a new Notice of Transfer or Discharge due to non-payment. During an interview on 10/15/24 at 1:22 p.m., State Ombudsman (SO) 10 indicated Resident C had been sent to the hospital due to health issues and while in the hospital the facility had taken Resident C's belongings to him and informed him, he was discharged . During an interview on 10/17/24 at 11:17 a.m., the Social Service Director (SSD) indicated Resident C had been discharged from the facility due to financial reasons. During an interview on 10/17/24 at 1:23 p.m., Resident C indicated he was sent to the hospital, on 2/8/24, due to a urinary tract infection. He was hospitalized several times during his stay at the facility and was allowed to return to the facility after each of the hospitalization s. Resident C was unaware he would not be returning to the facility until the Administrator and the Director of Nursing brought his belongings to the hospital, on 2/19/24, and informed Resident C he was discharged . During an interview on 10/17/24 at 1:55 p.m., the Administrator (ADM) indicated, on 2/19/24, he and the Director of Nursing (DON) had taken Resident C's belongings to the hospital and informed Resident C he was discharged from the facility. Resident C had become upset and told us to leave his room. At the time of Resident C's discharge, on 2/8/24, Resident C had been private pay. Resident C had been discharged because he had not paid to hold the bed privately. During an interview on 10/17/24 at 3:03 p.m., SO 10 indicated she had been involved with Resident C due to a previous facility- initiated 30-day discharge notice. She had been present at an Appeal Hearing about the involuntary discharge, on 2/7/24, and the case had been dismissed by the Administrative Law Judge. Resident C had been discharged to an acute care hospital the next day, 2/8/24. On 2/9/24, SO 10 went to the facility to visit Resident C and was told he had been sent to the hospital for health reasons. SO 10 went to the facility to visit Resident C, on 2/13/24, when she went to his room it was empty and she was told Resident C was still in the hospital. SO 10 was not informed, at that time, Resident C would not be returning to the facility. On 2/20/24, SO 10 received a call from Resident C informing her the facility had brought his belongings to the hospital and told him he had been discharged . During an interview on 10/18/24, Nurse Consultant (NC) 1 indicated Resident C belongings had been taken to him on the eleventh day of his hospital stay. On 10/17/24 at 2:54 p.m., the Administrator provided the Guidelines for Transfer and Discharge Policy, last reviewed 12/31/23, which read, .The resident has the right to refuse involuntary transfer out of, or discharge from, the facility under certain circumstances Purpose According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the service provided by the facility. 3. The safety of individuals in the facility is endangered. 4. The health of the individuals in the facility is endangered. 5. The resident had failed, after reasonable and appropriate notice, to pay for [or to have paid under Medicare or Medicaid] a stay at the facility. 6. The facility ceases to operate .Procedures 1. Non-Emergency Transfer or Discharges .This portion of the policy applies to transfers or discharges that are initiated by the facility, not by the resident or the resident's representative. The Social Service Designee or other designated staff member should manage all non-emergency transfers or discharges. Procedure should include: a. Notify the resident in writing, and in know, a family member or legal representative, 30 days in advance, of the transfer or discharge, the effective date of transfer or discharge, the location to which the resident is transferred or discharged , and the reason for the transfer or discharge, according to the criteria for transfer or discharge. Exceptions to the 30-day requirement are if/ when a resident is endangering the health or safety of themselves or others, when a resident's health has improved to allow an immediate transfer, or when a resident's urgent medical needs require immediate transfer, and when a resident has not resided in the facility for 30 days .b. Record the reason for, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged in the medical record and on a discharge form or a letter. Give a copy of the discharge notice to the resident and his/her family legal representative D. Provide the resident with a statement of the right to appeal the action to the state agency designated for such appeals, along with the name, address, and phone number of the State long-term care ombudsman . On 10/18/24 at 11:07 a.m., NC 1 provided the Bed Hold Policy, last reviewed on 11/1/16, which read, .The campus will properly inform residents in advance of their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed. For this optional payment, the campus must make clear that the resident/ responsible party must affirmatively elect to make them prior to being billed . Procedures 1. Private Pay Residents if the resident leaves the campus for hospitalization .if the resident is not eligible for or receiving Medicaid benefits, and upon notification agrees to resident's bed will be reserved through payment of the basic rate .If the resident elects to not reserve his/ her bed, then the resident will be discharged from the campus and readmission to the facility shall be subject to bed availability. 2. Medicaid Assistance Residents If the Resident is eligible for or is receiving Medicaid assistance, and the Resident leaves the Facility for hospitalization or therapeutic leave, the Resident's bed will be reserved for the applicable number of days paid for a reserved bed under the State Medicaid program .If the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of the Resident's bed under the Medicaid program or the Medicaid program does not cover hospital or therapeutic leaves, the Resident will be entitled to the first available accommodation suitable for the Resident's level of care if the Resident requires the Facility's services . This citation relates to Complaint IN00440998. 3.1-12(a)(7) 3.1-12(a)(10)

Based on interview and record review, the facility failed to accurately monitor urinary output and to monitor for symptoms of urinary tract infections for residents with urinary catheters for 2 of 3 residents reviewed for urinary catheters (Resident C and Resident E). Findings include: 1. The clinical record for Resident C was reviewed on 10/16/24 at 3:05 p.m. The diagnoses included, but were not limited to, pressure ulcer of left and right buttocks. A care plan, with start date of 6/16/23, indicated Resident C had a urinary catheter due to neurogenic bladder and stage 4 (full thickness) wound. The goal was for him to be free of adverse effects from catheter use. The interventions included, but were not limited to, observe for any signs of complications such as urinary tract infections and record urinary output. A physician's order, dated 11/10/23, indicated to monitor output every shift. A physician's order, dated 11/10/23, indicated Foley catheter care was to be completed each shift. The February 2024 Treatment Administration Record (TAR) indicated Foley catheter care was provided each shift from 2/1/24 through 2/8/24. The February 2024 TAR indicated Resident C's urinary output(s) were as follows: 2/1/24 - day shift- medium, evening shift - large, night shift - medium/400 milliliters (ml), 2/2/24 - day shift- 1200 ml, evening shift- large, night shift- large, 2/3/24 - day shift- large, evening shift - medium/ 600 ml, night shift- large, 2/4/24 - day shift- medium, evening shift- medium /550 ml, night shift- large, 2/5/24 - day shift- large, evening shift- 800 ml, night shift- large, 2/6/24 - day shift- large, evening shift- large, night shift- large, 2/7/24 - day shift- large, evening shift- large, night shift- large, and 2/8/24- day shift- large. A nursing progress note, dated 2/6/24 at 6:10 a.m., indicated Resident C had some blood in his urinary catheter. The physician was notified and would continue to monitor. The clinical record did not contain any further nursing progress notes addressing Resident C's urine from 2/6/24 at 6:10 a.m. until 2/8/24 at 2:58 p.m. A nursing progress note, dated 2/8/24 at 2:58 p.m., indicated the nurse practitioner had seen Resident C related to dark amber urine and blood noted in urine on 2/6/24. An order was received to complete a urinalysis with culture and sensitivity. Resident C was discharged to an acute care hospital on 2/8/24 for treatment of a urinary tract infection. 2. The clinical record for Resident E was reviewed on 10/15/24 at 12:49 p.m. The diagnoses included, but were not limited to, neurogenic bladder. An Annual Minimum Data Set (MDS) assessment, completed 7/15/24, indicated Resident E had moderately impaired cognition and an indwelling urinary catheter. A physician's order, dated 9/5/24, indicated to monitor urinary output every shift. The order was discontinued on 10/9/24. A physician's order, dated 9/5/24, indicated to provided catheter care every shift. The order was discontinued on 10/9/24. A care plan, last reviewed 9/25/24, indicated Resident E had a suprapubic (catheter inserted into bladder through the lower abdomen) catheter due to having a neurogenic bladder. The goal was for her to be free from adverse effects from catheter use. The interventions included, but were not limited to, record urinary output and observe for any signs of complications such as urinary tract infections. The October 2024 TAR indicated Resident E had catheter care completed each shift, from 10/1/24 through 10/5/24, when she went to an acute care hospital. The October 2024 TAR indicated the urinary output(s) were as follows: 10/1/24 - day shift- resident unavailable, evening shift- large, night shift- medium, 10/2/24 - day shift- medium, evening shift- large, night shift- medium, 10/3/24 - day shift- small/ 300 ml, evening shift- large, night shift- medium, 10/4/24 - day shift- resident unavailable, evening shift- 800 ml, night shift- medium, and 10/5/24- day shift- resident unavailable. Resident E returned from the acute care hospital on 10/9/24. The October 2024 TAR did not contain any further documentation that catheter care was completed, or urinary output was recorded from 10/9/24 through 10/21/24. During an interview on 10/21/24 at 12:30 p.m., Certified Resident Medication Assistant (CRMA) 5 indicated urinary catheters are emptied each shift, and the amount of urine should be documented in milliliters (ml). During an interview on 10/21/24 at 12:41 p.m., Certified Resident Care Assistant (CRCA) 6 indicated urine output was measured in milliliters each shift. During an interview on 10/21/24 at 4:17 p.m., the Administrator indicated urinary output from catheters should be emptied and measured in milliliters at the end of each shift. On 10/21/24 at 2:00 p.m., Nurse Consultant 1 provided the Suprapubic Catheter Care Standard Operating Procedure, last reviewed 12/31/23, which read, . Overview To prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract .General Guidelines . Observe the resident's urine level for noticeable increases or decreases . Check the urine for unusual appearance .maintain an accurate record of the residents daily output, if indicated .Observe the resident for signs and symptoms of urinary tract infection and urinary retention .empty the collection bag each shift and prn [as needed] . 5. The following information as applicable should be recorded in the resident's medical record .Character of urine, such as color [straw-colored, dark, or red], clarity [cloudy, solid particles, or blood], and odor .Any problems or complaints made by resident during the procedure. 6. Notify the physician of any abnormalities in the skin assessment or character of urine . This citation relates to Complaint IN00440998. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained with hand hygiene during medication administration for 3 of 4 residents observed and failed to ensure staff donned a gown prior to providing activities of daily living (ADL) care for a resident with enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for transmission-based precautions. (Residents 2, 9, 31, and 91) Findings include: 1. An observation was conducted of a medication administration with Licensed Practical Nurse (LPN) 6 for Resident 31 on 10/17/24 at 8:47 a.m. LPN 6 was observed at the medication cart preparing the resident's medication. During that time, she had pulled all the medications from the cart, touched the computer mouse, cups, and water pitcher. She then grabbed a straw and unwrapped the paper wrapper touching the end piece of the straw the resident would place in his mouth with her bare hands. After, LPN 6 was observed entering the resident's room and administering the medications to the resident. The resident did utilize the straw in the cup of water to drink from it. LPN 6 then washed her hands. There was no observation of hand hygiene prior to the administration of the medications to the resident. 2. An observation was made of a medication administration for Resident 9 with LPN 6 on 10/17/24 at 9:05 a.m. LPN 6 was observed at the medication cart preparing the resident's medication. During that time, LPN 6 had dropped a pill medication on the floor. She then picked up the pill medication with her bare hands and placed it on the medication cart. After, she donned on gloves and discarded the pill medication in the sharps container. She then doffed off the gloves and continued preparing the medications. There were no observations of LPN 6 utilizing hand hygiene after she picked up the pill medication off the floor nor prior or after donning and doffing gloves. She then went to the resident's room and obtained the resident's vitals utilizing a dynamap machine (electronic machine to obtain blood pressure, pulse, oxygen saturations and temperature). After, she donned on gloves and obtained the resident's blood sugar utilizing a glucometer. She then doffed her gloves and washed her hands. There was no hand hygiene prior to touching the resident nor donning of gloves. 3. An observation was made of a medication administration for Resident 91 with LPN 6 on 10/17/24 at 11:54 a.m. LPN 6 was observed pulling Resident 91's insulin from the medication cart and entered the resident's room. LPN 6 donned on gloves and administered insulin to the resident. After, LPN 6 doffed her gloves and washed her hands. There was no observation of LPN 6 utilizing hand hygiene prior to donning on her gloves. An interview was conducted with the Nurse Consultant (NC) 1 on 10/17/24 at 3:52 p.m. She indicated LPN 6 should have utilized hand hygiene after picking the pill off the floor. Hand hygiene should be utilized before and after donning and doffing gloves. A medication administration policy was provided by the Nurse Consultant (NC) 1 on 10/17/24 at 3:52 p.m. It indicated the following, .A. Preparation .2) Handwashing and Hand Sanitization: The person administering medication adheres to good hand hygiene: before beginning a medication pass, prior to handing any medication, after coming into direct contract with a resident, before and after administration .B. Administration .8) Hand hygiene is performed before putting on examination gloves . 40287 4. The clinical record for Resident 2 was reviewed on 10/15/24 at 1:02 p.m. The diagnoses included, but were not limited to, dysphagia (inability to swallow) and attention to gastrostomy (feeding tube placed in stomach). An Annual Minimum Data Set (MDS) assessment, completed 7/25/24, indicated he received nutrition through a feeding tube and was dependent on staff for bathing, toileting, and dressing. A physician's order, dated 8/3/24, indicated staff were to use enhanced barrier precautions, wear a gown and gloves at minimum, during high-contact care activities. A care plan, last reviewed on 8/6/24, indicated Resident 2 required enhanced barrier precautions (EBP) during high-contact care related to the presence of a feeding tube. The goal was the risk of transmission of infection would be minimized with the use of EBP. The interventions included, but were not limited to, utilize gown and gloves per EBP policy during high contact ADL care such as dressing, toileting, and bathing. On 10/15/24 at 1:02 p.m., Resident 2's room was observed. There was a sign posted at the entrance of the room which indicated Resident 2 required EBP during care and a storage bin with disposable isolation gowns was present inside of the room. On 10/21/24 at 10:25 a.m., Certified Resident Care Assistant (CRCA) 4 was observed providing care to Resident 2. CRCA 4 was turning Resident 2 in bed and changing his bed linens and brief. CRCA 4 was not wearing a gown while providing care to Resident 2. During an interview on 10/21/24 at 10:35 a.m., CRCA 4 indicated she should have donned a gown prior to providing care to Resident 2. On 10/21/24 at 4:00 p.m., the Director of Nursing provided the Enhanced Barrier Precautions Standard Operating Procedure, effective 4/1/24, which read, .Enhanced Barrier Precautions will be in place during high-contact care activities residents with the following conditions .All Residents with indwelling medical devices .Personal Protective Equipment [PPE] should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high-contact care activities . High- contact care activities include but are not limited to morning and evening ADL care, toileting, and showers 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 2 residents reviewed for abuse, 2 of 4 residents reviewed for dignity, 1 of 3 residents reviewed for ADLs (activities of daily living,) and 6 of 7 residents that attended in resident council. (Resident 's 1, 5, 8, 14, 21, 29, 19, 31, and 38) Findings include: 1. The clinical record for Resident 21 was reviewed on 7/18/23 at 10:45 a.m. The resident's diagnosis included, but was not limited to, stroke with hemiplegia affecting left side. The Quarterly MDS (Minimum Data Set), completed on 6/17/23, indicated Resident 21 was moderately cognitively impaired. The resident needs extensive assistance of one staff person with dressing. The clinical record for Resident 29 was reviewed on 7/20/23 at 11:45 a.m. The resident's diagnosis included, but was not limited to, heart failure. The Quarterly MDS (Minimum Data Set), completed on 6/27/23, indicated Resident 29 was cognitively intact. An interview was conducted with Resident 21 on 7/18/23 at 11:10 a.m. She indicated Certified Resident Care Assistant (CRCA) 5 was rough during care. She does not place my bra on correctly, and it hurts. This has been reported recently, but it still continues to go on. The CRCA she had today was gentle with the bra placement, but CRCA 5 was not when she does it. She did not want to receive care by CRCA 5. An observation and interview was conducted with Resident 21 and Family Member (FM) 7 on 7/21/23 at 9:41 a.m. Resident 21 indicated her bras were too small. At that time, the resident had lifted up her shirt, and an observation was made of the resident's bra. The sports bra the resident was currently wearing did not appear to be too small. The resident indicated CRCA 5 was rough putting on her bra causing pain to her affected arm. FM 7 indicated after the last reported incident about rough care with bra placement by CRCA 5, FM 7 had purchased larger sports bras for the resident instead of buying bras that snap in the front or back. FM 7 did not believe CRCA 5 was abusive she thought the larger bras would address the problem. The plan as of now, CRCA 5 will not provide care any longer to Resident 21. An interview was conducted with CRCA 5 via phone on 7/21/23 at 2:41 p.m. She indicated FM 7 sits out the clothes Resident 21 was to wear every day. The clothes that was sat out for the resident was what CRCA 5 placed on the resident. Since the previous incident with care concerns, she had not provided care to the resident until last week. CRCA 5 had received education and training on assistance with dressing a resident that has hemiplegia prior to providing care to the resident last week. During care, the resident had not voiced any concerns with care that she received by her. An interview was conducted with Resident 29 on 7/24/23 at 9:48 a.m. She indicated she was Resident 21's roommate. She has overheard verbal interactions between the staff and Resident 21. She was unable to identify which staff members, but the staff were not nice to Resident 21. They are disrespectful. Resident 21 can be loud and obnoxious at times, but she was not cognitively intact. The resident will turn on her call light and ask for something from the staff. The staff will then tell her roommate no and just be quiet. The staff will then leave the room and never return to provide her roommate what she has requested. That happens all the time. The staff appear to be agitated with Resident 21 during interactions and not trained how to address a resident in her condition. She did not believe the staff were abusive, but disrespectful. The investigation of the reportable incident was provided by the Executive Director on 7/26/23 at 10:36 p.m. The investigation indicated a teachable moment was provided to the CRCA 5. It indicated .What's Expected: CRCA [5] should explain to the resident what care they are there to perform to providing ADL care. When a resident reports pain/discomfort during ADL care, CRCA should stop, ensure safety, and notify the nurse prior to continuing care. CRCA should being by dressing the affected/impaired side first to promote the highest level of functioning and comfort during ADL care. 2. The clinical record for Resident 49 was reviewed on 7/18/23 at 11:00 a.m. The resident's diagnosis included, but was not limited to, heart failure. The Admissions MDS (Minimum Data Set), completed on 6/17/23, indicated Resident 49 was moderately cognitively impaired. The resident needs extensive assistance of one staff person with toileting. An interview was conducted with Resident 49 on 7/18/23 at 10:49 a.m. She indicated a couple of weeks ago, she had received care by a male CRCA she did not know his name, but was very rude and rough during toileting care. She indicated the CRCA while assisting her with toileting made statements to her, you need to do this stuff yourself. Staff don't have time for this. The CRCA then wiped her with a paper towel instead of toilet paper. She has not had the CRCA since. She indicated it was not CRCA 22 nor CRCA 23, because they are pleasant. An interview was conducted with the Executive Director and the Assistant Director of Nursing Services (ADNS) on 7/18/23 at 11:26 a.m. The ADNS indicated she was unsure who the male CRCA was that provided care to Resident 49. The only male CRCAs the facility has was CRCA 22 and CRCA 23. An interview was conducted with Nurse Consultant 1 on 7/24/23 at 4:00 p.m. The facility has made the assumption it was a former male employee that had provided care to Resident 49. 30344 3. The clinical record for Resident 5 was reviewed on 7/19/23 at 9:45 a.m. Her diagnoses included, but were not limited to: acute kidney failure, polyneuropathy, chronic obstructive pulmonary disease, morbid obesity, hyperlipidemia, atrial flutter, depression, spinal stenoises, hypertension, lymphedema, and degenerative joint disease. The 7/7/23 functional impairment care plan for Resident 5 indicated she required extensive/total assistance with transfers, bed mobility, and toileting, keeping in mind that ADL ability could fluctuate frequently. The 7/4/23 Admission MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. An observation and interview was conducted with Resident 5 on 7/19/23 at 9:51 a.m. She was lying in bed. Her legs were very dry and chafing, but had a moisturizing treatment applied to them. She indicated one day last week, she pressed her call light because she needed to use the bedpan. She was soaking wet, because she didn't feel it coming out. When the CNA (Certified Nursing Assistant) came to the room, she asked her to change her brief and informed her she needed to use the commode to have a bowel movement. The CNA left the room and said they would be back, but by the time the CNA returned, she had a bowel movement in the bed. The CNA was mad at me and snatched on my leg. Resident 5 informed her it hurt, but then she she snatched on the other leg. When the CNA was putting the brief on, Resident 5 informed her it hurt when she wiped her, but the CNA didn't pay any attention to me. I was crying, in tears. Resident 5 informed the CNA of her age and that she didn't appreciate being treated like this. Resident 5 could not recall the CNA's name, but gave a physical description of her. Resident 5 indicated she didn't think the CNA had enough training, like she didn't know any better, but when I told her it hurt, it still hurt, not empathizing with the patient at all. Resident 5 informed the nurse on duty at the time of what happened, who was the same nurse working the unit now. An interview was conducted with LPN 11 on 7/19/23 at 10:06 a.m. She indicated she remembered the incident Resident 5 was referencing and she informed LPN 6 of it. Resident 5 asked LPN 11 if she could help her out, because she didn't feel clean, like there was some paper stuck to her after getting her brief changed. Resident 11 wasn't crying at the time, but she looked serious, saying she needed some help. LPN 11 assisted Resident 5 and she did have a piece of tissue stuck on her. LPN 11 got a wash cloth, washed her up real good,' and let LPN 6 know that Resident 5 felt like the CNA was rough with her. LPN 11 didn't know who the CNA was. Resident 5 informed LPN 11 that she thought the CNA scratched her with her nails. LPN 11 changed Resident 5's brief 2 more times that day, looked for scratches, but she didn't find any scratches on her. An interview was conducted with LPN 6 on 7/19/23 at 10:10 a.m. She indicated she remembered the incident. The CNA involved was CNA 5, who was currently suspended. A telephone interview was conducted with CNA 5 on 7/21/23 at 2:42 p.m. She indicated she'd worked at the facility for 7 years. She'd cared for Resident 5 only one time, and it was in bed. She change her brief. Resident 5 responded pretty good. Resident 5 cried sometimes, but CNA 5 was unsure why she was crying. CNA 5 asked Resident 5 why she was crying and Resident 5 responded by requesting her to just shut her door. Resident 5 did not say anything to CNA 5 about her fingernails that day. CNA 5 indicated she had a layover on her fingernails that were about an inch past the tip of her finger. CNA 5 never found out why Resident 5 was crying, and no one ever discussed her care of Resident 5 with her until this interview. 4. The clinical record for Resident 38 was reviewed on 7/18/23 at 2:00 p.m. Her diagnoses included, but were not limited to, polyneuropathy. The 6/2/23 admission assessment indicated to provide assistance as needed for bed mobility, eating, toileting, and transfers. The 6/6/23 Admission MDS (Minimum Data Set) assessment indicated she required extensive assistance of 2 staff for bed mobility and transfers and was totally dependent on one staff person for toileting. She had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. An interview was conducted with Resident 38 on 7/18/23 at 2:08 p.m. She indicated the staff at the facility did not treat her with dignity and respect. The previous night, around 1:00 a.m., she had to go to the restroom, so she pressed her call light. The CNA came into her room and told her that she didn't need to push her call light every time she needed to get up, and that she could get out of bed on her own. Resident 38 did not recall the CNA's name, but gave a physical description of her. On 7/24/23 at 4:00 p.m., NC (Nurse Consultant) 1 provided the name and phone number of the CNA who worked Resident 38's unit the night shift of 7/17/23 into 7/18/23. It was CNA 5. A telephone interview was conducted with CNA 5 on 7/25/23 at 9:40 a.m. She indicated she did not provide care for Resident 38 on the night shift of 7/17/23, nor did she work that unit. 5. The clinical record for Resident 1 was reviewed on 7/19/23 at 10:20 a.m. Her diagnoses included, but were not limited to, hypertension. The 4/9/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 15, indicating she was cognitively intact. An interview was conducted with Resident 1 on 7/19/23 at 10:23 a.m. She indicated the past couple of mornings, the CNA had been rough with her, but she couldn't remember her name. The CNA wouldn't answer her questions. She's been terribly frustrated. The CNA was rushing with me. It hurt. It took a while for Resident 1's body to loosen up. She knew it was hurting me. The CNA raised her voice and I don't do well with that. It's more the tone and way she talks to me. I'm not stupid. She's forceful that way .She is my favorite, just rough and rude lately. 40287 6. The clinical record for Resident 14 was reviewed on7/19/23 at 11:03 a.m. The Resident's diagnosis included, but were not limited to, diabetes and anemia. A Quarterly MDS Assessment, completed 5/13/23, indicated she was cognitively intact. 7. The clinical record for Resident 31 was reviewed on 7/19/23 at 10:45 a.m. The resident's diagnosis included, but was not limited to, end stage renal disease. The Quarterly MDS (Minimum Data Set), completed on 6/18/23, indicated Resident 31 was cognitively intact. On 7/24/23 at 11:36 a.m., Resident 14 and Resident 31 were interviewed. Resident 14 indicated the staff are frequently on their phones while in the dining room. The residents in the dining room have to wait until the staff are done on their phones to have drinks served to them. The staff share information about residents of the building while in the dining room. Resident 31 indicated that the Dietary Manager has been rude to her when she has asked for substitutes during meals. 8. A resident council meeting was conducted on 7/18/23 at 2:31 p.m., with the attendance of Resident's 1, 5, 8, 14, 29, 19, and 31. The council indicated the CRCA staff were rude and disrespectful. They lack training in providing care to someone that has disabilities and diseases. An interview was conducted with the Director of Nursing Services on 7/25/23 at 3:30 p.m. She indicated the staff have been educated on care needs, resident rights and abuse. The Resident Rights Guidelines policy was provided by NC (Nurse Consultant) 1 on 7/25/23 at 8:44 a.m. It read, Our residents have aright to .a. Be treated with dignity and respect .f. Be treated fairly, courteously and with respect by all staff. 3.1-3(a) 3.1-3(t)

Based on observation, interview, and record review, the facility failed to timely address a resident's lower extremity edema, timely schedule an orthopedic appointment, to obtain blood sugar readings and administer insulin before meals as ordered, and failed to hold insulin when blood sugar results were below 110, as ordered by the physician, for 1 of 1 resident reviewed for edema, 1 of 3 residents reviewed for ADLs (activities of daily living), 1 of 1 resident reviewed for insulin, and 1 of 5 residents reviewed for unnecessary medications (Residents 5, 14, 31, and 38) Findings include: 1. The clinical record for Resident 38 was reviewed on 7/18/23 at 2:00 p.m. Her diagnoses included, but were not limited to, polyneuropathy. The 7/15/23 skilled nursing assessment indicated she had +1 pitting edema (up to 2 mm of depression, rebounding immediately) in her left and right lower legs. There was no information, including in the progress notes or physician's orders, in the clinical record indicating the lower extremity edema was addressed or that the physician was notified. The 6/6/23 Admission MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. An interview and observation was conducted with Resident 38 on 7/18/23 at 2:18 p.m. She was sitting in her wheel chair in her room. She was wearing ballet type slippers. Both feet were puffy. She was not wearing any tubi-grips or compression stockings. Resident 38 took off her left slipper to display how swollen her foot was. She indicated her feet were swollen, and she couldn't put on her shoes. She informed nursing last week, on 7/13/23, but it hadn't been addressed. Her feet hurt when she stood up and put pressure on them. She'd tried to put on her shoes twice since 7/13/23, but was unable to get them on, because they were too swollen, and she didn't want to force them into her shoes. Nursing was informed of Resident 38's edema concerns immediately after the above interview. The 7/18/23 physician's order read, Apply tubi-grip to BLE [bilateral lower extremities] each morning before rising. Remove ted hose at bedtime Twice A Day. An interview and observation was conducted with Resident 38 on 7/19/23 at 3:22 p.m. She was sitting in her wheel chair in her room. She was wearing tubi-grips on both legs/feet with gripper socks over them. Resident 38 indicated nursing put the tubi-grips on her yesterday before dinner and they'd been on ever since. They were itchy and starting to hurt. No one removed them last night at bedtime, and she didn't know they were supposed to be removed. An interview was conducted with QMA (Qualified Medication Aide) 2 on 7/19/23 at 3:46 p.m. He indicated he thought the ted hose portion of the order may be a typo and that her tubi-grips should have been taken off last night, as they typically remove a resident's tubi-grips at night. The 7/18/23, 4:48 p.m. nurse's note, recorded as a late entry by LPN (Licensed Practical Nurse) 6 on 7/19/23 at 4:57 p.m., read, resident requests compression hose due to edema in bilateral lower extremities. NP [Nurse Practitioner] made aware. New orders for tubi-grips to BLE until ted hose arrive. Resident made aware and verbalizes understanding. The 7/20/23 NP note read, .The chief complaint for this visit is Medical Management - BLE Edema .Nursing requested resident be seen for increasing BLE edema, TED hose have been ordered. She has history of seizure disorder, she denies cough, shortness of breath or other concern, denies numbness or tingling. She 2+ pitting edema to BLE and feet. Orders placed for Torsemide 20 mg daily. During the visit she is alert and oriented, appears comfortable .Skin: Warm, Dry, Fragile, toe infection. Extremities: PPP [progressive pigmented purpura], Edema +:2, BLE .Assessment/Treatment Plan Diagnosis R600: Localized edema (Start Torsemide 20 mg daily) .Verification of Necessity: In my judgement as the physician/provider, the care provided today required professional assessment, planning, management, or monitoring. 2. The clinical record for Resident 5 was reviewed on 7/19/23 at 9:45 a.m. Her diagnoses included, but were not limited to: acute kidney failure, polyneuropathy, chronic obstructive pulmonary disease, morbid obesity, hyperlipidemia, atrial flutter, depression, spinal stenoises, hypertension, lymphedema, and degenerative joint disease. The 7/7/23 functional impairment care plan for Resident 5 indicated she required extensive/total assistance with transfers, bed mobility, and toileting, keeping in mind that ADL ability could fluctuate frequently. The 7/4/23 Admission MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. The 7/20/23, 6:04 a.m. nurse's note read, Resident states, 'left great toe was in pain and that resident's toe was hit on door during transfer from Bingo on 7/19/23. redness, swelling and unable to do ROM [range of motion] on left great toe. PRN [as needed] pain med given and effective. New order noted for STAT [without delay] Left foot Xray x [times] 3 views complete. Notifications made. The 7/20/23, 2:55 p.m. nurse's note, written by LPN (Licensed Practical Nurse) 6 read, left toe xr [x-ray] result sent to NP [nurse practitioner.] new orders for WBAT [weight bearing as tolerated,] wrap with kerlix as tolerated and referral to ortho [orthopedics.] resident made aware. verbalizes understanding. The physician's orders indicated a referral to ortho for fracture of distal 1st phalanx, starting 7/20/23. There was no information in the clinical record indicating an orthopedic appointment was scheduled for her. An interview was conducted with LPN 6 on 7/25/23 at 1:05 p.m. She indicated she spoke with Resident 5 about an orthopedic appointment on 7/20/23. Resident 5 informed her she would let her know which orthopedic physician/clinic she would like to use, but Resident 5 hadn't yet let her know, and LPN 6 hadn't followed up with her about the appointment since. LPN 6 went into Resident 5's room all the time. An interview was conducted with Resident 5 on 7/25/23 at 1:15 p.m. She indicated no one had discussed anything with her about an orthopedic appointment. If the facility was supposed to set one up, she didn't know about it. She was supposed to be leaving the facility to go home this coming Friday. She would be fine with the facility choosing an orthopedic physician for her and setting up the appointment, even if the appointment was scheduled for after she went home. 34850 3. The clinical record for Resident 31 was reviewed on 7/19/23 at 10:45 a.m. The resident's diagnoses included, but was not limited to, end stage renal disease and type 2 diabetes. The Quarterly MDS (Minimum Data Set), completed on 6/18/23, indicated Resident 31 was cognitively intact. A physician order dated 6/9/23 indicated Resident 31 was to receive a sliding scale of humalog insulin before each meal. The humalog insulin sliding scale was the following: blood sugar reading of 151 to 200 = 2 units of insulin, blood sugar reading of 201 to 250 = 4 units of insulin, blood sugar reading of 251 to 300 = 6 units of insulin, blood sugar reading of 301 to 350 = 8 units of insulin, and blood sugar greater than 351 medical provider was to be notified The July 2023 Medication Administration Record indicated the following days and meals the staff had not obtained a blood sugar reading to administer insulin if appropriate to Resident 31: 7/3/23 - dinner meal - no reason given, 7/15/23 - breakfast meal - staff documented unavailable, 7/19/23 - dinner meal - staff documented unavailable, and 7/21/23 - lunch meal - staff documented LOA (leave of absence) The July 2023 Intake Report for Resident 31 indicated the following days, and the percentages of the meal the resident had eaten: 7/3/23 - dinner meal = 26-50%, 7/15/23 - breakfast meal = 76-100%, 7/19/23 - dinner meal = 76-100% and 7/21/23 - lunch meal = 76-100% An interview was conducted with Resident 31 prior to the noon lunch meal in the community activities room on 7/21/23 at 11:17 a.m. Resident 31 indicated she was to receive insulin 3 times a day, but she does not receive the insulin at times due to not being on the unit. She attends activities and hangs out in the front lobby to socialize with peers most days. The nursing staff have told her if she was not on the unit at the time of insulin administration they were not going to hunt her down, even though she has observed her peers receiving medications while they are off the unit. During an interview with Director of Nursing on 7/26/23 at 1:00 p.m., the nursing staff had attempted to obtained the 7/21/23 lunch meal blood sugar reading, but it was after the lunch meal. The resident was outside at that time. 40287 4. The clinical record for Resident 14 was reviewed on 7/19/23 at 11:03 a.m. The Resident's diagnosis included, but were not limited to, diabetes and anemia. A care plan, initiated 11/7/2019, indicated Resident 14 was at risk for hypo (low) and hyperglycemia (high blood sugar) due to her diagnosis of diabetes. The goal was for her to be free of symptoms of hypo/hyperglycemia. The interventions included, monitor blood sugars as ordered by the physician and to administer medications per physician's orders, initiated 11/7/2019. A physician's order, dated 12/21/22, indicated Resident 14 was to receive Basaglar insulin 24 units each evening between 7:00 p.m. and 10:00 p.m. The insulin was to be held if her blood sugar was below 110. The June and July 2023 MAR (Medication Administration Records) indicated the 24 units of Basaglar insulin was administered as follows: 6/7/23- 24 units administered- blood sugar recorded was 108, 6/8/23- 24 units administered- blood sugar recorded was 85, 6/17/23- 24 units administered- blood sugar recorded was 101, and 7/17/23- 24 units administered- blood sugar recorded was 98. During an interview on 7/24/23 at 2:02 p.m., LPN (Licensed Practical Nurse) 11 indicated that when a physician's order indicated to hold insulin for a blood sugar below 110, the dose of insulin should not be given when blood sugars are below 110. 3.1-37

Based on observation, interview and record review, the facility failed to initiate a grievance for a resident, to address grievances, to follow up on a resident's grievance, and to ensure their grievance policy included all necessary components for 2 of 4 residents reviewed for abuse and 1 resident reviewed for choices. (Resident 20, 31, and 38) Findings include: 1. The clinical record for Resident 20 was reviewed on 7/19/23 at 9:24 a.m. The Resident's diagnosis included, but were not limited to, end stage renal disease and diabetes. A Quarterly Minimum Data Set Assessment, completed 5/10/23, indicated he was cognitively intact. He could make his needs and wants known and understand what was being said to him, and that he received dialysis. During an interview on 7/19/23 at 9:57 a.m., Resident 20 indicated he was very upset because the facility owed him money and was not giving it back to him. He had attempted to pay his bill and had been informed by the business office that he had a credit to his bill of about $7,000.00. He had asked for a refund but had not received it. During an interview on 7/20/23 at 11:38 a.m., the BOM (Business Office Manager) indicated that Resident 20 did have a credit to his billing account. She had reached out to the corporate office about the credit. During an interview on 7/21/23 at 1:06 p.m., Resident 20 indicated he had attempted to pay his bill 4 months ago and was told that he did not owe anything, he had a credit to his account. He had spoken with the Business Office Manager about his bill about a month ago and was told he had a credit of around $7,000.00. He asked about a refund and the Business Office Manager had told him that since she was new and was not sure how to go about getting a refund for him, she would contact the corporate office. He had also asked the current SSD (Social Service Director) about his money and was told he would have to talk with the business office. During an interview on 7/21/23 at 3:14 p.m., the SSD indicated that Resident 20 had spoken to him about an outstanding credit to his bill about 2 weeks ago. He had not created a grievance about the concern. The SSD had encouraged Resident 20 to take up the issue with the business office. 34850 2. The clinical record for Resident 31 was reviewed on 7/19/23 at 10:45 a.m. The resident's diagnosis included, but was not limited to, end stage renal disease. The Quarterly MDS (Minimum Data Set), completed on 6/18/23, indicated Resident 31 was cognitively intact. An interview was conducted with Resident 31 on 7/19/23 at 9:04 a.m. She indicated the staff do not make her bed in the morning and she has repeatedly asked for it to be done. She goes to dialysis on Mondays, Wednesdays and Fridays and was gone from 4:30 a.m. to 10:30 a.m., on those days. The staff make her roommate's bed every morning, but do not make hers. She knows it might be a petty request, but she has asked housekeeping and nursing staff who was responsible for it and why can't her bed be made. The staff will not address her concern with bed making. This has been going on for a couple of months. The June and July 2023 grievances report provided by Nurse Consultant 1 on 7/21/23 at 10:43 a.m., did not include concerns with bed making for Resident 31. Observations were made of Resident 31's room on 7/21/23 at 9:29 a.m., 7/21/23 at 11:35 a.m., and 7/24/23 at 10:26 a.m. Resident 31 was not present in her room. The resident's bed was not made, but her roommate's bed was. An interview was conducted with Housekeeper 4 on 7/24/23 at 10:28 a.m. She indicated Resident 31 had discussed with her about the bed making and who was responsible for making the beds. She had told her housekeeping does not make the residents' beds. Housekeeper 4 had not told anyone about the discussion she had with Resident 31, because she had overheard the resident speaking with another staff member about it. An interview was conducted with Certified Resident Care Assistant (CRCA) 3 on 7/24/23 at 10:51 a.m. She indicated she was the CRCA for Resident 31 that day. She had not made the resident's bed that morning. She does not like to make the resident's bed while she was present in her room. She makes the resident's bed after lunch while the resident sits in the front lobby. 30344 3. The clinical record for Resident 38 was reviewed on 7/18/23 at 2:00 p.m. Her diagnoses included, but were not limited to, intellectual disability and epilepsy. The 6/6/23 Admission MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. An interview was conducted with Resident 38 on 7/18/23 at 2:14 p.m. She indicated another resident, Resident 1, called her an ***hole on 7/16/23 in the dining room. This made her feel upset. Resident 38 didn't tell anyone that day, because she was too upset about it, but informed CNA (Certified Nursing Assistant) 15 the next day, on 7/17/23. CNA 15 responded by telling Resident 38 not to pay any attention to Resident 1. There was no information in the clinical record to indicate follow up on Resident 38's verbal grievance. An interview was conducted with the ED (Executive Director) on 7/18/23 at 2:45 p.m., at which time, Resident 38's verbal grievance was discussed. He indicated this was the first he'd heard of it, and would have staff look further into it. On 7/21/23 at 1:05 p.m., the ED provided a list of all resident grievances from May, 2023 to present. There was no grievance for Resident 38. An interview was conducted with the ED on 7/20/23 at 3:46 p.m. He indicated he signed off on all grievances in the facility and he had no grievances for Resident 38. CNA 15 should have reported it to their supervisor on 7/17/23, when Resident 38 told her about it. The SSD (Social Services Director) looked into it after it was reported to the ED on 7/18/23. The 7/20/23 social services note, written by the SSD, read, .followed up with resident about a curse word being said to her by another resident. Per staff who interviewed resident on 7/18/23. Resident was ok & not concerned about what was said to her. When writer spoke to her today. Resident said she felt scared & threaten [sic] at that moment. At this time she does not have those feelings. An interview was conducted with the SSD on 7/21/23 at 2:05 p.m. He indicated he was unaware of the situation until 7/18/23. He indicated he would have liked to have known if Resident 38 was emotionally disturbed by the incident. She had an intellectual disability, so that was a concern. The facility needed to address it, because it could have progressed. Resident 38 may have wanted to react. When he followed up with Resident 38 on 7/20/23, he told her to sit with other residents in the dining room who are more courteous and respectful. He was going to make sure he had a presence in the dining room to calm things down. CNA 15 should have informed the ED of Resident 38's allegation. He was not surprised Resident 1 would say something like this to Resident 38, but he'd never heard Resident 1 curse at anyone before. An interview was conducted with the ED on 7/21/23 at 11:04 a.m. He indicated when a resident verbally indicated a grievance, the process was for the resident to inform staff, so staff could enter the grievance electronically. He was unsure if a resident could fill out a grievance by themselves. An interview was conducted with the SSD on 7/21/23 at 11:15 a.m. He indicated the process for a CNA to complete a grievance for a resident was for the CNA to put it on notebook paper and leave it in the mailbox of any staff member who had access to fill out an electronic grievance, such as himself, the ED, DON, or one of the nurses. A resident had to file a grievance with staff, but there was no way for a resident to file a grievance anonymously. An observations of the front desk was made with the SSD on 7/21/23 at 11:16 a.m. The Guest Relations staff member, who sat at the front desk, provided a copy of a resident grievance form that she found in the top right desk drawer of the reception desk. There was no sign of availability on the desk, and the drawer was inaccessible to residents or visitors. The Resident Concern Process policy was provided by the ED on 7/21/23 at 12:00 p.m. It read, Purpose To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service. Procedures .3. The facility staff will follow the Resident Concern Process flow chart when any concern or complaint is voiced 5. Enter the concern using the desktop icon labeled 'Resident Concern Form.' All concerns should be entered electronically 6. Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution .11. The Social Services Director will monitor for follow through and resolution with Executive Director support. The policy did not reference notifying a resident of their right to file a grievance; how to file a grievance anonymously; preventing further potential violations of any resident right; or maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. An interview was conducted with the SSD on 7/21 at 2:16 p.m. He reviewed the Resident Concern Process policy and indicated he did not see where it referenced notifying a resident of their right to file a grievance; how to file a grievance anonymously; preventing further potential violations of any resident right; or maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. 3.1-7(a)(2) 3.1-7(b)

Based on interview and record review, the facility failed to ensure that care plan meetings were conducted quarterly for 1 of 1 resident reviewed for care planning (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 7/19/23 at 9:24 a.m. The Resident's diagnosis included, but were not limited to, end stage renal disease and diabetes. A Quarterly Minimum Data Set Assessment, completed 5/10/23, indicated he was cognitively intact. He could make his needs and wants known and understand what was being said to him, and that he received dialysis. During an interview on 7/19/23 at 9:24 a.m., Resident 20 indicated he had not attended any care plan meetings. During an interview on 7/21/23 at 10:20 a.m., NC (Nurse Consultant) 1 indicated the last care plan meeting note in the medical record was dated 1/23/23. During an interview on 7/21/23 at 10:45 a.m., the SSD indicated he was unaware of why a care plan meeting had not been held for Resident 20 since 1/23/23. On 7/21/23 at 11:12 a.m., the SSD provided the Resident's First Meeting Guidelines Policy, last revised 4/25/22, which read .To facilitate communication and participation regarding the resident's plan of care, medical condition and care needs between the resident, family, residents representative and care givers .Subsequent meeting for non-Medicare Residents should be conducted at a minimum of quarterly and with significant change . Director of Social Services or designee should send invitations to the residents notifying them of the date and time of the conference as far in advance as possible . 3.1-35(c)(2)

Based on observation, interview and record review, the facility failed to provide showers as ordered for 1 of 4 residents reviewed for Activities of Daily Living (ADL). (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 7/19/23 at 1:45 p.m. The resident's diagnosis included, but was not limited to, dementia. The Admissions MDS (Minimum Data Set), completed on 4/13/23, indicated Resident 45 was severely cognitively impaired. The resident was total dependence of 1 staff person with bathing and was needing extensive assistance of one staff person with personal hygiene and dressing. An ADL care plan dated 4/18/23 indicated the resident was to receive assistance for ADL tasks. The resident's clinical record did not include a care plan that included interventions in place to address refusals of showers nor preference of a bed bath instead of shower. A physician order dated 4/11/23 indicated the resident was to receive showers Mondays and Thursdays on day shift. A physician order dated 4/11/23 indicated the resident is to be changed from day to night clothes (and vice versa) in the am (a.m.) and pm (p.m.). An observation was made of Resident 45 on 7/18/23 at 1:43 p.m. The resident was lying in bed. During a Confidential Interview, they indicated Resident 45 does not receive his showers. The June 2023 bathing report was provided by the Corporate MDS Clinical support on 7/21/23 at 11:45 a.m. It indicated the following days resident did not receive a shower as ordered: Thursday - 6/1/23 bed bath completed, Monday - 6/5/23 bed bath completed, Thursday - 6/8/23 bathing was not provided, Monday - 6/12/23 bed bath completed, Thursday - 6/15/23 other bathing completed, Thursday - 6/22/23 - bed bath completed, Monday - 6/26/23 - partial bed bath, Thursday - 6/29/23 - partial bed bath, The June 2023 shower sheets was provided by Nurse Consultant 1 on 7/24/23 at 1:36 p.m. It indicated the following days showers were not provided: Thursday 6/1/23 - no shower sheet provided, Monday 6/5/23 - resident refused bathing, Thursday 6/8/23 - resident refused bathing, Monday 6/12/23 - resident refused bathing , Thursday 6/15/23 - did not specify type of bathing, Thursday 6/22/23 - bed bath completed, Thursday 6/29/23 - bed bath completed, The bathing report for July 2023 was provided by the Corporate MDS Clinical Support on 7/21/23 at 11:45 a.m. It indicated the following days showers were not provided: Monday - 7/3/23 - bathing did not occur, Monday - 7/10/23 partial bed bath, Thursday - 7/13/23 partial bed bath, The July 2023 shower sheets was provided by Nurse Consultant 1 on 7/24/23 at 1:36 p.m. It indicated the following days showers were not provided: Monday - 7/3/23 - no shower sheet provided, Thursday - 7/6/23 - Family provided shower, Monday - 7/10/23 - no shower sheet provided, Thursday 7/13/23 - bed bath completed, An interview was conducted with Nurse Consultant 1 on 7/24/23 at 1:40 a.m. She was unable to find shower sheets for some of the days. The activities staff had completed a bathing preference assessment on 5/26/23 with the resident. He preferred to receive bed baths. Resident 45's Representative was notified and was okay with the resident receiving bed baths. She was unsure why the clinical record had a physician order to ensure showers were completed on Mondays and Thursdays. The resident's clinical record did not include documentation Resident 45's Representative was aware of the resident's preference of bed baths instead of showers. The physician order to receive showers on Mondays and Thursdays was not discontinued. 3.1-38(a)(2)(a)

Based on observation, interview and record review, the facility failed to ensure fall interventions were implemented for 1 of 2 residents reviewed for falls and failed to properly orient and train volunteers, who would be assisting residents with mobility affecting 1 of 3 residents reviewed for ADLs (activities of daily living) (Resident 5 and 45) Findings include: 1. The clinical record for Resident 45 was reviewed on 7/19/23 at 1:45 p.m. The resident's diagnosis included, but was not limited to, dementia. The Admissions MDS (Minimum Data Set), completed on 4/13/23, indicated Resident 45 was severely cognitively impaired. A fall care plan dated 4/6/23 indicated Resident 45 was a risk for falling and needed assistance with mobility. The interventions put in place for fall prevention included but was not limited to, non skid socks initiated on 4/10/23, visual signage to use call light initiated on 6/24/23, non slip grip to wheelchair seat initiated on 6/27/23, and urinal at bedside initiated on 7/12/23. A fall event dated 6/24/23 indicated the resident had a fall while transferring self to toilet without assistance. The resident was attempting to self transfer to toilet. The new interventions put in place was for visual reminders to use call light for assistance. A fall event dated 6/27/23 indicated the resident had a fall while transferring self to toilet without assistance. The resident was found sitting on floor of the bathroom with wheelchair. The resident had slipped out of the wheelchair. The new intervention was for non-slip grip to wheelchair seat. A fall event dated 7/2/23 indicated the resident had an unwitnessed fall on 7/2/23. It indicated resident had fallen in the bathroom. The root cause was the resident self transfers to the toilet without assistance. The new interventions put in place was urinal to be placed at bedside. Observations were made of the resident in his room on 7/18/23 at 1:43 p.m., and 7/20/23 at 10:35 a.m. The resident was observed lying in his bed. The resident was not wearing non skid socks nor a urinal was placed at bedside. An observation made of Resident 45 in his room with Qualified Medication Assistant (QMA) 2 on 7/20/23 at 11:07 a.m. The resident was observed lying in bed with white socks on that were not non slip, and there was no urinal observed at bedside. QMA 2 indicated at that time, the resident had been wearing shoes prior to placement in bed, so the staff would not have put non-slid socks on at that time. QMA 2 was able to locate a urinal in the bathroom. 30344 2. The clinical record for Resident 5 was reviewed on 7/19/23 at 9:45 a.m. Her diagnoses included, but were not limited to: acute kidney failure, polyneuropathy, chronic obstructive pulmonary disease, morbid obesity, hyperlipidemia, atrial flutter, depression, spinal stenosis, hypertension, lymphedema, and degenerative joint disease. The 7/7/23 functional impairment care plan for Resident 5 indicated she required extensive/total assistance with transfers, bed mobility, and toileting, keeping in mind that ADL ability could fluctuate frequently. The 7/4/23 Admission MDS (Minimum Data Set) assessment indicated she required limited assistance (resident highly involved in activity, staff providing guided maneuvering of limbs or other non weight bearing assistance) of one staff person for locomotion on and off the unit. She had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. The 7/20/23, 6:04 a.m. nurse's note read, Resident states, 'left great toe was in pain and that resident's toe was hit on door during transfer from Bingo on 7/19/23. redness, swelling and unable to do ROM [range of motion] on left great toe. PRN [as needed] pain med given and effective. New order noted for STAT [without delay] Left foot Xray x [times] 3 views complete. Notifications made. The 7/20/23, 2:55 p.m. nurse's note, written by LPN (Licensed Practical Nurse) 6 read, left toe xr [x-ray] result sent to NP [nurse practitioner.] new orders for WBAT [weight bearing as tolerated,] wrap with kerlix as tolerated and referral to ortho [orthopedics.] resident made aware. verbalizes understanding. An interview was conducted with Resident 5 on 7/25/23 at 1:15 p.m. She indicated one of the younger male volunteers who was in the facility last week was pushing her back into her room and her left foot hit the side of the doorway. Her foot was on the foot pedal at the time. When it hit, it didn't hurt too bad, but then once in her room after 30 or 40 minutes, it started throbbing and sweating. She had on a sock and it took her and a staff member to get it off, because it hurt that bad to even have it touched with a sock. It felt better now, but she still had a twinge of pain. The volunteer group in the facility were all very helpful, and she didn't blame the young volunteer for her broken toe. An interview was conducted with the AD (Activity Director,) DON (Director of Nursing,) and ED (Executive Director) on 7/25/23 at 2:23 p.m. The AD indicated a specific organization was currently volunteering in the facility for several weeks this summer from 6/24/23 through 7/27/23. The organization sent 5-7 volunteers, including 5 children under the age of 18 with 2 adults, weekly. The AD did an orientation and tour with the organization's group leader in approximately May, 2023 and sent a volunteer packet for completion. She spoke with the group leader over the phone about any requirements and types of activities the campers would be doing. The individual campers didn't go through any type of training. The AD would give the group a list of activities to do each day like watering plants in the courtyards, talking with residents, one on one activities with residents such as playing cards or board games. One resident watched a movie in the movie room with a camper. Campers also assisted in transporting residents in their wheel chairs to and from their rooms. The campers did not receive specific training on transporting them in their wheel chairs, but the AD would inform the campers if they felt uncomfortable doing anything, like putting a resident's feet on their wheelchair pedals, to come and find a staff member. The AD gave a copy of the Volunteer Handbook and volunteer application to the head person from the organization, but did not give each camper an application or handbook. The AD did not go over the Volunteer Handbook with campers. The AD provided a copy of the Volunteer Handbook on 7/25/23 at 2:50 p.m. The Key Points portion of the handbook had a section entitled Wheelchair Safety that read, When working with and/or transporting residents in wheelchairs, please follow the [name of facility] safety procedures for your own safety as well as the safety of the resident Enter and exit an area slowly, making sure that you look in all directions. There is a danger of running into other residents if caution is not used. Do not cut corners. Keep the resident's arms and hands within the chair-watch elbows when rounding a corner. Make sure the resident's feet are securely on the pedals. An interview was conducted with Volunteer 9 on 7/25/23 at 3:05 p.m. in the activity room. She indicated she arrived at the facility this week to volunteer. No one had given her the Volunteer Handbook or went over it with her. Their contact person from their organization informed their group where to show up, discussed appropriate dress, but nothing about transporting residents in their wheel chair. The Volunteer policy was provided by the ED on 7/25/23 at 3:10 p.m. The ED indicated the organization currently volunteering in the facility were considered visitors, not volunteers. It read, A volunteer is a community member who seeks involvement with the Campus specifically to complete a volunteer task that may include 1-1 contact with a resident. They: Complete a volunteer application .Receive a volunteer welcome packet .In contrast, a visitor is a community member who enters the Campus primarily to be with a loved one, or to provide very infrequent visits for the residents with no or minimal interaction Each volunteer/group will be interviewed, oriented, trained, and supervised. A fall policy was provided by Nurse Consultant 2 on 7/20/23 at 1:30 p.m. It indicated .Purpose Trilogy health Services (THS) strive to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. THS recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury .Procedure: 1. The fall risk assessment is included as part of the Admission and Quarterly Nursing Observation and other Events/Observations in EHR [Electronic Health Record]: a. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. b. Care plan interventions should be implemented that address the resident's risk factors . 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to administer a narcotic pain medication, as ordered by the physician. This failure resulted in a resident having uncontrolled pain and mental distress for 1 of 1 resident randomly observed for pain (Resident B). Findings include: The clinical record for Resident B was reviewed on 4/24/23 at 11:15 a.m. The Resident's diagnosis included, but was not limited to, arthritis of multiple sites and cervical disc disorder. A care plan, dated 4/11/22, indicated she was at risk for general pain and discomfort due to cervical myelopathy and arthritis. The goal was for her pain to be at a tolerable level with interventions. The approaches, dated 4/11/22, indicated to administer medications as ordered and notify MD for any side effects observed or lack of effectiveness, remove old patch before placing new patch on, attempt non-pharmacological interventions, notify MD of increased pain, observe for and record verbal or non-verbal signs of pain, and reposition as needed. A care plan, dated 8/31/22, indicated her cognitive functions were intact and that she was alert and oriented. The goal was for her cognitive functions would remain intact. A physician's order, dated 2/9/23, indicated Resident B was to receive one tablet of oxycodone-acetaminophen (narcotic pain medication) 5-325 mg (milligram) every 4 hours routinely. It was discontinued on 4/21/23. An Annual MDS (Minimum Data Set) Assessment, completed 4/3/23, indicated Resident B was cognitively intact and received narcotic medication daily. A progress note, written 4/13/23 at 11:06 by NP (Nurse Practitioner) 10 indicated Resident B's pain appeared well managed on the current regimen and the oxycodone- acetaminophen 5-325mg every 4 hours would be continued. Her chronic pain was stable. During an interview on 4/24/23 at 1:59 p.m., Resident B indicated she did not receive her scheduled pain medication over the past weekend. Her pain was worse than bad, at time causing her to cry. She had asked why she was not receiving her scheduled pain medication, and no one seemed to know. The staff had told her it was discontinued, and they didn't know why. Resident B normally did not got headaches but had experienced headaches over the weekend and was unable to watch her television programs, which she loved, because of the headaches. She was in pain from her toes up. She had family visit over the weekend and she did get up in her wheelchair. She tried to act normal because she did not want her family to worry, but her family had asked her what was wrong. She had told her family she was hurting. She had been unable to eat because of the pain. She had felt horrible all weekend. She had been given Tylenol because the nurses told her that was all she had ordered for pain. The Tylenol did not help control her pain. Resident B had told the nurse this morning about her uncontrolled pain and not getting her pain medications. He had fixed the problem and she was receiving her scheduled pain medication again. The April 2023 MAR (Medication Administration Record) indicated that Resident B had received her oxycodone- acetaminophen 5-325mg as scheduled from April 1, 2023, through April 21,2023 at 8:00 a.m. A physician's order, dated 4/24/23, indicated Resident B was to receive 1 tablet of oxycodone-acetaminophen 5-325 mg every 4 hours routinely. During an interview on 4/25/23 at 10:15 a.m., Pharmacy Technician 6 indicated the pharmacy had not received an order that the oxycodone- acetaminophen had been discontinued and was unsure why Resident B had not received the medication as ordered. On 4/25/23 at 10:39 a.m., LPN (Licensed Practical Nurse) 3 and the DNS (Director of Nursing Services) were interviewed. LPN 3 indicated on Friday 4/21/23 the computer system was malfunctioning. The order for the oxycodone-acetaminophen 5-325mg must have been accidentally discontinued while they were attempting to fix the problem. The DNS indicated she remembered the problem with the computer system. During an interview on 4/25/23 at 1:24 p.m., LPN 3 indicated that when he started his shift that morning Resident B had told him she had not received her pain medication all weekend and that she was aching from her toes up. He had gotten the medication restarted. During an interview on 4/25/23 at 1:25 p.m., Resident B indicated that the nursing staff had not asked what her pain level or pain intensity was over the weekend. During an interview on 4/25/23 at 1:54 p.m., RN (Registered Nurse) 2 indicated that he had worked the 3rd shift on 4/22 and 4/23/23. He had cared for Resident B. Resident B had being upset about not receiving her scheduled pain medications. RN 2 did not know who discontinued the oxycodone- acetaminophen or why it had been discontinued. He had wondered why she had gone from oxycodone to Tylenol as it seemed like a big change to him. It had not been passed on to him in report. RN 2 could tell that Resident B was in pain. He had not called anyone to ask about the oxycodone being discontinued. During an interview on 4/25/23 at 2:11 p.m., QMA (Qualified Medication Aide) 4 indicated he had worked on the 2nd shift over the past weekend. He not asked Resident B about her pain. He noticed that her oxycodone had been discontinued but assumed the physician had just stopped it. During an interview on 4/25/23 at 2:55 p.m., NP (Nurse Practitioner) 10 indicated was made aware that day of Resident B not receiving her scheduled oxycodone over the past weekend due to a computer error. NP 10 had not been on-call during the past weekend but had reviewed the call log and there had been no calls received about Resident B. NP 10 would have wanted to know about Resident B being in pain and would have immediately restarted the oxycodone- acetaminophen. On 4/25/23 at 2:43 p.m., the Director of Nursing Services provided the Guidelines for Pain Observation and Management policy, last reviewed 12/31/22, which read .If there is a change in pain indicators or verbalizations from resident, a pain event form will be completed to indicate change and care plan updated .educate the resident/ family/ care givers on the pain management interventions and importance of notifying staff of changes in pain status .implement the care plan approached to assist with pain management . 3.1-37(a)

Based on interview and record review, the facility failed to timely recognize a change in condition resulting in delayed hospitalization for a gangrenous wound [MEDICAL CONDITION] and failed to provide adequate monitoring to prevent the development of a pressure ulcer/pressure injury for a resident identified at risk for developing pressure ulcer for 2 of 3 residents reviewed for pressure ulcers (Resident E and K) Findings include: 1. The clinical record of Resident E was reviewed on 8/25/20 at 11:06 am. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) Assessment, completed 12/7/2019, indicated she was able to make herself understood, she was able to understand others, was moderately cognitively impaired, and had no pressure ulcers. The resident required the physicial assistance of two staff members for bed mobility. The Quarterly MDS Assessment, completed 3/8/2020, indicated she was able to make herself understood, she was able to understand others, was moderately cognitively impaired, and had one stage 2 pressure ulcer and two stage 3 pressure ulcers. The resident required the physical assistance of two staff members for bed mobility. During an interview on 8/26/2020 at 4:36 p.m., FM (Family Member) 2 indicated that on 3/16/2020, Resident E was sent to an acute care hospital due to being non responsive. FM 2 was informed by the acute hospital physician that Resident E had septic shock because of the wound on her bottom which was infected with gangrene. A progress note, dated 1/29/2020 at 1:07 p.m., indicated she had developed an open area to her coccyx, which measured 2.5 cm (centimeters) x 2.0 cm, with 90 % (percent) yellow slough (dead tissue). The area was cleansed and covered with a foam dressing. The FM and the NP (Nurse Practitioner) were made aware. A physician's order, dated 1/31/2020, indicated the coccyx wound was to be treated daily with Santyl ointment (a selective [MEDICATION NAME] ointment which helps remove dead tissue). The wound was to be cleansed and a small amount of ointment was to be applied to gauze and placed on the wound. The gauze was to be covered with a foam dressing. The treatment was to be performed daily. The TAR (Treatment Administration Record) for February 2020 indicated the dressing to the coccyx wound was changed, as ordered, daily from 2/1/2020 through 2/12/2020. The treatment order was discontinued on 2/12/2020. The clinical record did not contain documentation on the appearance of the wound, the appearance of the tissue surrounding the wound, if the wound had drainage or signs and symptoms of infection, or the resident's tolerance of the dressing change. A new physicians' order, dated 2/12/2020, indicated the coccyx wound was to be treated with Santyl ointment. It was to be cleansed with normal saline, skin prep was to be applied to the skin around the wound, and a nickel thick layer of Santyl ointment was to be applied to the wound. The wound was to be covered with a foam dressing. The dressing was to be changed daily. The Wound Management Detail Report, dated 2/19/2020, indicated the coccyx wound was 2.7 cm x 1.5 cm x 0.2 cm. The wound was a stage 3 pressure wound and had a light amount of serosanguinous (pale, red to pink, thin) drainage. The TAR for February 2020 indicated the dressing to the coccyx wound was changed, as ordered, daily from 2/13/2020 through 2/25/2020. The treatment was discontinued on 2/25/2020. The clinical record did not contain documentation on the appearance of the wound, the appearance of the tissue surrounding the wound, if the wound had drainage or signs and symptoms of infection, or the resident's tolerance of the dressing change. The clinical record did not contain a scheduled treatment order for the coccyx wound from 2/26/2020 through 3/11/2020. The Wound Management Detail Report, dated 2/26/2020, indicated the coccyx wound was 2.6 cm x 1.4 cm. The wound was a stage 3 pressure wound and had a light amount of serosanguinous drainage. It had 100% granulation tissue (new connective tissue) present in the wound bed. The Wound Management Detail Report, dated 3/4/2020, indicated the coccyx wound was 2.6 cm x 1.2 cm x 0.2 cm. The wound was a stage 3 pressure wound and had a light amount of serosanguinous drainage. It had 75% granulation tissue and 25 % slough present in the wound bed. A nursing progress note, dated 3/4/2020 at 12:06 p.m., indicated the wound on the coccyx was stable. Resident E's family was present and updated on wound orders. The resident was calling 911 related to pain in the wounds. The Wound Management Detail Report, dated 3/11/2020, indicated the coccyx wound was 3.8 cm x 3 cm x 0.3 cm. The wound was unstageable due to slough and / or eschar (black dead tissue). It had 80% slough and 20 % granulation tissue present in the wound bed. The wound healing status was declining. The MD and NP had been made aware and labs were ordered. A nursing progress note, dated 3/11/2020 at 3:07 p.m., indicated the wound had increased in sized. The MD and NP had been made aware and new orders were received for labs. The wound orders had been update. The resident was encouraged to reposition frequently and that she tolerated the dressing change well. There was no physician's order for labs on 3/11/2020 and no lab results from 3/11/2020 through 3/16/2020 present in the medical record. A physician's order, dated 3/11/2020, indicated to treat the coccyx wound with Santyl Ointment once a day. The TAR for March 2020 indicated the treatment to the coccyx wound was administered, as ordered, on 3/11/2020, 3/12/2020 and 3/13/2020. The clinical record did not contain documentation on the appearance of the wound, the appearance of the tissue surrounding the wound, if the wound had drainage or signs and symptoms of infection, or the resident's tolerance of the dressing change. A care plan, with a start date of 3/12/2020, indicated Resident E had a stage 3 pressure ulcer on her coccyx. The goal was for the ulcer to heal without complications. The approaches, with start dates of 3/12/2020, included to administer [MEDICATION NAME] per physicians order, to assess and record the condition of the skin surrounding the pressure ulcer, to encourage fluids unless contraindicated, to observe and report signs of infection, and to provide treatment per the physicians order and notify the physician if the treatment was not effective. A physician's order, dated 3/15/2020, indicated to administer an additional dose of [MEDICATION NAME]- [MEDICATION NAME] 5-325 mg. The additional dose was administered on 3/15/2020 at 3:00 a.m. A nursing progress note, dated 3/15/2020 at 3:00 a.m., indicated Resident E was screaming out in pain. She had been repositioned and given her scheduled and as needed pain medication and continued to scream in pain. She voiced that she feels as if her body in on fire. Her vital signs were within normal limits. An ice pack was offered to help relieve pain, but she continued to scream out. The Nurse Practitioner was notified. A nursing progress note, dated 3/15/2020 at 2:19 p.m., indicated Resident E was yelling and crying out during the shift and only wanted drinks of water The staff educated her on her fluid restriction, She continued to yell out. There was no notation of the nurse practitioner or the physician being notified of the yelling out or request for water. A nursing progress note, dated 3/16/2020 at 6:10 a.m., indicated Resident E had been up yelling all night. She was unable to be redirected. She had yelled that she wanted water and was given water on several occasions. She had been given a cup of ice at bedside. She had indicated she could not use her arms or her body. There was no notation of the nurse practitioner or the physician being notified of the yelling out during the night shift or of the feeling that she could not move her arms or body. A nursing progress note, dated 3/16/2020 at 10:46 a.m., indicated Resident E was hard to arouse. Aroused only with sternal rub. Her medications had been held due to her condition. The NP (Nurse Practitioner) had assessed her and given an order to send her to an acute care hospital. Her family had been notified. During an interview on 8/27/2020 at 10:46 a.m., the DNS (Director of Nursing Services) indicated she was unsure if NP 1 had been made aware of the changes in Resident E's condition from 3/15/2010 at 2:19 p.m. and 3/16/2020 at 10:46 a.m. She was aware of her overall decline. During an interview on 8/27/2020 at 10:20 a.m., NP 1 indicated that if she had been made aware that her interventions were not working for Resident E, she would have sent her to an acute care hospital earlier. The acute care hospital records for 3/16/2020 through 3/18/2020 were reviewed on 8/26/2020 at 3:15 p.m. On 3/16/2020, Resident E's WBC (White Blood Cell) count was 40.3. The normal lab values range for WBC's is 4.5 to 11. The acute care hospital discharge summary, dated 3/18/2020, read . Hospital Course .female patient who presents with complaints of [MEDICAL CONDITION] and was admitted with a principal [DIAGNOSES REDACTED].Suspected secondary to sacral wound. CT (Computerized Tomography Scan) A/P with extensive soft tissue gas in the subcutaneous soft tissues posterior to the sacrum, left ischial anal fossa and medial left gluteus muscle most compatible with gangrene . patient is stable to discharge . on hospice . 2. A record review for Resident K was conducted on 8/26/20. The resident's [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired. The Quarterly MDS (Minimum Data Set), completed on 5/12/20, indicated Resident K required extensive assistance of 2 staff members for: bed mobility, transfers, dressing and toileting. The resident required extensive assistance of 1 staff member for eating and hygiene and she was totally dependent with 2 staff members physical assistance for bathing. The resident was non ambulatory and required the use of a hoyer lift for transfers. A Nursing note, dated 6/18/20 at 6:20 p.m., indicated the resident had an Area noted to right buttock and superior right buttock. Resident stated that she had pain at the site. Pain was relieved by off loading pressure to that side. Treatment in place. No signs of infection noted. Will continue to observe. An IDT (Interdisciplinary Team) review: Wound Event note written on 6/19/20 at 8:45 a.m., indicated the Resident presenting with new skin areas on right buttocks. Treatment in place. Wound nurse to eval(sic, evaluate) and treat. Team in agreement with event and plan of care. Will continue to observe for s/s(sic, signs and symptoms) of healing. A Nursing note, dated 6/24/20 at 6:28 a.m., indicated the resident had excoriation with open areas to each buttock. The area was cleansed and [MEDICATION NAME] was applied. The resident voiced to the nurse that her buttocks were sore. A Wound Care note, dated 6/24/20 at 2:17 p.m., indicated the Resident has several open areas to bilateral buttocks along the inner gluteal cleft from MASD (sic, moisture-associated skin damage) and bright pink scarring present from previously healed wounds on buttocks, inner thighs, and peri-areas. Open areas bleed when cleansed and resident c/o(sic, complains of) pain in this area upon palpation. New orders updated in (name of facility's charting system) . A Nursing Note, dated 6/29/20 at 3:10 p.m., indicated Resident K was sent to the emergency room . A hospital inpatient consult to Wound Care note, dated 6/30/20 at 12:30 p.m., was provided by CNC (Clinical Nurse Consultant) on 8/27/20. The note indicated the resident had a cluster of wounds to her left buttock that measured at 15 cm(centimeters) by 7 cm; granulation tissue was 60% and slough was 40%. The tissue color was pink/yellow with a scant amount of drainage that was serosanguinous in nature; no tunneling or undermining was present. Resident K also had a cluster of wounds to her right buttock that measured at 15 cm by 7 cm. Granulation tissue was 60% with 40% slough. Tissue color was pink/yellow with scant amount of serosanguinous drainage; no tunneling or undermining was present. A Wound Care note, dated 7/8/20 at 1:01 p.m., indicated the Resident readmitted with cluster of open wounds to her bilateral buttocks; previously MASD. Wounds are at various stages of healing and present with granulose tissue mixed with slough, irregular edges, and some areas of dry, thin, flakey skin . Recommend LAL mattress . A Wound management detail report, dated 7/8/20 at 12:59 p.m., indicated the resident's left buttock wound measured 15 cm by 7 cm with a depth of 0.1 cm. It had a light amount of serosanguinous drainage with 60% granulation tissue and 40% slough. The wounds edges were irregular and macerated. This wound was classified as a Stage III wound. A Wound management detail report, dated 7/8/20 at 12:54 p.m., indicated the resident's right buttock wound measured 15 cm by 7 cm with a depth of 0.1 cm. It had a light amount of serosanguinous drainage with 60 % granulation tissue and 40% slough. The wound edges were irregular and macerated. This wound was classified as a Stage III wound. The wound care admission assessment from the hospital and the wound care assessment upon re-admittance to the facility indicated, Resident K's wounds were the same size from when she left the facility to when she returned to the facility. The facility had indicated the wounds were present on admission from the hospital when the wounds were present prior to Resident K going to the hospital. During an interview, on 8/26/20 at 3:52 p.m., the DNS (Director of Nursing Service) indicated a MASD wound changes to a pressure ulcer when the wound has slough present. During an interview, on 8/27/20 at 10:15 a.m., the DNS indicated the nursing assessment for wounds was for the nurse to assess the resident's wound area and there should be a description of how the wound/skin looks when changing a dressing. All findings should have been documented in the nursing notes. The Prevention and treatment of [REDACTED].National Pressure Ulcer Advisory Panel Website on 8/27/2020. indicated .with each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications). Wound status can change rapidly. Wound improvement or deterioration indicated by change in wound dimensions, change in tissue quality, an increase or decrease in wound exudate, signs of infection or other complications all provide indications of the effectiveness of the current management plan. Address signs of deterioration immediately. This recommendation is based on expert opinion. Signs of deterioration include increase in wound dimensions, change in tissue quality, and increase in wound exudate or other signs of clinical infection. Assess and document physical characteristics including: location, category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Use the findings of a pressure ulcer assessment to plan and document interventions that will best promote healing. This Federal tag relates to complaint IN 057 and IN 797. 3.1-40

Based on interview and record review, the facility failed to assess and timely treat pain, resulting in increased pain levels and causing crying during care for 1 of 3 residents reviewed for pain ( Resident E ), Findings include: The clinical record for Resident E was reviewed on 8/25/2020 at 11:06 a.m. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) Assessment, completed 12/7/2019, indicated she was able to make herself understood, she was able to understand others and was moderately cognitively impaired. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A care plan, dated 6/11/2019, indicated she was at risk for pain related to a history of right shoulder dislocation and complaints of chronic left neck and face discomfort. The goal was that her pain would be a tolerable level with interventions. The interventions, dated 6/11/2019, were to administer medications as ordered and notify physician of side effects observed or lack of effectiveness of pain medications, to attempt non-pharmacological interventions, to notify physician of increased pain, to observe for and record verbal and non-verbal signs of pain, and to reposition as needed. During an interview on 8/26/2020 at 1:13 p.m., FM (Family Member) 2 indicated Resident E would cry when she visited her. She did not feel that the Resident's pain was being managed. During an interview on 8/26/20 at 4:35 p.m., FM (Family Member) 1 indicated Resident E frequently cried when she visited her and complained of pain. At one point she had attempted to address the resident's complaints of pain with the physician and the previous administrator. Her mother would frequently called 911 when she felt she was waiting too long for care. A nursing progress note, dated 1/13/2020 at 1:43 p.m., indicated Resident E was tearful and yelling out this morning. She asked for the bed controller and indicated the pain eased when she moved the head of the bed up and down. A progress note, dated 1/29/2020 at 1:07 p.m., indicated she had developed an open area to her coccyx. The pain care plan was not updated to reflect the coccyx wound or with a non pharmalogical interventions of moving the head of the bed up or down to assist with pain control. A nursing progress note, dated 2/26/2020 at 12:12 a.m., indicated Resident E was yelling in her room. She requested her bed remote. She raised the head of her bed up to the highest point and attempted to fall out of bed. She was educated on fall risk, but was unable to be redirected. She had begun yelling again when left alone in her room. The DNS (Director of Nursing Services) had been informed. A nursing progress note, dated 2/26/2020 at 3:14 a.m., indicated Resident E had called 911, When the EMT (Emergency Medical Technician) and the fire department arrived, she denied that she was having a stroke and she indicated she needed pain medications. She was instructed by the EMT that she would not receive pain medications from them, she began yelling and crying. She continued to yell and scream stating she was going to die. She had agreed not to go to the hospital. A nursing progress note, dated 2/26/2020 at 4:45 a.m., indicated a CRCA (Clinical Resident Care Assistant) had gone in to check and change Resident E. She yelled and cried while getting changed. The clinical record did not contain any assessment of the resident's pain, or the administration of the as needed [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg from 2/26/2020 at 12:12 a.m. through 2/26/2020 at 4:45 a.m. On 2/26/2020 at 9:58 a.m., the MAR (Medication Administration Record) indicated she received an as needed dose of [MEDICATION NAME]- [MEDICATION NAME] 5-325 mg for pain, with a pain scale rating of 10/10, which was effective. A nursing progress note, dated, 3/4/2020 at 12:04 p.m., indicated her family was present and updated on wound care orders. The family expressed concern that they believed the resident was calling 911 due to the pain in her wounds. A physician's progress note, dated 3/6/2020 at 12:28 p.m., indicated Resident E was seen by NP (Nurse Practitioner) 1. The chief complaint for the visit was pain. The nursing staff had requested NP 1 to see her due to worsening pain in the past 1 to 2 weeks, significant weight loss and crying frequently. The [MEDICAL TREATMENT] company had also reported the resident crying during visits secondary to pain. She voiced crying because of pain in her neck and everywhere, everything hurt and it hurt to be touched during care. A [MEDICATION NAME] (narcotic pain medication) was added to her medications. She was seen for pain, depression and weight loss to direct medical care. During an interview on 8/27/2020 at 10:26 a.m., the DNS indicated Resident E should have been assessed for pain when asking for pain medication from EMT's on 2/26/2020. The nursing staff communicates with the NP or Physician during routine visits about pain status and as needed for acute changes in pain. During an interview on 8/27/2020 at 8:07 a.m., NP 1 indicated that she had not been made aware of Resident E's crying during [MEDICAL TREATMENT] or her increased pain levels. If she had known sooner she would have increased or changed her pain medications. She had added the [MEDICATION NAME] after she was made aware. On 8/26/2020 at 1:15 p.m., the CNS (Clinical Nurse Consultant) provided the Guidelines for Pain Observation and Management Policy which read .Purpose To ensure each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual. Procedures . 4. If there is a change in pain indicators or verbalizations from resident, a pain event form will be completed to indicate changes and care plan update. a. Observe the resident for a condition that would indicate that pain might be expected .b. Observe for behaviors that may be indicators of pain or activities that increase indicators of pain .7. Evaluate the effectiveness of pain management interventions and modify as indicated . This Federal Tag relates to complaint IN 057. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident was protected from injury when a resident was dropped to the floor during a mechanical lift transfer, resulting in a subarachnoid hemorrhage (bleeding around the brain) and right scalp hematoma (collection of blood outside a blood vessel) and admission to a critical care unit. for 1 of 3 residents reviewed for accidents. ( Resident B) The past noncompliance of injury during a mechanical transfer began on 10/26/19. The deficient practice was corrected on 10/28/19, prior to the surveyor's entrance, after the facility implemented a systemic plan that included the following actions: all lifts in the facility inspected by the manufacturer's representative to ensure condition, all residents assessed for transfer status; all residents requiring mechanical assist with transfers re-assessed and care plans updated, facility wide inservices for all employees for safe and appropriate transfers; return demonstrations for all staff responsible for resident transfers, an audit system to continue observing and assessing transfers were put into place. Findings include: An Incident Report Form, filed with the State Department of Health on 10/26/19, documented an incident date of 10/26/19 at 7:34 [NAME]M. Resident B being transferred from her bed to w/c (wheelchair) by CRCA 1, and fell from mechanical lift. Resident was sent out by 911 (per emergency) with raised bump to her right temple and was subsequently admitted [DATE] to ICU (Intensive Care Unit) with subarachnoid hemorrhage. An Event Report form for Resident B dated 10/27/2019 at 5:34 P.M., indicated an incident date of 10/26/2019 at 7:30 AM. a Hoyer (mechanical) lift was used, Resident B had swelling to R (right) side of temple, was lethargic, drowsy and does not perceive the environment fully, no speech, eyes opened wide as usual but not following commands, resident requires assistance to transfer. The record of Resident B was reviewed 11/13/19 at 1:00 P.M. [DIAGNOSES REDACTED]. The resident was admitted under the care of hospice. An admission Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident B had communication deficits including unclear speech. A brief Interview for Mental Status was not attempted. A staff assessment of cognitive function indicated the resident was severely cognitively impaired. Functional Status assessment indicated the resident required extensive assistance of 2 staff for bed mobility, transfers, and eating. The resident was totally dependent for locomotion, dressing, toilet use, personal hygiene, and bathing, The resident did not ambulate. The resident used a wheelchair for locomotion and was assessed as not having a rehabilitation potential of increased independence. Balance was assessed as not steady for moving from seated to standing, moving on and off the toilet, and surface to surface transfers. The resident was always incontinent of bowel and bladder. Care plans for Resident B included: staff assistance to complete ADL tasks (activities of daily living); impairment in functional status in regards to bed mobility, transfers, toileting, and eating; at risk for falling, a goal was resident will remain free from fall with major injury .Approach (with start date of 10/27/2019): 2 person assistance with all transfers; significant severe cognitive deficits with further deterioration anticipated due to the [MEDICATION NAME] nature of the disease process . A Lift Evaluation form dated 10/25/2019 Resident B is not ambulatory and the recommendation was total mechanical lift. The Nurse's Progress Notes for Resident B on 10/26/2019 7:34 [NAME]M.: Writer (LPN 2) heard CRCA yelling from resident's room for help from nurses et (and) rushed to resident's room. Upon getting there, resident was found on the floor laying on her right side with a raised bump to R (right) temple. CRCA informed writer that res (resident) fell from Hoyer lift upon transfer from bed to w/c (wheel chair). No open area to skin upon assessment. During neuro (neurological) assessment, res was barely able to follow commands when asked .Res sent to (acute care hospital) for evaluation . Hospital records for Resident B, noting an admission date of [DATE], included: .Not verbally responding or following commands; Pupils fixed, nonreactive (Resident B) is an .adult who presented .after falling at her facility. Reportedly, she was about 5 ft (feet) up in a lift when she fell . Did hit her head, unknown L[NAME] (level of consciousness) .Primary survey intact on arrival with a GCS (Glasgow Coma Scale) of 9 and questionable ability to protect airway. She was intubated .without difficulty. (A Glasgow Coma Scale of 9 indicates moderate [MEDICAL CONDITION]; 8 or less indicates severe injury.) Admit to SICU (Surgical Intensive Care Unit)- Intubated and sedated .Subarachnoid hemorrhage .R scalp hematoma .acute respiratory insufficiency, secondary to mental status . Inpatient Discharge Summary: Subarachnoid Hemorrhage; Scalp Hematoma . presented to ED on 10/26 following a fall in her facility and was intubated .Due to chronic [MEDICAL CONDITION], .[MEDICAL CONDITION] and PEG tube placement (gastrostomy tube) was performed 11/01 .Patient was accepted at (acute long term care facility) .patient was discharged on ,[DATE]. 10/28/2019 8:34 [NAME]M.: IDT (Inter Disciplinary Team) fall review, Resident had a fall that was witnessed. CRCA was transferring resident to wheelchair in the Hoyer lift. Resident fell from Hoyer lift during transfer. Injury noted to head and resident was sent out to ER (emergency room ) for evaluation. Intervention included to transfer resident with Hoyer x 2 assist (with 2 staff assisting in transfer.) On 11/13/19 at 11:45 [NAME]M., the Executive Director (E.D.) noted that CRCA 1 was attempting to transfer Resident B from bed to wheelchair using a mechanical (Hoyer) lift when the resident fall from the lift, striking her head on the floor. The E.D. noted that CRCA 1 was performing the transfer alone. The E.D. noted that CRCA 1 did not provide a description of the incident or how it occurred. A facility policy titled Guidelines for Resident Transfers dated 5/10/2017 received from the Clinical Support Specialist on 11/13/19 at 1:30 P.M., indicated: Purpose: To ensure the safety of residents and staff when performing mobility/transfer tasks. Procedures: Upon admission the admitting nurse and/or therapy department shall determine the type of transfer device needed as well as the amount of assistance required to assist with mobility based on observation and data collection. This Federal tag relates to Complaint IN 717. 3.1-45(a)

Based on interview and record review, the facility failed to ensure the safety of a cognitively impaired resident who was sent to the doctor's office without supervision resulting in the resident going to the emergency room for evaluation of pain in the hip and knee after falling out of the wheelchair for 1 of 3 residents reviewed for accidents (Resident Z). Finding includes: During a telephone interview on 3/15/16 at 12:26 p.m., Resident Z's daughter/healthcare representative indicated her mother was transported to a physician's appointment in January 2016 She indicated the facility failed to send staff along with her mother or notify her of the appointment so she could have gone. She indicated, while with the transportation service, her mother fell out of the wheelchair and had to be evaluated and treated at the emergency room for complaints of pain in her knees and hips. Resident Z's record was reviewed on 3/15/16 at 1:30 p.m. A document titled Face Sheet, dated 10/1/14, indicated Resident Z was not responsible for herself and her daughter was her responsible party. Resident Z had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment tool, dated 1/15/16, indicated Resident Z required extensive assistance of two staff for transfers, was not steady and only able to stabilize with staff assistance during transitions and walking, and had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. A current care plan, dated 9/25/15, indicated Resident Z had a history of [REDACTED]. A goal indicated she would remain free from injuries from falls. A progress note, dated 12/30/16 at 1:03 p.m., indicated the facility had scheduled an appointment with a nephrologist (kidney doctor) on Friday 1/13/16 at 12:00 p.m. Progress notes, dated 12/30/16 through 1/17/16, were reviewed on 3/15/16 at 1:40 p.m. The record lacked indication Resident Z's daughter/healthcare representative was notified of her appointment with the nephrologist. A progress note, dated 1/15/16 at 2:27 p.m., indicated Resident Z was on a leave of absence for an appointment. A progress note, dated 1/15/16 at 3:40 p.m., indicated the supervisor from the transportation service had called the facility to inform them they were sending Resident Z to the emergency room due to complaints of pain after she had fallen out of her wheelchair. An emergency room document, dated 1/15/16, indicated Resident Z was evaluated in the emergency for complaints of right hip pain and left knee pain secondary to a fall. The note indicated she fell while transferring herself from her wheelchair in which she leaned over and fell forward to the ground. The note indicated her right hip pain was mild to moderate and her left knee pain was moderate in quality. The note further indicated x-rays were obtained and were negative and Resident Z was sent back to the facility in stable condition. During an interview on 3/16/16 at 9:20 a.m., Transportation Service Employee #1 indicated if a resident required assistance for transfers and/or was cognitively impaired, facility staff or family was required to accompany them to appointments. She indicated they could not leave a cognitively impaired resident alone in an office for an appointment. She indicated there was not a written form of communication which indicated such information that was exchanged at the time of the transfer. She indicated it was implied when a facility called for transportation. She indicated if a resident could not transfer without assistance or were cognitively impaired the facility should order stretcher transportation. Otherwise, they should order wheelchair service. She further indicated if they ordered a stretcher EMTs (Emergency Medical Technicians), who were trained in transfer techniques, would accompany the driver and the resident during transportation. She indicated the transportation service only provided transportation to and from appointments. She indicated when wheel chair service was ordered trained staff were not available to monitor cognitively impaired residents or provide physical assistance with transfers. During an interview on 3/16/16 at 10:00 a.m., the Director of Nursing (DON)indicated documentation which indicated the facility notified Resident Z's daughter of her appointment on 1/15/16 was not available. She indicated Resident Z's daughter usually met her mother at off campus appointments. During an interview on 3/16/16 at 10:05 a.m., Unit Manager #1 indicated if a resident was cognitively impaired and family was not available to attend the scheduled appointment, if possible the appointment should be rescheduled to accommodate the family or staff should go with the resident to the appointment. He indicated the transportation services would not allow stretcher service unless it was medically necessary. During an interview on 3/17/16 at 12:40 p.m., the Assistant Director of Nursing (ADON) indicated the progress note, dated 12/30/16 at 1:03 p.m., had a typo. She indicated the nephrologist appointment date was Friday, January 15, 2015 not 1/13/16. During an interview on 3/17/16 at 1:59 p.m., the DON indicated the facility did not have a policy regarding transportation of residents to appointments. She indicated the procedure was to notify family when a resident required transport service. She indicated family was informed the facility would not send a caregiver and were given the option to ride with the resident or meet the resident at their appointment. She further indicated when facility staff ordered transportation for residents they had to indicate whether the resident required a wheel chair or stretcher. She indicated if the resident required stretcher services, the facility was required to provide documentation which indicated the medical necessity for stretcher services. She indicated she was unaware of what the criteria was for requesting wheel chair verses stretcher services. She indicated the facility did not have a policy which indicated what the criteria was for obtaining stretcher verses wheelchair service. During an interview on 3/17/16 at 2:40 p.m., the Executive Director indicated the facility did not have a policy regarding transportation services. She indicated transportation services would only provide stretcher service if it was medically necessary based on Medicare guidelines. She was unable to indicate what those guidelines were. During an interview on 3/17/16 at 3:00 p.m., the Director of Nursing indicated staff did not go with residents to appointments. She indicated families were notified of appointments so they could be present at the appointment to monitor and assist cognitively impaired residents and/or residents that required physical assistance with transfers. A Falls Management Program policy identified as current by the Executive Director on 3/17/16 at 3:15 p.m., indicated, Purpose .Trilogy health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. THS recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury This Federal tag relates to Complaint #IN 862. 3.1-45(a)(2)