Every finding on record at Aspen Place Health Campus

Based on record review and interview, the facility failed to ensure a resident received medications as ordered for 1 of 3 residents reviewed for pharmacy services. (Resident B)Findings include:1. Resident B's clinical record was reviewed on 08/20/2026 at 11:21 A.M. An admission Minimum Data Set (MDS) assessment, dated 06/22/2026, indicated the resident's diagnoses included, but were not limited to, cancer, pathological fracture in neoplastic disease (a bone has broken because an abnormal tumor or cancer has weakened its structure) heart failure, and anxiety. The resident experienced frequent, moderate pain and received as needed (PRN) pain medications during the assessment review period. The resident's physician's orders included, but were not limited to the following:- A physician's order, with a start date of 07/03/2026, indicated nursing staff were to administer the resident's hydrocodone-acetaminophen (a narcotic pain medication) 5-325 milligrams (mg) every four hours for moderate to severe pain. The order was discontinued on 07/08/2026 when the physician changed the medication dose and frequency.- A physician's order, dated 07/09/2026, indicated nursing staff were to administer the resident's hydrocodone-acetaminophen 7.5-325 mg, four times a day for pain.The July 2026 Electronic Medication Administration Record (EMAR) indicated the resident received hydrocodone 7.5-325 mg every four hours for pain on the following dates and times:- On 07/09/2026 at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M.,- On 07/10/2026 at 1:00 A.M., and 5:00 A.M.A Physician's Note, dated 07/09/2026, indicated the physician reviewed the orders and noted a transcription error from nursing. The written order was for hydrocodone-acetaminophen,7.5-325 mg, one tablet by mouth four times daily, routinely. The order in the computer read hydrocodone-acetaminophen 7.5-325 mg every four hours. That was incorrect. Please update the order in the computer to reflect the correct written order, as the purpose of changing the strength of the medication was to decrease the frequency of administration.2. Resident B's physician's orders and EMAR for July 2026 were reviewed and included, but were not limited to the following :- A physician's order, with a start date of 06/17/2026 and an end date of 08/01/2026, indicated the resident was to receive ezetimibe (a medication for high cholesterol)10 mg at bedtime. A note indicated the medication was not administered on 07/26/2026 because it was unavailable. The medication was missing from the pack and there was not one in the EDK (Emergency Drug Kit),- A physician's order, with a start date of 07/16/2026 and an end date of 07/26/2026, indicated the resident was to receive cefdinir (an antibiotic) 300 mg, twice a day (between 6:00 A.M. and 10:00 A.M. and between 6:00 P.M., and 10:00 P.M.) for pneumonia. A note indicated the medication was not administered on 07/26/2026 between 6:00 A.M. and 10:00 A.M. because the medication was unavailable. The pharmacy was aware,- A physician's order, with a start date of 07/07/2026 and an end date of 08/01/2026, indicated the resident was to receive furosemide (a water pill), 40 mg daily. The medication was not administered on 07/26/2026. A note indicated the medication was unavailable. The pharmacy was aware,- A physician's order, with a start date of 07/08/2026 and an end date of 08/01/2026, indicated the resident was to receive lisinopril (a cardiac medication), 10 mg daily. The medication was not administered on 07/26/2026. A note indicated the medication was unavailable. The nurse and the pharmacy were aware,- A physician's order, with a start date of 07/21/2026 and an end date of 08/01/2026, indicated the resident was to receive magnesium oxide, 400 mg three times a day. The medication was not administered between 6:00 A.M., to 10 A.M. and between 11:00 A.M. and 1:30 P.M. on 07/26/2026. Both times the note indicated the medication was unavailable. The nurse and pharmacy were aware,- A physician's order, with a start date of 07/15/2026 and an end date of 08/01/2026, indicated the resident was to receive metoprolol succinate (a cardiac medication) extended release 25 mg tablet; staff were to administer daily with a 50 mg tablet to equal 75 mg. The medication was not administered on 07/26/2026. A note indicated the medication was unavailable. The nurse and the pharmacy were aware,- A physician's order, with a start date of 07/15/2026 and an end date of 08/01/2026, indicated the resident was to receive metoprolol succinate extended release 50 mg tablet; staff were to administer with a 25 mg tablet to equal 75 mg. The medication was not administered on 07/26/2026. A note indicated the medication was unavailable. The nurse and the pharmacy were aware,- A physician's order, with a start date of 07/23/2026 and an end date of 08/01/2026, indicated the resident was to receive omeprazole (a medication that reduces stomach acid) delayed release 20 mg daily. The medication was not administered because it was unavailable on 07/27/2026 and 07/31/2026,- A physician's order, with a start date of 07/22/2026 and an end date of 07/26/2026, indicated the resident was to receive prednisone (a steroid medication) 20 mg daily, The medication was not administered on 07/26/2026. A note indicated there was no new roll. The nurse and pharmacy were aware, and - A physician's order, with a start date of 06/17/2026 and an end date of 08/01/2026, indicated the resident was to receive spironolactone (a potassium sparing water pill) 50 mg daily. The medication was not administered on 07/26/2026 because it was unavailable. The nurse and pharmacy were aware.During an interview, on 08/21/2026 at 1:37 P.M., RN 2 indicated residents' medications came in a packet with multiple medications together in the packet. The packets came on a roll. If a resident did not have medications available, she would check the medication cart to make sure there weren't any medications available on the big roll-if there were she would take the medication from the big roll and let the pharmacy know that's what she did. If the medication wasn't in the cart, she would check the EDK. Most common medications were available in the EDK. If a medication wasn't available in the facility she would make a note, notify the pharmacy, and notify the physician that the medication was not administered.The current facility policy, titled PREPARATION AND GENERAL GUIDELINES.MEDICATION ADMINISTRATION-GENERAL GUIDELINES, with a revision date of 11/2018 was provided by the Administrator on 8/21/2026 at 2:34 P.M. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices.FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered.If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication may be removed from the emergency drug supply.This citation relates to Intake 3121157.410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on record review, interview, and observation, the facility failed to follow infection control guidelines related to infection tracking and trending, and Enhanced Barrier Precautions (EBP) related to infection control. (Residents 10 and 40) Findings include: 1. During a review of the Infection Control Tracking and Trending documentation on 05/13/25 at 10:08 A.M., The facility lacked documented tracking of antibiotic use for February and March 2025. During an interview on 05/13/25 at 3:35 P.M., the Infection Preventionist indicated she came to this facility in April and infections and antibiotic usage was not tracked in February and March. The current facility policy titled, Infection Prevention and Control Program with a review date of 12/17/24, was provided by the Administrator on 05/06/25. The policy indicated .The purpose of this policy is to: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .The campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases .The campus shall designate a member of the clinical team to monitor the campus .program to perform surveillance to identify, investigate, control, and prevent the spread of infection and reporting . 33613 2. The clinical record for Resident 10 was reviewed on 05/08/25 at 1:33 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/09/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), hypertension, heart failure, dementia. The resident had an unhealed pressure ulcer on her right buttocks. An open-ended physician's order, with a start date of 12/13/24, indicated staff were to use Enhanced Barrier Precautions (EBP), wearing a gown and gloves at minimum during high contact care activities. During an observation, on 05/12/25 2:09 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Everyone must wear gloves and a gown for High-Contact Resident Care Activities, including wound care. RN 7 entered the resident's room and provided direct care as she removed and then reattached the wound dressing to visualize the wound without donning a gown. During an interview, on 05/12/25 at 2:12 P.M., RN 7 indicated nursing staff should wear gloves and a gown when providing direct care for residents who are in EBP. She should have worn a gown when she was touching the wound dressing for Resident 10. 38239 3. Resident 40's clinical record was reviewed on 05/07/25 at 3:09 P.M. A Significant Change MDS assessment, dated 03/17/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, non-Alzheimer's dementia, and peripheral vascular disease. The resident had pressure ulcers and venous ulcers that were present on admission. The resident's current physician's orders included, but were not limited to, an open-ended order, with a start date of 04/29/25, that indicated the resident was in EBP and staff were to wear a gown and gloves at minimum during high-contact care activities. During an observation, on 05/12/25 at 1:21 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Everyone must wear gloves and a gown for High-Contact Resident Care Activities, including wound care. RN 7 and RN 8 entered the resident's room and proceeded to cleanse and administer wound care treatments to the resident's multiple wounds without donning gowns. During an interview, on 05/12/25 at 2:12 P.M., RN 7 indicated nursing staff should wear gloves and a gown when providing direct care for residents who are in EBP. She should have worn a gown during the wound dressing changes for Resident 40. The current facility policy, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 04/01/24, was provided by the DON on 05/12/25 at 3:01 P.M. The policy indicated, .EBP will be in place during high-contact care activities for residents with the following conditions .All Residents with chronic wounds, including but not limited to, pressure ulcers .at minimum, staff shall wear gloves and gowns during high-contact care activities . 3.1-18(b)

Based on record review and interview, the facility failed to ensure the staff had the required six hours of dementia training within six months of hire and three hours annually for 3 of 10 employee records reviewed. (CNA 2, CNA 3, and CNA 5) Findings include: The employee records were provided by the Employee Experience Manager on 05/08/25. The following staff members, working on the skilled unit failed to have the required number of hours of dementia training prior to working with residents that had a diagnosis of dementia: - Certified Nurse Aide (CNA) 2 was hired on 06/19/24 and had 1.5 hours of dementia training, - CNA 3 was hired on 12/20/24 and had 1 hour of dementia training, and - CNA 5 was hired on 10/16/24 and had 1.5 hours of dementia training. During an interview, on 05/09/25 at 11:13 A.M., the Employee Experience Manager indicated she had provided all the documented dementia training in the employee files. Reports were sent to the staff through email, and it was their responsibility to complete the training. The department managers received a report indicating which staff members still had training to complete. The department managers were to follow up with their staff. She believed new staff members were to have six hours of dementia training and was unsure of older employees. During an interview, on 05/09/25 at 11:28 A.M., Corporate Clinical Support Nurse indicated the facility did not have a policy related to dementia training they would follow State and Federal regulations. 3.1-14(u)

Based on interview and record review, the facility failed to report an allegation of abuse in a timely manner for 1 of 15 residents reviewed for reporting of alleged violations. (Resident 20) Findings include: During an interview, on 05/06/25 at 1:16 P.M., Resident 20 indicated a few weeks ago she had gone to the bathroom and her wet wipes were gone. Certified Nurse Aide (CNA) 11 was assisting her roommate. The resident asked the CNA to get her some wipes because someone had taken hers out of the bathroom. The CNA gave her about five wipes and the resident told her that wouldn't be enough, and she wanted a full pack. The CNA had brought her a full pack of wipes and stood in the doorway to the bathroom and tossed the full package of wipes at her. The wipes hit the back of her wheelchair and landed in the seat. She believed the CNA was angry when she tossed the wipes into the bathroom. She reported to other staff member, but didn't think it had been taken care of. She felt safe in the building but thought it was unacceptable that the CNA tossed the wipes towards her. During an interview, on 05/12/25 at 1:26 P.M., CNA 11 indicated a few weeks ago she was assisting Resident 20's roommate when Resident 20 was in the bathroom asking for wet wipes. She handed the resident a few wipes, but the resident told her it wasn't enough and threw the wipes down on the ground. She went and got the resident a pack of wipes and went back into the bathroom. The resident was sitting on the toilet with the wheelchair in front of her. She went to give the resident the wipes and they hit the back of the wheelchair and landed in the seat. She never threw the wipes at her. She asked the resident if she needed anything else and she told her no. The nurse working that night had her go into the resident's room because the resident wanted to make a complaint and the nurse wanted both of them in the room. They all went into the room and the resident said she wasn't going to talk with the CNA in the room. She left the room and made sure another staff member has cared for that resident since that night. During an interview, on 05/12/25 at 9:24 A.M., the Director of Nursing (DON) indicated she had gotten called to the business office on a Friday related to an accusation that CNA 11 had thrown a package of wet wipes at the resident a few days prior. The CNA was working that day and had gone and talked with her. She was removed from taking care of that resident. The resident made Qualified Medication Aide (13) aware that CNA 11 had thrown wipes at her the night that it happened. Licensed Practical Nurse (LPN) 12 had taken the CNA to the resident's room that night to resolve the issue, but the resident wouldn't speak to her about it. She investigated and did not believe the CNA threw the wipes at the resident. The facility investigation was provided by the DON on 05/13/25 at 11:23 A.M. The investigation included, but was not limited to the following: - A typed statement from Resident 20, dated 05/02/25 , that indicated the incident occurred on 04/28/25. The resident had indicated that CNA 11 had thrown a package of wipes at her. - A written statement from LPN 12, that indicated she had entered the resident's room to answer the call light, and the resident had appeared upset. She had asked her if she was ok and she said no that she was upset. The resident told her that she needed to file a complaint. The LPN explained that she would need to get a complaint form and left the room to get one. She walked to the nurse's station to get the form and asked CNA 11 about the resident because the resident was upset. The CNA explained that the resident had wanted wipes but she was busy so she gave her a handful until she could get her a pack, but she was upset. LPN 12 has asked CNA 11 to go to the room with her to get both sides of the story. When they entered the room, the resident asked why she had brought the CNA with her. The resident had said she wouldn't talk to the LPN, and she would talk to someone later. - A written statement from QMA 13 indicated on 04/30/25 Resident 20 had called her into the room to tell her about an incident with CNA 11. Resident 20 had told her that the CNA had thrown wipes at her. - A written statement from CNA 11 indicated on 04/29/25 she was assisting Resident 20's roommate when Resident 20 was in the bathroom asking for wet wipes. She handed the resident a few wipes, but the resident didn't like that and wanted a new pack. She told her she would get her some when she was done. She had gone and gotten a pack of wipes and put them in the resident's wheelchair. The nurse had wanted her to go into the resident's room and the resident didn't like that and that she would just talk to the higher ups. She had tried to keep herself away from the resident's room. During an interview, on 05/12/25 at 2:13 P.M., CNA 14 indicated if a resident reported any type of abuse to her, she would report it to the Administrator immediately anytime of the day. During an interview, on 05/13/25 at 10:35 P.M., the DON indicated staff should report allegations of abuse immediately to her or the Administrator. She would immediately remove the staff from the situation and report it to the state. The staff should have reported this incident sooner. The clinical record for Resident 20 was reviewed on 05/08/25 at 10:15 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/13/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, heart failure, hypertension, diabetes, malnutrition, depression, and bipolar. During an interview, on 05/13/25 at 2:45 P.M., the Administrator indicated they did not have a policy for reporting, and they would follow the state guidelines. 3.1-28(b)(2)(c)

Based on observation, interview, and record review, the facility failed to ensure medications were administered appropriately to prevent significant medication errors for 1 of 3 residents reviewed for significant medication errors. (Resident 23) Findings include: QMA 9 was observed preparing medications for Resident 23 on 05/12/25 at 8:48 A.M. QMA 9 sanitized her hands and opened the plastic packages that contained the resident's various medications and placed the medications in a cup. The medications included, but were not limited to, a 20 milliequivalent (mEq) Extended Release (ER) Potassium Chloride tablet. QMA 9 indicated the resident took her medications crushed. She removed a soft gel vitamin supplement tablet from the medication cup and indicated the gel tablet couldn't be crushed. She poured the remaining medications into a clear packet and crushed them with the pill crusher on the medication cart. She poured the crushed medications back into the cup, added pudding and the gel tablet to the cup, and preceded to administer the medications to the resident. During an interview, on 05/12/25 at 9:09 A.M., QMA 9 indicated there were several medications that were not allowed to be crushed because of the coating on the medications. There was a do not crush list on the medication cart. She reviewed the list and indicated the potassium chloride table she administered to the resident was on the do not crush list. She was not aware that it was not to be crushed. She learned something new. The resident's clinical record was reviewed on 05/13/25 at 3:50 P.M. A Quarterly Minimum Data Set assessment, dated 03/11/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, coronary artery disease, hypertension, and malnutrition. The resident's most recent laboratory values were reviewed, and her potassium level was within normal limits. The Medications Not To Be Crushed list, with a revision date of 12/22, was provided by the Corporate Clinical Support Nurse on 05/13/25 at 3:30 P.M. The list indicated the Potassium Chloride tablet was not to be crushed because it was an extended-release medication. 3.1-48(c)(2)

Based on record review and interview, the facility failed to follow a physician's order related to blood pressure monitoring for 1 of 15 residents reviewed for quality of care. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 05/08/25 at 10:35 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. A physician's order, dated 01/30/25 through 02/24/25, indicated the staff were to check the resident's blood pressure daily. The resident's clinical record lacked document blood pressures for the following dates: - 02/02/25 through 02/04/25, - 02/08/25, - 02/09/25, - 02/11/25 through 02/13/25, - 02/17/25, - 02/19/25, - 02/20/25, - 02/22/25, and - 02/23/25. During an interview, on 05/12/25 at 9:18 A.M., RN 15 indicated if a physician ordered for a resident's vital signs to be monitored then they would be documented the in Electronic Medication Administration Record. During an interview, on 05/13/25 at 3:27 P.M., Corporate Clinical Support Nurse indicated they did not have a policy for following physician orders, it was just standards of practice. 3.1-37(a)

Based on interview and record review, the facility failed to ensure residents with a urinary tract infection received antibiotic treatment in a timely manner for 2 of 15 residents reviewed for laboratory services. (Resident 26 and 31) Findings include: 1. The clinical record for Resident 26 was reviewed on 05/08/25 at 10:35 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. A Progress Note, dated 04/15/25 at 1:51 P.M., indicated the resident's urine was obtained for a Urinalysis Culture and Sensitivity (UA C&S). A Progress Note, dated 04/17/25 at 2:47 P.M., indicated the resident's urine culture was pending at that time. A Progress Note, dated 04/21/25 at 3:07 P.M., indicated the resident's urine culture result showed a Urinary Tract Infection (UTI) and a new order was obtained for Macrobid (an antibiotic) 100 milligrams, twice a day for 10 days. A Laboratory Report document indicated the resident's urine was collected on 04/14/25 at 2:15 P.M., received at the laboratory (lab) on 04/16/25 at 12:10 P.M., and the culture results were reported on 04/18/25 at 10:54 P.M. 2. The clinical record for Resident 31 was reviewed on 05/07/25 at 2:56 P.M. An Annual MDS assessment, dated 02/04/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, metabolic encephalopathy, anemia, heart failure, hypertension, neurogenic bladder, diabetes, paraplegia, malnutrition, anxiety, depression, and respiratory failure. A Progress Note, dated 03/11/25 at 4:52 P.M., indicated the resident's urine was obtained and was in the refrigerator waiting for the lab to pick it up. A Physician Progress Note, dated 03/14/25 at 6:14 A.M., indicated the resident had their urinary catheter replaced on 03/11/25 due to leaking and a UA was obtained and was pending at time of visit. A Progress Note, dated 03/17/25 at 11:55 P.M., indicated the Nurse Practitioner was in for rounds and a new order was received to start the resident on Linezolid 600 milligrams, twice a day for 10 days, for a UTI. A Laboratory Report, indicated the resident's urine was collected on 03/11/25 at 4:15 P.M., received at the lab on 03/12/25 at 1:51 P.M., and the culture results were reported on 03/14/25 at 7:17 A.M. A physician's order, dated 03/17/25 through 03/27/25, indicated the resident was to receive linezolid 600 milligrams, twice a day, for 10 days. The March 2025 Electronic Medication Administration Record indicated the resident had not received the first dose of the antibiotic until 03/18/25 from 6:00 P.M. to 10:00 P.M. due to the medication being unavailable. During an interview, on 05/12/25 at 9:18 A.M., RN 15 indicated when they received orders for a UA C&S, they would obtain the urine and have it ready for the lab to pick it up. The lab techs came nightly. They would have the preliminary results by the afternoon. If the urine needed to be cultured, it would take 48 to 72 hours to get those results back. Once they had the results they would send them to the physician. The resident should start on an antibiotic as soon as possible when the results were back. There was always a physician available to call once they got the results of the culture back to get orders. During an interview, on 05/13/25 at 10:08 A.M., the Infection Preventionist indicated when a resident had an order for a UA C&S, the nursing staff would get the urine, and the lab would pick it up in the evening. The preliminary results usually came back within 24 hours, and the final culture came back after 72 hours. If the staff were not seeing the culture results after 72 hours, then they should be calling the lab to obtain those results. Residents should start on an antibiotic within 72-84 hours after obtaining the urine. The lab came to the facility every day except Saturdays and staff could always call the lab and get results. There were some nurses that had access to view the labs online. During an interview, on 05/12/25 at 3:15 P.M., Corporate Clinical Support Nurse indicated the facility did not have a policy on timeliness of labs. 3.1-49(a)

Based on record review and interview, the facility failed to monitor daily weights, administer an ordered medication related to fluid retention, and monitor meal consumptions for 2 of 3 residents reviewed for nutrition. (Resident 27 and 26) Findings include: 1. The clinical record for Resident 27 was reviewed on 05/09/25 at 9:16 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/27/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited, heart disease, hypertension, and diabetes. An open-ended physician's order, with a start date of 10/28/24, indicated the resident was to be weighed daily. An open-ended physician's order, with a start date of 10/28/24, indicated a PRN (as needed) dose of Lasix was to be administered if the resident gained two pounds in one day or five pounds in a week. The resident's clinical record lacked a document weight for the following dates: - 03/05/25, - 03/07/25, - 03/08/25, - 03/13/25, - 03/28/25, - 03/30/25, - 03/31/25, - 04/01/25, - 04/02/25. - 04/03/25, - 04/06/25, - 04/10/25, - 04/16/25, - 04/24/25, - 04/29/25, and - 05/01/25. The Resident's weight gain was two pounds or greater on the following days and a PRN dose of Lasix was not administered: - 03/19/25 weight was 218 pounds, - 03/20/25 weight was 221 pounds, - 04/11/25 weight was 203 pounds, - 04/12/25 weight was 205 pounds, - 04/19/25 weight was 205 pounds, - 04/20/25 weight was 208.3 pounds, - 04/26/25 weight was 206.6 pounds, - 04/27/25 weight was 209.1 pounds, - 05/04/25 weight was 205.2 pounds, and - 05/05/25 weight was 209 pounds. During an interview on 05/12/25 at 2:54 P.M., Qualified Medication Aide (QMA) 16 indicated she would obtain the resident's weight upon rising or between 6:00 A.M. and 10:00 A.M. The mechanical lift had a scale to obtain the resident's weight, so even if the resident didn't want to get up their weight could still be measured. She would notify the nurse of the weight, and the nurse would give permission for the PRN dose of Lasix to be given. Resident 26 was usually agreeable to being weighed. During an interview on 05/13/25 at 1:06 P.M., RN 15 indicated the CNA would obtain the resident's weight first thing of a morning and report it to her. She would look at the previous day's weight and administer the medication if there was a weight gain greater than two pounds. During an interview on 05/13/25 at 3:27 P.M., Corporate Clinical Support Nurse indicated they did not have a policy for following physician orders, it was just standards of practice. 38769 2. The clinical record for Resident 26 was reviewed on 05/08/25 at 10:35 A.M. A Quarterly Minimum Data Set assessment, dated 04/18/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. The resident's clinical record lacked documented meals for the following dates and times for a resident with a diagnosis of malnutrition: - 03/01/25 at dinner, - 03/02/25 at breakfast, lunch, and dinner, - 03/03/25 at breakfast and lunch, - 03/05/25 at breakfast and lunch, - 03/12/25 at dinner, - 03/15/25 at breakfast and lunch, - 03/17/25 at breakfast and lunch, - 03/26/25 at breakfast and lunch, - 03/30/25 at breakfast and lunch, - 04/17/25 at breakfast and lunch, - 04/18/25 at breakfast and lunch, - 04/22/25 at breakfast and lunch, - 05/10/25 at breakfast and lunch, and - 05/11/25 at dinner. During an interview, on 05/13/25 at 11:12 A.M., Certified Nurse Aide 14 indicated resident meals were documented in the resident's clinical record. The current facility policy titled; Guidelines for Meal Service was provided by the Director of Nursing on 05/13/25 at 1:23 P.M. The policy indicated, .Meal intake should be recorded in the electronic health record . 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure medications were available for 1 of 15 residents reviewed for pharmacy services. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 05/08/25 at 10:35 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. A physician's order, dated 11/24/24 through 02/25/25, indicated the resident was to receive tramadol (a pain medication) 50 milligrams, twice a day from 6:00 A.M. to 10:00 A.M. and 6:00 P.M. to 10:00 P.M. The January 2025 Electronic Medication Administration Record indicated the resident had not received the medication on the following dates and times: - On 01/22/25 from 6:00 P.M. to 10:00 P.M., the resident's medication was not administered due to the medication being unavailable. - On 01/24/25 from 6:00 A.M. to 10:00 A.M., the resident's medication was not administered due to the medication being unavailable and the resident needed a new prescription. - On 01/25/25 from 6:00 A.M. to 10:00 A.M., the resident's medication was not administered due to the medication being unavailable. - On 01/26/25 from 6:00 A.M. to 10:00 A.M., the resident's medication was not administered due to the medication being unavailable. - On 01/28/25 from 6:00 P.M. to 10:00 P.M., the resident's medication was not administered due to the medication being unavailable. - On 01/29/25 from 6:00 A.M. to 10:00 A.M., the resident's medication was not administered due to the medication being unavailable. A Physician Progress Note, dated 01/21/25, indicated the resident was seen by the Nurse Practitioner with no indication a new prescription was needed for the tramadol. The resident was being seen for having recurring abdominal discomfort and a gallbladder ultrasound order. A Progress Note, dated 01/25/25 at 7:45 P.M., indicated the resident was out of Tramadol and needed a new prescription. The writer went to the nurse to request to the provider for a 3-day supply. The request was placed in the provider book at the 200 Hall nurse's station. A Physician Progress Note, dated 01/27/25 at 6:11 A.M., indicated the resident was seen by the Nurse Practitioner. The note lacked any indication that the resident needed a new prescription for tramadol. A Progress Note, dated 01/29/25 at 8:10 A.M., indicated a message was sent to the Nurse Practitioner requesting a hard script for tramadol. During an interview, on 05/12/25 at 9:18 A.M., RN 15 indicated when a resident was out of a medication that required a prescription they could pull one emergency dose from the emergency drug kit. They would need to call the physician to get a prescription sent to the pharmacy. They should have a new prescription within 24 hours. If nursing staff communicated with the physician related to medications being unavailable, it should be documented in a progress note. The current facility policy titled, Guidelines for Medication Orders, with a review date of 12/17/24 was provided by the Director of Nursing on 05/12/25 at 3:01 P.M. The policy indicated, .The purpose of the policy it to establish uniform guidelines in the receiving and recording of medication orders . The current facility policy titled, Medication Ordering and Receiving from Pharmacy, with a revised date of 11/18, was provided by the Director of Nursing on 05/12/25 at 3:01 P.M. The policy indicated, .Reorder medication several days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand . 3.1-25(a)

Based on observation and interview, the facility failed to appropriately store medications for 1 of 3 medication carts reviewed (100 Hall Medication Cart). Findings include: On 05/13/25 at 1:13 P.M., the 100 Hall Medication Cart was observed with RN 10 and contained the following: - A Basaglar insulin pen for Resident 30. The pen was 1/2 full and was not labeled with an opened on date, and - A 198-milliliter bottle of liquid fish oil for Resident 30. The bottle was two-thirds full and was not labeled with an opened-on date. During an interview, on 05/13/25 at 1:18 P.M., RN 10 indicated the resident received 32 units of the insulin twice a day and received 2.5 ml of the fish oil daily. Both medications should have been labeled with opened on dates. The Basaglar insulin pen package insert indicated, .Throw away all insulin .in use after 28 days, even if there is insulin left . The current facility policy, titled MEDICATION STORAGE IN THE FACILITY, with a revision date of 11/18, was provided by the Corporate Clinical Support Nurse on 05/13/25 at 3:15 P.M. The policy indicated, .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated .a date opened sticker shall be placed on the medication . 3.1-25(o)

Based on observation, interview, and record review, the facility failed to appropriately store medications for 1 of 2 medication carts reviewed (300 Hall Medication Cart), and for 1 of 2 medication rooms (300 Hall Medication Room) reviewed. Findings include: 1. On 06/14/24 at 9:57 A.M., the 300 Hall Medication Cart was observed with LPN (Licensed Practical Nurse) 7 and contained the following: - A Lispro insulin pen for Resident 28. The pen was well over 3/4 full and was not labeled with an opened on date. During an interview on 06/14/24 at 9:59 A.M., LPN 7 indicated Resident 28 usually received insulin four times a day, so he went through insulin pens pretty quickly. The undated pen was delivered by the pharmacy on 05/13/24, but it was kept in the refrigerator until it was opened. The pen was nearly full, so she didn't think it had been in use for very long. She had not administered the insulin to the resident that morning. The insulin pen was good for 28 days after it was opened. The pen should have been labeled when it was opened. 2. The 300 Hall Medication Storage Room refrigerator was observed on 06/14/24 at 10:10 A.M., with RN 6 and contained the following: - An opened box that contained a nearly empty vial of TB (Tuberculin) serum. The vial was not labeled with an opened on date. During an interview on 06/14/24 at 10:12 A.M., RN 6 indicated the TB serum was good for 30 days from the opened on date. The serum should have been dated when it was first opened. During an interview on 06/14/24 at 10:42 A.M., the Regional Corporate Support Nurse indicated several staff members were recently tested for TB with the undated serum. Resident records reviewed indicated the following residents' TB tests were performed using the unlabeled vial of TB serum: - Resident 159 received a TB test on 06/05/24, - Resident 43 received a TB test on 06/05/24, - Resident 56 received a TB test on 06/08/24, and - Resident 57 received a TB test on 06/13/24. The TB serum package insert was provided by the Administrator on 06/14/24 at 2:00 P.M. The directions for storage indicated, .vials in use more than 30 days should be discarded . The current facility policy, titled MEDICATION STORAGE IN THE FACILITY, with a revision date of 11/18, was provided by the Administrator on 06/14/24 at 10:34 A.M. The policy indicated, .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated .a date opened sticker shall be placed on the medication . 3.1-25(o)

Based on observation and interview, the facility failed to store food appropriately for 1 of 2 kitchen observations. Findings include: During the initial kitchen tour on 06/10/24 at 10:18 A.M., with the Dietary Manager the following was observed in a walk-in refrigerator: - five store bought chuck roasts with a use by or freeze by date of 06/06/24 for one of them, 06/07/24 for two of them, and 06/08/24 for two of them, - a metal tray that had a cantaloupe sitting in it, with a sticker on the tray that indicated produce with a use by date of 05/28/24, - a cart with several trays of alcohol that contained a 3/4 full jar of maraschino cherries with a use by date of 05/24/23, - a 1/4 full jar of jelly with a use by date of 06/08/24, and - a prepared fruit cup laying on the floor that contained grapes and honey dew melon with a use by date of 06/05/24. The Dietary Manager indicated it was the responsibility of the cooks, Assistant Dietary Manager, and herself to ensure outdated foods were discarded. The refrigerator was to be checked once a day. The weekend cook was responsible for checking the refrigerators on the weekends. The current facility policy titled, Food Labeling and Dating, with a revised date of 04/26/22, was provided by the Clinical Support on 06/14/24 at 9:55 A.M. The policy indicated, .To provide knowledge and direction on how to properly label and date food items and food production . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheters for a resident who had a history of UTIs (Urinary Tract Infections) for 1 of 3 residents reviewed for urinary catheters / UTIs. (Resident 34) Findings include: During an observation on 06/11/24 at 10:39 A.M., Resident 34 was in their wheelchair propelling themselves and exiting their bathroom. Two to three inches of their indwelling urinary catheter tubing was dragging on the floor under their wheelchair. During an observation on 06/11/24 at 10:44 A.M., the resident was sitting in their wheelchair in their room. Their urinary catheter tubing contained tan colored pieces of debris approximately 2 to 3 mm (millimeters) in length and width. During an observation on 06/11/24 at 1:34 P.M., the resident was in the Therapy Gym sitting in his wheelchair. Part of his indwelling urinary catheter bag and tubing were touching the floor. During and observation and interview on 06/12/24 at 10:03 A.M., the resident was in their wheelchair in their room. Their urinary catheter bag was touching the floor as was 6 to 8 inches of the catheter tubing. The tubing contained cloudy yellow urine. The resident indicated a staff member had put medicine in their catheter earlier that morning. They were able to get themselves into their wheelchair but needed staff's help hanging their urinary catheter bag under their wheelchair. During an observation on 06/12/24 at 3:03 P.M., the resident was in their room sitting in their wheelchair. Their urinary catheter bag and tubing were touching the floor. The urine in the catheter tubing was cloudy and yellow. During an interview on 06/12/24 at 3:15 P.M., the Therapy Manager indicated the resident did not transfer by themselves. They had been discharged from therapy as a one person assist. During an interview and observation on 06/12/24 at 3:18 P.M., CNA (Certified Nurse Aide) 3 indicated the resident required the assistance of one staff member when using the bathroom and getting ready for bed. They needed help pivoting and transferring. While observing the resident in their room, the CNA indicated the urinary catheter bag and tubing should not be touching the floor. The clinical record was reviewed on 06/12/24 at 3:08 P.M. An Annual MDS (Minimum Data Set) assessment, dated 05/31/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, neurogenic bladder, diabetes, dementia, and hemiplegia. The resident required extensive assistance of two staff members for transfers. During an interview on 06/14/24 10:15 AM., the IP (Infection Preventionist) and the MDS Coordinator indicated the resident received a bladder irrigation as a UTI prevention because they had recurrent UTIs. The physician's orders related to the resident's indwelling catheter were provided by the Clinical Support on 06/14/24 at 10:51 A.M. The orders included, but were not limited to, a current open-ended order, with a start date of 02/08/24, for Clorpactin (an antibacterial agent) flush, 60 ml (milliliters) infused in the bladder and clamped for 15 minutes. The current Urinary Catheter Care policy, with a reviewed date of 12/31/23, was provided by Clinical Support on 06/14/24 at 9:55 A.M. The policy indicated, .To prevent infection of the resident's urinary tract .Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on record review and interview, the facility failed to follow hospital discharge orders and verify admission weights for 1 of 3 residents reviewed for hydration/nutrition. (Resident D) Findings include: 1. The clinical record for Resident D was reviewed on 06/13/24 at 11:04 A.M. An Admission MDS (Minimum Data Set) assessment, dated 03/11/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, atrial fibrillation, hypertension, and respiratory failure. The hospital discharge summary for the resident, dated 03/06/24, indicated the resident's heart failure instructions for daily management was to be weighed daily on the same scale and at approximately the same time of day. The weight should be reported to the physician if the resident had a weight gain of three pounds in a day or five pounds in a week. The facility was to use the hospital discharge weight as a baseline reference. The facility was to continue a low sodium diet and limit the fluid intake to 1.5 to 2 liters per day. The resident's hospital discharge weight was 177 pounds. A Facility Progress Note, dated 03/06/24 at 1:30 P.M., indicated the resident arrived at the facility at 1:30 P.M. The resident's admitting diagnoses was pericardial effusion (the buildup of extra fluid in the space around the heart). The resident had a pericardial drain while in the hospital that was healed and had 1800 ml (milliliters) of fluid removed. The resident had the following weights documented while in the facility: - 03/06/24, the resident's weight was 191 pounds, - 03/11/24, the resident's weight was 189.9 pounds, - 03/18/24, the resident's weight was 190.2 pounds, - 03/25/24, the resident's weight was 190.2 pounds, - 04/01/24, the resident's weight was 164.8 pounds and 165.9 pounds, - 04/02/24, the resident's weight was 166 pounds, - 04/03/24, the resident's weight was 166 pounds, - 04/04/24, the resident's weight was 165.2 pounds, and - 04/05/24, the resident's weight was 165.2 pounds. The clinical record lacked documentation the resident was weighed daily until 04/01/24, lacked the prescribed low sodium diet, fluid intake monitoring, and lacked follow-up with the admission weight when it was different than the hospital discharge weight. During an interview on 06/13/24 at 1:38 P.M., RN 6 indicated when a resident admitted to the facility from the hospital she would get report from the hospital. Once the resident got to the facility, she would complete a consent to treat, admission assessment, skin assessment, obtain the resident's code status, and orient the resident to their surroundings. She would review the resident's admitting physician orders and transcribe them into the clinical record. A second nurse would verify the orders and then the hospital forms would be scanned into the clinical record. During an interview on 06/13/24 at 1:42 P.M., CNA (Certified Nurse Aide) 8 indicated when a resident required a daily weight, she would obtain that weight when the resident got up in the morning. The residents could be weighed by sitting in a weight chair or by the full body lift. The facility had not had any concerns with their scales recently. If a resident had a significant weight change, she would alert the nurse on duty for the day. During an interview on 06/13/24 at 4:00 P.M., the DON (Director of Nursing) indicated if the resident's discharge paperwork indicated they were to be weighed daily, then it should have been transcribed on admission. The resident had a significant weight decrease while a resident, but his hospital discharge paperwork showed he weighed 177 pounds when he was discharged . The resident could not gain that much weight when leaving the hospital and getting to the facility. She was unsure why there was a weight difference, but it should have been addressed. The current facility policy titled Notification of Change with a review date of 12/31/23, was provided by the Clinical Support on 06/13/24 at 3:06 P.M. The policy indicated, .To ensure appropriate individuals are notified of change in condition . This citation relates to Complaint IN00435626. 3.1-46(a)(1) 3.1-46(a)(2)

Based on record review and interview, the facility failed to provide bathing for 2 of 3 residents reviewed for Activities of Daily Living. (Residents D and E) Findings include: 1. During an interview on 06/13/24 at 1:43 P.M., CNA (Certified Nurse Aide) 8 indicated resident showers were offered twice a week or more if they preferred. The showers were documented in the computer system or a shower sheet. The residents would be offered a shower or a bed bath and in between their shower days they were given a partial bed bath. The partial bed bath was just to wash their peri area and their arm pits. If a resident refused the shower or bed bath it would be document in the clinical record and on the shower sheets. The clinical record for Resident D was reviewed on 06/13/24 at 11:04 A.M. An Admission MDS (Minimum Data Set) assessment, dated 03/11/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, atrial fibrillation, hypertension, and respiratory failure. The Point of Care History and the Shower Sheets indicated the resident had the following showers or complete bed baths since admission to the facility on [DATE]: - 04/09/24, shower, - 04/02/24, shower - 03/29/24, complete bed bath - 03/26/24, shower, - 03/22/24, shower, - 03/11/24, complete bed bath. The resident had 6 out of 10 showers, complete bed baths, or refusals from admission to discharge on 04/08/24. 2. The clinical record for Resident E was reviewed on 06/12/24 at 3:08 P.M. An Admission MDS assessment, dated 03/12/24, indicated the resident was cognitively intact. The diagnoses for the resident, included but were not limited to, fracture of the right fibula, anemia, hypertension, and diabetes. During an interview on 06/14/24 at 2:19 P.M., LPN (Licensed Practical Nurse) 7 indicated the resident was non-compliant with care at times. He refused his showers and liked to use the bed pan. The refusal of showers was to be documented in the computer charting or on a shower sheet. The Point of Care History and the Shower Sheets indicated the resident had the following showers, refusals, or complete bed baths from admission on 03/07/24 through 04/30/24: - 03/07/24, complete bed bath, - 03/15/24, refused, - 03/16/24, complete bed bath, - 03/19/24, shower, - 03/22/24, refused, - 03/26/24, refused, - 03/29/24, shower, - 04/02/24, shower, - 04/12/24, refused, - 04/16/24, shower, and - 04/22/24, shower. The resident was given or offered a bath or shower 11 of 15 times from 03/07/24 through 04/30/24. The current facility policy, titled Guidelines for Bathing Preference with a review date of 12/31/23, was provided by the Clinical Nurse Consultant on 05/08/24 at 2:51 P.M. The policy indicated, .Bathing shall occur at least twice a week unless resident preference states otherwise . The current facility policy, titled Nursing ADL Documentation Guidelines with a review date of 12/31/23, was provided by the Clinical Nurse Consultant on 05/08/24 at 2:51 P.M. The policy indicated, To document the type and amount of assistance provided to the resident for activities of daily living .Completion of ADL service will be validated through the use of the CARE ASSIST ADL reports .ADL services will be conducted and documented by the CNA each shift at the [point of care] or as reasonably possible after care . This citation relates to Complaint IN00435626. 3.1-38(a)(2)(A)

Based on observation, interview, and record review, the facility failed to assess a resident to self-administer medications for 1 of 14 residents reviewed. (Resident 43) Findings include: During an observation on 06/12/24 at 9:30 A.M., Resident 43 had a medicine cup full of pills sitting on his over the bed table on his breakfast tray. No staff members were in the room. At 9:31 A.M., LPN (Licensed Practical Nurse) 5 stopped in the resident's room and told him to not forget to eat his breakfast and to take his morning medications, then left the room. Eight pills of various colors, shapes, and sizes were in the medication cup. The resident indicated one was for phantom pain, one was a blood thinner, and one was an iron pill. A second cup was on the tray filled to the top with a reddish clear fluid. During an observation and interview on 06/12/24 at 10:00 A.M., the resident's breakfast tray was still on the over the bed table. The tray had two medicine cups sitting on it, one with a small white pill the resident identified as their water pill that they didn't like to take so they put it off as long as they could, and a cup filled to the top with a reddish clear fluid. During an observation and interview on 06/12/24 at 11:37 A.M., the resident was sitting up on their bed. A medicine cup with a Lasix (water pill), as identified by the resident, was still sitting on the over the bed table. The resident indicated they were getting ready to take it. During an interview on 06/13/24 at 2:49 P.M., LPN 7 indicated if a resident self-administered their medications there would be an assessment completed in Observations on the EHR (Electronic Health Record). They currently did not have any residents who self-administered their medications other than maybe an inhaler. They had one resident, who was not Resident 43, who liked to have their medications left at the bedside to take when they wanted to, but they had to have a self-administer assessment completed. During an interview on 06/13/24 at 3:59 P.M., LPN 7 indicated Resident 43 was bad about acting like they took their medications and picked out the ones they wanted. The resident should not have had medications left at the bedside. They did not have a Self-Administration Assessment completed in order for them to be able to have medications left at the bedside. During an interview on 06/14/24 at 9:32 A.M., the Clinical Support indicated the resident may have an order to self-administer medications, but they should also have had the assessment completed prior to self-administering their medications and she did not believe the resident had the assessment completed. The clinical record was reviewed on 06/14/24 at 11:07 A.M. An Admission MDS (Minimum Data Set Assessment), dated 05/10/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, infection and inflammatory reaction due to internal left knee prosthesis, arthritis, psychotic disorder, and history of malignant neoplasm of the kidney. The record lacked an assessment allowing the resident to safely self-administer their medications. The current MEDICATION ADMINISTRATION - GENERAL GUIDELINES policy, with a revised date of 11/18, was provided by the Clinical Support on 06/13/24 at 2:22 P.M. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices .Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications .The resident is always observed after administration to ensure that the dose was completely ingested . The Guidelines for Self-Administration of Medications policy, with a reviewed date of 12/31/23, was provided by the Clinical Support on 06/14/24 at 9:55 A.M. The policy indicated, .Residents requesting to self-medicate .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. i.e.:all oral meds, oral meds with the exception of ., nebulizer treatment only, all medications including injection, oral, inhalers, drops, etc . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to storage and dating of respiratory supplies for 3 of 4 residents reviewed for respiratory care. (Residents C, D, and E) Findings include: 1. During an observation and interview on 01/31/24 at 11:02 A.M., Resident C was sitting up in her bed in her room. The side of her bed was pushed up flat against the wall. The opposite side of the bed had a plastic bag taped to the bed rail and was dated 10/2. The resident had oxygen tubing with a nasal cannula coiled up and tucked into the handle of her oxygen concentrator machine. The tubing was not dated. The resident indicated staff sometimes placed the tubing in the bag on the side of her bed dated 10/2 and she had recently had RSV (Respiratory Syncytial Virus). During an observation with the IP (Infection Preventionist) and the DON (Director of Nursing) on 1/31/24 at 12:24 P.M., Resident C was sitting in her bed in her room. The DON verified the date of 10/2 labeled on the plastic bag hanging on the side of the resident's bed. There was another bag on the other side of the bed against the wall that was dated 1/13. The IP struggled to get access to the bag, due to the side of the bed being pressed up against the wall. The resident had oxygen tubing with a nasal cannula coiled up and tucked into the handle of her oxygen concentrator machine. The DON indicated oxygen tubing should be dated if it was not kept in a plastic bag. Tubing was changed every 30 days. Resident C had been one of their residents who had recently had RSV. The clinical record for Resident C was reviewed on 01/31/24 at 11:35 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 10/16/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), anemia, hypertension, renal insufficiency, neurogenic bladder, diabetes, paraplegia, malnutrition, anxiety, depression, and respiratory failure. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for January 2024 was provided by the Administrator on 01/31/24 at 1:53 P.M., and included, but was not limited to, the following physician's orders: - Contact/Droplet Precautions, with a start date of 01/12/24, and a discontinued date of 01/22/24. - Change oxygen tubing monthly once a day on the first of the month, with a start date of 06/29/23. - Oxygen at 2 Liters per nasal cannula at night, with a start date of 06/29/23. The Respiratory Surveillance Line List indicated the resident had symptoms of RSV with an onset date of 01/01/24. A Hospital Emergency Department Note, dated 01/12/24, indicated, under the Discharge Assessment, the resident had RSV. 2. During an observation on 01/31/24 at 11:58 A.M., Resident D was sitting in her room in a recliner wearing oxygen per a nasal cannula. The tubing was attached to a water reservoir on the oxygen concentrator machine. The tubing and the water reservoir were not dated. The resident indicated she did not know if the staff changed the tubing or not. Several inches of tubing were lying on the floor. No plastic bags for the tubing were in the room. The resident indicated she did not have a mask for breathing treatments, she just used inhalers. During an observation with the IP and the DON on 01/31/24 at 12:28 P.M., Resident D was observed sitting in her room in her chair wearing her oxygen. Several inches of her oxygen tubing were lying on the floor between the oxygen concentrator and the resident's chair. The IP could not find a date on the tubing or the water reservoir and indicated they should have both been dated. An Admission MDS assessment, dated 01/17/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, pneumonia, COPD, and acute respiratory failure. The EMAR/ETAR for January 2024 included, but was not limited to, the following current physician's order: - Oxygen at 2 Liters per nasal cannula continuous, with a start date of 01/11/24. The record lacked an order to change the tubing and any indication as to when then current oxygen tubing was put into service. 3. During an observation on 01/31/24 at 12:08 P.M., Resident E was sitting in his room in his recliner, he was wearing oxygen per a nasal cannula. He had a breathing treatment mask laying on his bedside table that was not in a plastic bag. The tubing was not dated, nor was the mask. His oxygen was running at 2.5 liters per minute. During an observation with the IP and the DON on 01/31/24 at 12:20 P.M., Resident E was sitting in his room in his chair wearing oxygen tubing with a nasal cannula. His respiratory treatment mask was lying on the nightstand. The IP indicated she assumed the tape on his oxygen mask must have fallen off because she did not see any dates on the mask or the tubing. The DON indicated the masks were usually kept in a plastic bag, not lying on the nightstand. No plastic bags were observed in the immediate area. A Quarterly MDS assessment, dated 11/03/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, aphasia, hypertension, dementia, and COPD. The EMAR/ETAR for January 2024 included, but was not limited to, the following current physician's orders: - Change oxygen tubing monthly once a day on the first of the month, with a start date of 06/17/22. - Oxygen at 2-3 Liters per nasal cannula, continuous, with a start date of 05/22/23. The current Administration of Oxygen policy, with a reviewed date of 12/31/23, was provided by Clinical Support on 01/31/24 at 2:11 P.M. policy indicated, .Guideline to properly Administering Oxygen and any Respiratory procedure .Date the tubing for the date it was initiated .Tubing should be changed monthly and PRN (as needed) . This citation relates to Complaint IN00426895. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to appropriately secure a resident's catheter, resulting in an injury of a split and wound to the resident's penis (Resident 46), follow the physician's orders related to catheterization (Resident 46), and the proper positioning of an indwelling urinary catheter drainage bag for a resident that developed a UTI (Resident 28) for 2 of 18 residents reviewed. Findings include: 1. During an observation of Resident 46 on 04/26/23 at 2:53 P.M., the ADON (Assistant Director of Nursing) alerted the resident that she was going to observe and cleanse his penis. The resident agreed. The resident's pants and brief were removed. The resident had just had a suprapubic catheter placed. The penis was split from the underneath side of the head down the back side of the shaft. The record for Resident 46 was reviewed on 04/25/23 at 2:29 P.M. An Annual MDS (Minimum Data Set) assessment, dated 03/06/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, diabetes, non-Alzheimer's dementia, UTI (Urinary Tract Infection), and BPH (Benign Prostatic Hyperplasia). The resident required extensive assistance of two or more staff members for transfers, toileting, and bed mobility. A Care Plan, with a start date of 07/21/22, was reviewed on 04/25/23 at 2:29 P.M., the Care Plan indicated the resident used a anchored Foley catheter for a diagnosis of obstructive uropathy, an intervention included, but was not limited to, apply catheter securing device to maintain tubing proper alignment with a start date of 07/21/22. The care plan was reviewed and revised on 04/25/23 at 3:28 P.M. by MDS Support 3, and the intervention was removed, at that time, from the care plan. A Care Plan, dated 03/01/23, indicated the resident had a mechanical injury to the penis from the anchored Foley catheter. An intervention included, but was not limited to, apply a catheter secure device to maintain tubing in proper alignment, with a start date of 04/17/23. A Urology Note, dated 10/25/22, indicated the resident was being seen for urinary retention. The assessment and plan were that the urinary catheter was removed. The resident would unlikely be able to urinate spontaneously but was on maximum medical therapy. The resident had a 30% chance of being able to urinate sitting in the chair with a urinal. They would have the nursing home start in and out catheterization four times daily as that was a lower risk for sepsis than a chronic catheter. The resident would return in one month to see how he had done. The October 2022 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) was provided by the DON on 04/28/23 at 5:03 P.M., and included, but was not limited to, a physician's order dated 10/28/22 through 10/31/22, for In and Out Cath (catheterization), three times a day (not four times daily as the urologist specified). The record indicated the in and out catheterization was not administered the following dates and times: - 10/28/22 at 8:15 P.M., the reason was the resident no longer had a catheter, - 10/29/22 at 4:15 A.M., the reason was the resident no longer had a catheter, - 10/29/22 at 1:15 P.M., the reason was the resident had voided that shift, - 10/29/22 at 8:15 P.M., the reason was when the catheter was progressed there was [NAME] (evident) blood expelled from the penis around the urethra. There was no urine that progressed into the catheter, - 10/30/22 at 4:15 A.M., the reason was that during the last in and out the resident had blood from the urethra, - 10/30/22 at 1:15 P.M., the reason was the resident voided that shift, and - 10/30/22 at 8:15 P.M., the reason was the resident voided on the toilet. A Progress Note, dated 12/13/23 at 1:03 P.M., indicated the resident had a split in his penis. The resident had previously seen the Urologist, on 11/29/22, and they were aware of the condition. A Facility Wound Management Detail Report, dated 12/13/22, indicated the resident had trauma to the penile shaft that measured 5.2 cm x 2.4 cm. The wound was mucosa area under the penile shaft where the indwelling urinary catheter was inserted. An IDT (Interdisciplinary Team) Progress Note, dated 12/13/23 at 4:03 P.M., indicated the resident had an open area that measured 5.2 cm (centimeters) x (by) 2.4 cm x less than 0.1 cm. The area was dark pink with a small amount of purulent (pus) drainage. The area was cleansed with betadine and a urinary catheter anchor was applied to the right thigh. The RN had notified the urology office related to the split in the penis. The resident had been seen by urology in November and they were aware of the issue. A Wound Clinic Note, dated 01/31/23, indicated the resident had developed destruction to the penis secondary to the catheter. There was nothing to be done to salvage the penis unless he had a suprapubic catheter placed and then would require reconstructive surgery of the penis. At the patient's age and overall health, they did not feel it was a realistic expectation. The actual catheter tubing was somewhat short and the placement of the tube holder on his leg was causing a downward traction. The resident had a Stage 3 (Full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough [non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed] and/or eschar [dead tissue] may be visible but does not obscure the depth of tissue loss) pressure ulcer to the penis that had been present for four weeks. The problem was determined to have been caused by a medical device. There was a minimum amount of serous (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood) and yellow or brown exudate draining from the ulcer. The ulcer bed had exposed subcutaneous tissue. The ulcer was not malodorous. The ulcer boarder was poorly defined. There was 100% granulation tissue with a confluent pattern of pale and beefy red quality. The wound measured 4.3 cm (centimeters) x (by) 1.5 cm x 0.8 cm. The wound treatment was to cleanse daily with normal saline, apply Medihoney (a wound cleansing ointment) , and cover with an absorbent pad placed in the brief or cover with stretch netting. A Wound Clinic Note, dated 02/28/23, indicated the resident had a Stage 3 pressure ulcer to the penis that had been present for 8 weeks. There was a minimum amount of serous exudate draining from the ulcer. The ulcer bed had exposed subcutaneous tissue. The ulcer boarder was poorly defined. There was 100% granulation with a confluent pattern of pale and beefy red quality. The wound measured 4 cm x 1.5 cm x 0.6 cm. The treatment remained the same. The traction on the catheter had been reduced by proper positioning. The penis was unchanged. There was really nothing to be done for this unless the resident or family wanted a suprapubic catheter. The resident was discharged from wound care. The facility lacked any monitoring or assessments for the resident's pressure ulcer to the penis. The only assessments document were the two wound clinic notes. The wound clinic notes indicated the resident's wound was present for four weeks prior to 1/31/23. A Urology Note, dated 03/24/23, indicated the resident's situation was discussed with the resident and his family members. The resident had BPH with obstruction leading to urinary retention associated with his severe deconditioning. The following options were discussed: - 1. In and out catheterization four times daily. This evidently did not work well at the current nursing home. - 2. Chronic Foley catheter with monthly replacement. I was told this does not work well either as they have not been changing his catheter every month. - 3. Suprapubic Tube placement which would require an anesthetic. This would have the advantage of decreasing testicle and prostate infections but not overall number of infections. The penis would not heal. - 4. Trial and void with removal of catheter now that the resident could stand spontaneously. After discussion, option four was chosen. During an interview on 04/26/23 at 9:00 A.M., QMA (Qualified Medication Aide) 18 indicated the resident had a wound to his penis and the penis was split from his indwelling urinary catheter. The resident's catheter had pulled on his penis causing the split. The resident had gone out that day to have a suprapubic catheter placed. During an interview on 04/26/23 at 1:20 P.M., the ADON indicated the resident had a mechanical issue from his catheter and talked to the family about getting a suprapubic catheter. The resident still had a split in the penis, but the wounds were healed. The intervention put into place was for a catheter securement device. If the resident was already care planned for a catheter securing device, then it should have been in place prior to the wounds on 12/13/22. During an interview on 04/27/23 at 9:28 A.M., RN 5 indicated if a resident had an order for in and out catheterization then the nurse would insert a catheter into the resident and remove it when there was no more urine flow. The order should have been followed as it was specified. During an interview on 04/27/23 at 11:21 A.M., a Wound Clinic nurse indicated the resident's catheter was anchored to the leg and that caused a pressure ulcer from the tension of it pulling. The resident's penis had a split and the pressure ulcer was where the catheter laid underneath. The wound had granulation tissue and was a Stage 3. He was seen twice there and discharged due to not being able to continue to do anything for the wound. The resident would have needed a suprapubic catheter to let the wound heal. During an interview on 04/28/23 at 4:14 P.M., the DON indicated the resident's order from urology should have been followed. No policy could be provided for In and Out Catheterization. The current facility policy titled, Urinary Catheter Care with a review date of 12/31/22, was provided by Clinical Support 4 on 04/28/23 at 4:18 P.M. The policy indicated, .Ensure the catheter remains secured. A leg strap may be used to reduce friction and movement at the insertion site . The current facility policy titled, Patient with a Foley Catheter, with a revised date of 08/05/22, and provided by Administrator 9 on 04/28/23 at 2:33 P.M. The policy indicated, .Make sure catheter tubing is secure to leg to avoid any unnecessary pulling on the bladder . 33613 2. During an observation on 04/24/23 at 1:42 P.M., the resident was sitting in his recliner with the urinary catheter drainage bag hanging on the right side of the chair and resting on the floor. During an observation on 04/26/23 at 4:02 P.M., the resident was sitting in his recliner with the urinary catheter drainage bag hanging on the right side of the chair and resting on the floor. The record for Resident 28 was reviewed on 04/27/233 at 11:06 A.M. An Admission MDS, dated [DATE], indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, prostate cancer, heart failure, hypertension, diabetes, and renal insufficiency. The resident had had a UTI in the last 30 days and had an indwelling urinary catheter. A physician's order, dated 03/30/23, indicated Tobermycin (an antibiotic) 80 mg (milligrams) to be given intravenously every 12 hours for 6 days, for a UTI. During an interview on 04/28/23 at 2:08 P.M., CNA 12 indicated the catheter drainage bag should be kept lower than the resident's bladder and should never touch the floor. The current facility policy titled, Urinary Catheter Care with a review date of 12/31/22, was provided by Clinical Support 4 on 04/27/23 at 4:18 P.M. The policy indicated, .Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-18(a)

Based on record review and interview, the facility failed to notify the physician of a change in a resident's condition for 1 of 18 resident's review. (Resident 15) Findings include: The record for Resident 15 was reviewed on 04/27/23 at 10:15 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/23/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertensive heart and chronic kidney disease with heart failure, hypertension, renal insufficiency, diabetes, non-Alzheimer's dementia, malnutrition, and depression. A Progress Note, dated 11/26/22 at 5:51 P.M., indicated the resident had a severe choking episode in the dining room. The CNA (Certified Nurse Aide) was able to clear the airway and assess that the resident was pocketing food. The vital signs and lung sounds were within normal limits. The resident's diet was downgraded to mechanical soft by the nurse pending a speech therapy evaluation. The record lacked documentation that the physician was notified of the choking incident on 11/26/22 until a speech therapy plan of treatment was signed on 12/02/22. During an interview on 04/27/23 at 1:31 P.M., the DON (Director of Nursing) indicated the record lacked documentation the physician was notified and the physician should have been notified of any choking episodes. During an interview on 04/27/23 at 1:52 P.M., QMA (Qualified Medication Aide) 6 indicated if a resident had a choking episode she would assist the resident, then call the nurse that was in facility to assess the resident. The nurse would make a request for a speech therapy evaluation. If the incident happened on a weekend, she would call the weekend nurse supervisor and they could put in an immediate override of the resident's diet until the speech evaluation could be completed. The nurse was supposed to call and notify the physician and family of any changes in a resident's condition. The current facility policy, titled Notification of Change in Condition with an effective date of 05/10/2016 was provided by Clinical Support 4 on 04/27/23 at 2:46 P.M. The policy indicated, .To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the physician and if known notify the resident's legal representative when: An accident involving the resident which results in an injury and has the potential for requiring physician intervention .A significant change in the resident's physical, mental or psychosocial status .A need to alter treatment significantly . 3.1-5(a)(2)

Based on interview and record review, the facility failed to provide activities of daily living related to routine bathing for 1 of 24 residents reviewed. (Resident 26) Findings include: During an interview on 04/24/23 at 10:12 A.M., Resident 26 indicated she had been having a problem with getting showers. She usually only received one shower a week. The staff usually gave her showers in the morning. The record was reviewed on 04/25/23 at 10:58 A.M. An Admission MDS (Minimum Data Set) assessment, dated 02/26/23, indicated the resident was severely cognitively impaired. The resident required extensive assistance of one staff member for personal hygiene and bathing. The diagnoses included, but were not limited to, heart failure, arthritis, osteoporosis, stroke, and dementia. During an interview on 04/27/23 at 1:33 P.M., CNA (Certified Nurse Aide) 14 indicated residents were showered twice a week at a minimum. Bathing would be documented in the EHR (Electronic Health Record). They completed shower sheets (paper) sometimes as well. On 04/27/23 at 1:42 P.M., paper shower sheets from February through 04/27/23, were sorted with Clinical Support 2 and another staff member. No shower sheets for the resident were identified. A three-ring binder that contained paper shower sheets was later provided with no shower sheets for the resident identified. The POC (Point of Care) history report from the EHR, dated 02/21/23 through 04/27/23, was provided by MDS Support 3 on 04/27/23 at 1:54 P.M. The record indicated the resident had not had a complete bed bath or shower from 04/18/23 to 04/27/23 (nine days). The record indicated the resident received a complete bed bath or a shower on the following dates: - Tuesday, 04/18/23, shower, - Friday, 04/14/23, shower, - Tuesday, 04/04/23, shower, - Friday, 03/31/23, shower, - Wednesday, 03/22/23, complete bed bath, - Tuesday, 03/21/23, complete bed bath, - Friday, 03/17/23, (refused), - Wednesday, 03/15/23, complete bed bath, - Friday, 03/03/23, shower, and - Tuesday, 02/28/23, shower. The resident was admitted on [DATE] and did not receive a shower or complete bed bath until seven days later, on 02/28/23. The resident received a shower or complete bed bath ten times. The resident should have been bathed twice a week for a total of 18 times. During an interview on 04/27/23 at 2:34 P.M., QMA (Qualified Medication Aide) 7 indicated if a resident refused a shower the nursing staff were supposed to educate the resident on the importance of bathing and at least encourage them to get a sponge bath. The CNA staff were to report refusals to the nurse or QMA on duty and the refusal should be documented in the Progress Notes. The Progress Notes, from 02/21/23 through 04/27/23, were provided by MDS Support 3 on 04/27/23 at 3:09 P.M. The record lacked documentation the resident had refused any showers or bathing. During an interview on 04/27/23 at 2:37 P.M., CNA 8 indicated the resident was supposed to be bathed on day shift on Tuesdays and Fridays. During an interview on 04/27/23 at 2:52 P.M., Clinical Support 2 indicated if a resident had not stated a preference, they were bathed twice a week. The Profile Care Guide Care Plan was provided by Clinical Support 2 on 04/27/23 at 2:56 P.M. An Approach indicated the resident was to be showered on Tuesdays and Fridays on day shift, with a start date of 02/23/23. The current facility policy, titled Guidelines for Bathing Preference with a review date of 12/31/22, was provided by Clinical Support 2 on 04/27/23 at 2:46 P.M. The policy indicated, .Bathing shall occur at least twice a week unless resident preference states otherwise . The current facility policy, titled Nursing ADL Documentation Guidelines with a review date of 12/31/22, was provided by Clinical Support 4 on 04/27/23 at 2:46 P.M. The policy indicated, To document the type and amount of assistance provided to the resident for activities of daily living .Completion of ADL service will be validated through the use of the CARE ASSIST ADL reports .ADL services will be conducted and documented by the CNA each shift at the [point of care] or as reasonably possible after care . 3.1-38(a)(2)(A)

Based on interview, observation, and record review, the facility failed to follow the Emergency Preparation Plan or use a Hoyer lift to transfer a resident, who required the extensive assistance of two staff and a Hoyer lift for transfers, resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/28/23 at 2:45 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 12/10/22, indicated the resident was severely cognitively impaired. She required extensive assistance of two staff for mobility, transfer, and ADLs (Activities of Daily Living). The diagnoses included, but were not limited to, dementia, heart disease, weakness, and morbid obesity. A current Care Plan for Resident B, with an intervention approach date of 11/20/19, indicated the resident required extensive assistance with a Hoyer lift for transfers, two staff assistance with bed mobility, and extensive assistance with a Hoyer lift for toileting. A physician's order, dated 2/27/23, indicated the staff were to obtain a 2-view x-ray to the left shoulder. A Progress Note, dated 2/28/23 at 2:53 a.m., indicated Resident B returned from the ED (Emergency Department) with a diagnosis of a fracture of the proximal end of the left humerus and a fracture of the surgical neck of left humerus. A Patient Report for Resident B, dated 2/27/23, indicated the resident had an X-ray of the left shoulder. There was an acute impacted proximal humeral fracture at the surgical neck. There was an avulsion fragmentation of the greater tuberosity. A Progress Note, dated 2/27/23 at 1:30 p.m., indicated Resident B was sitting in her recliner in her room; a tornado warning was called for the city. Resident B asked to be moved out her room for the warning. She required the use of a Hoyer lift; but due to the eminent weather conditions, the staff had used three staff to assist her to her wheelchair, to move her to an area of safety. When assisting the resident back to her room after the warning was canceled, the resident started to complain of pain in her left shoulder. The area was examined, and an abnormal alignment was noted. The Point of Care ADL (Activities of Daily Living) indicated the resident required extensive assistance or total dependence for the following dates and times: - On 2/26/23 at 11:20 a.m., total dependence of two or more staff members and a mechanical lift, - On 2/26/23 at 5:22 p.m., total dependence of two or more staff members and a mechanical lift, - On 2/25/23 at 9:40 a.m., extensive assistance of one staff member and a transfer aid, - On 2/25/23 at 5:55 p.m., extensive assistance of one staff member and a mechanical lift, and - On 2/24/23 at 9:16 p.m., extensive assistance of one staff member and a mechanical lift. During an interview on 2/28/23 at 11:18 a.m., the DON (Director of Nursing) indicated on 2/27/23 there was a tornado warning. During the tornado warning Resident B was transferred from a recliner to a wheelchair by three CNA's (Certified Nursing Aide) and a QMA (Qualified Medication Assistant) to assist her to an area of safety, resulting in fractures of the proximal end of the left humerus and surgical neck of the left humerus. Resident B was a Hoyer lift, but the Hoyer was not available, so they manually transferred her. She was sent out to the hospital. During an interview on 2/28/23 at 11:23 a.m., CNA 2 indicated the tornado sirens were going off, and Resident B wanted to get up from her recliner in her room, into the wheelchair, to move to the hall. CNAs 3, 4, and QMA 5, assisted with a manual lift of Resident B. There was a Hoyer pad under her. CNA 2 grabbed the strap on one side, CNA 3 grabbed the strap on the other side and the QMA grabbed the straps between her legs. They lifted her up, turned her, and CNA 4 positioned the wheelchair under her. Resident B only complained of leg pain at that time. The resident had no complaints about her arm when she was in the hallway. After the all clear was announced, they returned the resident to her room, used the Hoyer to place the resident in her recliner. At that time, she complained of arm pain and was unable to lift her left arm. CNA 2 was able to feel the separation in the bone of the arm and immediately reported it. Resident B was sent out to hospital. During an interview on 2/28/23 at 11:35 a.m., the DON indicated there were two Hoyer lifts in the building. There was one Hoyer lift for the 200 Hall for seven residents that required a Hoyer lift transfer, and the other Hoyer lift was shared between the 100 and 300 Halls for two residents that required a Hoyer lift transfer on the 100 Hall. During an interview and observation on 2/28/23 at 1:29 p.m., the DON indicated Resident B had osteopenia. The Regional Clinical Support (RCS) indicated when the staff transferred the resident, they used the Hoyer pad and had an arm under each arm of the resident. The RCS had asked CNA 2 to demonstrate the transfer of Resident B. He sat in a chair with a Hoyer pad under him, CNA 2 indicated she was on the right side of the resident and another CNA was on the left. Both CNAs placed an arm under the RCS arms on each side and used both hands to hold the pad strap while the DON used the straps between the RCS's legs. They then stood him up, pivoted him to the left, and the third CNA placed a rolling chair under him. During an interview on 3/1/23 at 1:07 p.m., CNA 6 indicated if a resident required the use of a Hoyer lift, staff could not transfer them manually. She had checked on Resident B five minutes before she was manually transferred during the tornado warning. The resident said she was fine, and the CNA closed the curtains and gave her a blanket to cover herself. There was a lot of chaos, and everyone was over talking each other. Things needed to be a lot calmer and she had never completed a code black warning drill before. During an interview on 3/1/23 at 1:17 p.m., Licensed Practical Nurse (LPN) 7 indicated if a resident required the use of a Hoyer lift, it would not be appropriate to transfer by a manual lift. During an interview on 3/1/23 at 1:20 p.m., CNA 8 indicated if a resident required the use of a two person Hoyer lift, it would require two people and the lift. It would not be appropriate to manually lift them. The current facility policy titled Emergency Operations Plan and dated 11/1/17, was provided by the Administrator on 2/28/23 at 2:38 p.m. The policy indicated, .Severe Weather and Tornado .3. In the event of a Tornado Warning .B .ii. If residents .cannot quickly get up, move .as far away from the window as possible with the privacy curtains pulled around them and blankets on them . The current facility policy titled Hoyer User Instruction Manual and dated 2014, was provided by the RCS on 3/1/23 at 10:27 a.m. The policy indicated, .Statement of Intended Use .The intended us of this lifting devise is for the safe lifting and transfer of an individual from one resting surface to another . The current facility policy titled Guidelines for resident utilizing a lift and dated 5/11/17, was provided by the RCS on 3/1/23 at 10:27 a.m. The policy indicated, .Purpose: To ensure the safety of residents and staff when performing lift transfer task .Procedures: .3. Staff should seek the assistance of a second person for those residents' care planned for assistance of two with the lifting device . 3.1-45(a)(2)

Based on record review and interview, the facility failed to position a resident in bed appropriately that resulted in a fracture for 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record for Resident B was reviewed on 02/22/22 at 11:00 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 10/08/21, indicated the resident was moderately cognitively impaired. Diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)], hypertension, non-Alzheimer dementia, depression, anxiety, and muscle weakness. The resident had impairments to one side of the upper extremity and both sides of the lower extremities. She required extensive physical assistance of 2 or more staff members with bed mobility. A Progress Note, dated 10/28/21 at 10:00 A.M., indicated the nurse was called to the room. When entering the room, the resident was observed in the prone (face down) position, and her arms were underneath her. The CNA (Certified Nurse Aide) had told the writer she had been getting the resident ready to take a shower and had the resident laying on her left side while putting the hoyer sling underneath her. The resident kept moving until she rolled off the bed. The staff had her hands on the resident at all times, but had been unable to keep the resident in the bed. The resident had complained of right arm pain. The resident was assessed and placed back in the bed. The NP (Nurse Practitioner) came to see the resident. A Progress Note, dated 10/28/21 at 10:15 A.M., indicated the physician order was obtained for the resident to have a right shoulder x-ray STAT (immediately). A Patient Report for Resident B, dated 10/28/21, indicated the resident had an X-ray of the right shoulder. There was an acute oblique minimally displaced fracture of the proximal humeral diametaphysis without a dislocation. The Point Of Care ADL (Activities of Daily Living) indicated, the resident required the extensive or total assistance of 2 or more staff for the following dates and times: -10/26/21 at 12:46 P.M., total assistance of 2+ (plus) staff members -10/26/21 at 3:52 P.M., extensive assistance of 2+ staff members -10/27/21 at 10:28 A.M., total assistance of 2+ staff members -10/27/21 at 2:51 P.M., total assistance of 2+ staff members During an interview on 02/22/22 at 11:52 A.M., CNA 2 indicated on 10/28/21 she had gone into the resident's room to assist her to get up for a shower. The resident was not a 2 person assist with bed mobility at the time. She had been standing on the side of the bed and turned the resident away from her and the resident overturned and rolled out of bed. She gave the resident a pillow and had retrieved the nurse. The resident had obtained a fracture. After the incident she was educated on the proper way to turn a resident during care and the resident became a 2 staff assist of care with bed mobility. The current facility policy titled, Fall Management Program Guidelines, dated 5/22/18 was provided by Clinical Support on 02/22/22 at 4:04 P.M. The policy indicated, .strive to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures . This Federal tag relates to Complaint IN 436. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to maintain a safe environment, free from accident hazards, and provide adequate supervision, resulting in a major injury for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: During the clinical record review for Resident B on 10/18/21 at 10:24 a.m., the record indicated her diagnoses included but was not limited to, severely cognitively impaired, repeated falls, Alzheimer's, dementia, and cognitive communication deficit. The Annual MDS (Minimum Data Set) dated 9/24/21 indicated Moderate difficulty hearing, unclear speech, understood and understands, vision not assessed. Two person extensive assistance for mobility, transfer, and ADLs. Always incontinent of bladder and bowel. One fall since admission with major injury. A Progress Note dated 9/22/21 at 8:00 p.m. indicated the resident was incontinent of stool and was laid in bed for care. Staff went to get supplies and when returned to the room, the resident was observed lying on the floor, on her right side, between the bed and the room divider. The resident was observed with a skin tear to her right pointer finger measuring 5cm in length, a dark bruise on her RFA (right forearm) measuring 12cm x 9cm (centimeter), and with some guarding to her right shoulder. The resident stated that it hurt with movement, observed a raised hard area on her right shoulder, and arm splinted with sheet for comfort. On 10/19/21 at 10:38 a.m., the Interim Director of Nursing (DON) provided a radiology report for Resident B dated 9/23/21 at 11:05 a.m. The report indicated grossly displaced fracture of the clavicle laterally with moderated to sever acromial clavicular joint separation. During an interview on 10/18/21 at 10:53 a.m., Resident B's son indicated he had visited with his mother the day before she fell and broke her shoulder, and she was doing really well. After the fall she had a rapid decline and passed away on 10/1/21. He indicated the roommate told him what really happened and then the DON told him and stated the CNA had been reeducated. During an interview on 10/18/21 at 12:15 p.m. Resident E indicated Resident B had been her roommate, was always falling out of bed, but the bed was usually down near the floor. She indicated she had been in the room when Resident B fell out of the bed and broke her shoulder, she didn't see it all because the privacy curtain was pulled, but the bed was up high this time. She indicated she knew the bed was up high because she could see Resident B's feet. There was a CNA in the room making her bed, the other CNA just went to get a top sheet, and Resident B fell out of the bed. During an interview on 10/18/21 at 2:30 p.m., the DON indicated a CNA had placed Resident B in the bed, discovered she had a large bowel movement, left the room to get supplies and when she came back the resident was on the floor. On 10/19/21 at 9:50 a.m. the DON provided an Event Report dated 9/22/21 at 7:30 p.m. The report indicated a CNA went to get supplies, Resident B fell out of bed, and sustained a shoulder injury. Included with the report was a written statement from CNA 2 which indicated she had left the room while providing care. Also included with the report was an Employee Counselling Record Form dated 9/23/21 which indicated, Employee left resident to get supplies - but failed to put bed in lowest position. Resident rolled out of bed causing major injury. During an interview on 10/19/21 at 9:57 a.m. CNA 2 indicated on 9/22/21 she had place Resident B in the bed, raised the bed to about waist high, realized she had a bigger mess than she had anticipated, left the room to get linens because she wasn't thinking, just in a hurry, and as she returned to the room the resident fell out of the bed onto the floor. There was another CNA in the room on the other side of the wooden room divider but she didn't think to tell her she was leaving the room. CNA notified the nurse, and the resident had a complaint of shoulder pain. On 10/19/21 at 12:50 p.m. the DON provided Hospice Notes for Resident B. An RN Note dated 6/24/21 indicated, Environmental - no significant concerns or issues noted or reported, and patient was at risk for falling. An RN Note dated 7/29/21 indicated, Environmental - no significant concerns or issues noted or reported, and patient was at risk for falling. An RN Note dated 9/2/21 indicated, Environmental - no significant concerns or issues noted or reported, patient was at risk for falling, and no functional changes. An RN Note dated 9/14/21 indicated, Environmental - no significant concerns or issues noted or reported, patient was at risk for falling, and no functional changes. An RN Note dated 9/22/21 indicated, Hospice was notified of Resident B's fall, and during a hospice assessment Resident B's bed was noted to be in the lowest position, and was observed wincing when her right shoulder was palpated, bruising and swelling noted to right shoulder, and received an order for Xray. Current interventions were bed in lowest position and call light in reach. During an interview on 10/19/21 at 12:51 p.m., RN 3 indicated she was notified by a CNA that Resident B was on the floor in her room. When she went into the room Resident B was lying on the floor between the bed and room divider and the bed was raised to about mid-upper-thigh height. When Resident B was in bed, the bed was usually in the lowest position. She indicated CNA 2 told her she had left the room to get supplies and upon return the resident was in the floor. The current facility policy Abuse and Neglect Procedural Guidelines and a revised date of 8/29/2019, was provided by the DON on 10/18/21 at 10:30 a.m. The policy indicated, .Purpose .developed and implemented processes .to ensure the prevention .of .neglect .Procedures .k. Neglect - is the failure of the facility, its employees . to provide .services to a resident that are necessary to avoid physical harm, pain . The current facility policy Fall Management Program Guidelines and a revised date of 5/31/2017, was provided by the DON on 10/18/21 at 10:30 a.m. The policy indicated, .Purpose .to maintain a hazard free environment, mitigate fall risk .Procedures .Definition: A fall is considered to be: an unintentionally coming to rest on the ground, floor, or lower level .1. The fall risk assessment .a. Identified risk factors should be evaluated for the contribution they may have to resident's likelihood of falling .b. care plan interventions should be implemented that address the resident's risk factors . This Federal tag relates to Complaint IN 192 3.1-45(a)

Based on record review and interview, the facility failed to ensure a resident was provided supervision to prevent accidents related to a fall during a transfer that resulted in a right tibia (lower leg bone) fracture for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: The clinical record for Resident C was reviewed on 08/15/19 at 10:53 [NAME]M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/02/19, indicated the resident was moderately cognitively impaired. The resident's [DIAGNOSES REDACTED]. A current Care Plan for Resident C, with an intervention approach dated 04/11/17, indicated the resident required the extensive assistance of two staff members with transfers and toileting. During an interview on 08/15/19 at 12:52 P.M., CNA (Certified Nurse Aide) 2 indicated prior to the fall on 07/10/19 the resident required extensive assistance of two physical staff members for all transfers. On the night of the fall the resident was in the bathroom and she helped the resident with her care. She had assisted the resident to stand and provided the necessary personal care. The resident expressed to her that she was getting tired. The CNA pulled up the resident's pants and asked her to sit on the toilet. The resident turned to sit in the wheelchair and the CNA saw that the wheelchair was too far away and asked the resident again to sit on the toilet. The resident still went towards the wheelchair and the CNA grabbed the wheelchair and tried to pull it closer to the resident. The wheelchair brakes were locked and the resident sat on the edge of the wheelchair. The CNA pulled the call light for assistance, she had waited about 30 seconds, as the resident was getting impatient and tried to pull herself back using the bar on the wall but the resident did not have enough strength. The CNA tried to pull the resident back also but she did not have enough strength from the angle she was at. The CNA assisted the resident to the floor and didn't see the angle of the resident's leg. The resident's leg was under the wheelchair. The resident was lowered to the floor and the CNA went to get help. The nurse came to the room and assessed the resident. The resident was transferred to the hospital. A progress note, dated 07/10/19 at 7:15 P.M., indicated the resident was on the toilet and CNA 2 assisted the resident to her wheelchair. The resident sat on her wheelchair near the front, had her right foot behind her, and started to slide off of the wheelchair. The CNA lowered the resident to the floor and heard a pop. The resident's right leg was bent at the knee and had a knot protruding at the right side of the knee with her foot flat on the floor. The physician, power of attorney, and Director of Nursing were aware of the fall. A new order was obtained to send the resident to the emergency room for evaluation and treatment. A progress note, dated 07/11/19 at 1:34 [NAME]M., indicated the resident was admitted to the local hospital for a tibia fracture. An Emergency Department Note, dated 07/10/19, indicated .Diagnosis: [REDACTED]. During an interview on 08/15/19 at 12:13 P.M., RN 3 indicated the resident required two physical staff members for all transfers. The resident was weak in both of her legs. During an interview on 08/15/19 at 1:12 P.M., the DON (Director of Nursing) indicated the resident required extensive assist of two staff members for transfers. When the resident had a fall on 07/10/19, CNA 2 was by herself during the transfer. On 08/15/19 at 2:47 P.M., Corporate Clinical Nurse 5 provided documentation of an in-service sign in sheet related to ADL (Activities of Daily Living)/transfers dated 07/10/19, and an Employee Counseling Record Form indicating the CNA received counseling for not following the resident's care plan dated 07/11/19. The current facility policy titled Guidelines for Resident Transfers and Assistance with a revision date of 05/10/17, was provided by the DON on 08/15/19 at 1:58 P.M. The policy indicated, .Purpose: To ensure the safety of residents and staff when performing mobility/transfer tasks . The current facility policy titled Comprehensive Care Plan Guideline with a revision date of 05/22/18, was provided by Corporate Clinical Nurse 5 on 08/15/19 at 2:22 P.M. The policy indicated .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines . 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure effective monitoring and interventions to prevent a delay in medical care and /or hospitalization for 5 of 5 residents reviewed. This failure resulted in a delay in medical care and hospitalization for 1 resident (Resident B), and the delay in medical care for 4 residents (Residents C, D, E, and F). This Immediate Jeopardy began on 11/21/2015 when the facility failed to monitor/assess vital signs for a period between 11/20/2015 at 9:37 a.m. and 11/22/2015 at 6:51 a.m. and a 5.2 pound weight gain between 11/22/2015 and 11/23/2015 was not reported to the physician and was identified on 6/10/2016. The Executive Director, Assistant Director of Health Services, the Interim Director of Health Services, Clinical Support RN # 1, Clinical Support RN # 2, and the Medical Records Coordinator were notified of the Immediate Jeopardy at 1:42 p.m. on 6/10/2016. The Immediate Jeopardy was removed on 6/11/2016, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B's admission Minimum Data Set (MDS) assessment, dated 11/17/2015, indicated a Brief Interview for Mental Status (BIMS) score of 14; indicating he was cognitively intact. The resident had no behaviors and did not reject care. The resident required extensive, 2+ person physical assist for transfers and was non-ambulatory. The resident had an indwelling Foley catheter and received oxygen therapy. [DIAGNOSES REDACTED]. Resident B's Skilled Charting - Admission Assessment, dated 11/10/2015 at 11:22 p.m., indicated the resident was alert and oriented to person, place, time and situation, did not have difficulty sleeping at night, did not use oxygen, denied shortness of breath, and did not have anxiety present. The assessment indicated Resident B's respirations were regular and unlabored, he did not have a cough, and lung sounds were clear in all fields. The resident had 1 + [MEDICAL CONDITION] in his left and right lower extremities. The resident had a Foley catheter and no urinary symptoms. The resident denied pain. Initial Nutrition Plan of Care indicated, observe weight .daily .Vitals: Pulse: 67/per minute. Respirations: 20/per minute. Blood Pressure: 146/77. O2 Saturation: 95%. Activity: Resting .Oxygen Use: No Hospital Extended Care Admitting Orders for Resident B, dated 11/10/2015 at 2:15 p.m., indicated, .Diet: 1500 ml (milliliter) fluid restriction) .No Longer Take the following medications: [REDACTED].Discharge Instructions/Patient Education Materials: .weigh yourself every day, at the same time of day, and in the same kind of clothes. When to call your doctor: Call your doctor right away if you have any of these signs of worsening heart failure: sudden weight gain (more than 2 pounds in 1 day or 5 pounds in 1 week, or whatever weight gain you were told by your doctor). Trouble breathing related to not being active. New or increased swelling in your legs or ankles .Breathing trouble at night Resident B's Hospital Nephrology Discharge Note, dated 11/10/2015, indicated, .Chronic SOA (shortness of air) - (at) baseline. Chronic LE (lower extremity) swelling - states at baseline .ext (extremities) trace BLE ([MEDICAL CONDITION] bilateral lower extremities) .hesitant to start .diuretic for now, but should he develop sig (significant) [MEDICAL CONDITION] or worsening breathing, a loop diuretic could be restarted Resident B's Physician order [REDACTED]. Once a day; p.m .Fluid restriction of 1500 ml per day .Foley cath output every shift Physician's Progress Notes for Resident B, signed by the resident's primary care physician (PCP), dated 11/11/2015 at 4:15 p.m., indicated, .breathing at baseline .Lungs - CTA (clear to auscultation) B (bilaterally) .Ext (extremities) - 2+ [MEDICAL CONDITION] on R (right), 1+ ([MEDICAL CONDITION]) on L (left) .[MEDICAL CONDITION] - stable - monitor for fluid overload. Daily weights. A Progress Note for Resident B, dated 11/21/2015 at 1:45 p.m., indicated, Resident has 3+ swelling to bilateral feet, Resident in recliner with feet elevated. A Progress Note for Resident B, dated 11/22/2015 at 11:41 p.m., indicated, Resident continues to have bilateral lower leg [MEDICAL CONDITION] . There were no additional assessments, events, or physician notification related to these progress notes dated 11/21-22/2015. Resident B's admission weight, dated 11/10/2015 at 11:22 p.m., was 238.4 pounds. There were no weights recorded for November 11, 12, 14, 15, 16, 17 or 21, 2015; 7 of the 27 days he was at the facility. Resident B experienced a 5.2 pound weight gain between 11/22/2015 and 11/23/2015. Resident B experienced an additional 1.4 pound weight gain on 11/24/2015; which totaled a 6.6 pound weight gain in 2 days. The resident experienced a 4 pound weight gain between 12/3/2015 and 12/4/2015. Vitals Report, dated 12/4/2015 at 11:07 a.m., indicated, Weight: 244.2 lbs (in red) .Acceptable Range: 5 percent change in weight in 30 days. There was no evidence in the clinical record that the recorded weights were re-checked, associated assessments were competed, the physician was notified, or a change of condition/event was initiated. Resident B's Vitals Report indicated his intake of fluids was 1840 ml fluids on 12/3/2015. A Progress Note for Resident B, dated 12/4/2015 at 4:35 a.m., indicated, .He c/o (complaint of) SOB at 0300 (3:00 a.m.). I tried to talk to him to calm him down, cracked his window, turned up his oxygen from 2.0 (L) to 2.5 (L) to 3.0 (L), tried repeatedly to have him do pursed lip breathing. At 0330 (3:30 a.m.) I gave PRN (as needed) [MEDICATION NAME] inhilation (sic) therapy. Resident still c/o (complained of) short of breath and O2 sat at 92%. Resident refused to use face mask while having shortness of breath and (had) rapid mouth breathing. I had to walk him through the pursed lip breathing several times. Increased the O2 to 3.5 L via nasal canula (sic). Resident is very anxious .has not slept all night. On 12/6/2015 at 12:06 a.m., Resident B's vital signs indicated, Respirations: 24/minute. O2 Saturation: 90% (in red) (acceptable range: 91-100%). Activity: Resting .Oxygen Use: Yes - Liter flow: 2. Respirations: 24/minute Type: Mouth. Describe: Rapid. A Progress Note for Resident B, dated 12/6/2015 at 12:44 a.m., indicated, Resident frequently c/o shortness of breath. He recuses (sic) to sit up in his chair because he doesn't want his feet to be unelevated. The window will be cracked open to help with the feeling of air circulation to help calm his nerves .the resident is often confused with his [DIAGNOSES REDACTED]. On 12/6/2015 at 2:00 a.m., Resident B's vital signs indicated, Blood Pressure 191/157 mmHg (in red) (acceptable range: 98-190 mmHg/40-100 mmHg). Pulse: 68. Bounding. 02 Saturation: 91%. Activity: Low .Oxygen Use: Yes - Liter flow: 3.5. Respirations: 32/minute (in red) (Acceptable Range: 10-30 per minute). Activity: Low. Type: Mouth. Describe: Rapid. <

Based on observation, record review and interview, the facility failed to notify the physician of significant changes in resident conditions in a timely manner for 4 of 5 residents reviewed for notification of change. This deficient practice resulted in a delay in medical care and hospitalization for 1 resident (Resident B), and the delay in medical care for 3 residents (Residents D, E, and F). This Immediate Jeopardy began on 11/21/2015 when the facility failed to assess vital signs for a period between 11/20/2015 at 9:37 a.m. and 11/22/2015 at 6:51 a.m. and a 5.2 pound weight gain between 11/22/2015 and 11/23/2015 was not reported to the physician and was identified on 6/10/2016. The Executive Director, Assistant Director of Health Services, the Interim Director of Health Services, Clinical Support RN # 1, Clinical Support RN # 2, and the Medical Records Coordinator were notified of the Immediate Jeopardy at 1:42 p.m. on 6/10/2016. The Immediate Jeopardy was removed on 6/11/2016, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate Jeopardy . 1. Resident B's closed clinical record was reviewed on 6/8/2016 at 11:10 a.m. [DIAGNOSES REDACTED]. Resident B's Skilled Charting - Admission Assessment, dated 11/10/2015 at 11:22 p.m., indicated the resident was alert and oriented to person, place, time and situation, did not have difficulty sleeping at night, did not use oxygen, denied shortness of breath, and did not have anxiety present. The assessment indicated Resident B's respirations were regular and unlabored, he did not have a cough, and lung sounds were clear in all fields. The resident had 1 + [MEDICAL CONDITION] in his left and right lower extremities. The resident had a Foley catheter and no urinary symptoms. The resident denied pain. Initial Nutrition Plan of Care indicated, observe weight .daily .Vitals: Pulse: 67/per minute. Respirations 20/per minute. Blood Pressure: 146/77. O2 Saturation: 95%. Activity: Resting .Oxygen Use: No Resident B's admission weight, dated 11/10/2015 at 11:22 p.m., was 238.4 pounds. There were no weights recorded for November 11, 12, 14, 15, 16, 17 or 21, 2015; 7 of the 27 days he was at the facility. Resident B experienced a 5.2 pound weight gain between 11/22/2015 and 11/23/2015. Resident B experienced an additional 1.4 pound weight gain on 11/24/2015; which totaled a 6.6 pound weight gain in 2 days. The resident experienced a 4 pound weight gain between 12/3/2015 and 12/4/2015. Vitals Report, dated 12/4/2015 at 11:07 a.m., indicated, Weight: 244.2 lbs (in red) .Acceptable Range: 5 percent change in weight in 30 days. There was no evidence in the clinical record that the recorded weights were re-checked or the physician was notified. Resident B's Physician order [REDACTED]. Once a day; p.m .Fluid restriction of 1500 ml per day .Foley cath output every shift A Progress Note for Resident B, dated 11/21/2015 at 1:45 p.m., indicated, Resident has 3+ swelling to bilateral feet, Resident in recliner with feet elevated. A Progress Note for Resident B, dated 11/22/2015 at 11:41 p.m., indicated, Resident continues to have bilateral lower leg [MEDICAL CONDITION] . There were no additional assessments, events, or physician notification related to these progress notes dated 11/21-22/2015. Resident B's Urine Output Record indicated the following: 12/1/2015: 1,725 mL + Large 12/2/2015: 1,200 mL + Large 12/3/2015: 1,050 mL 12/4/2015: 850 mL 12/5/2015: 850 mL 12/6/2015: 725 mL There was no evidence in the clinical record from 12/1/2015 through 12/6/2016 that the physician was notified of the decreased urine output. A Progress Note for Resident B, dated 12/4/2015 at 4:35 a.m., indicated, .He c/o (complaint of) SOB at 0300 (3:00 a.m.). I tried to talk to him to calm him down, cracked his window, turned up his oxygen from 2.0 (L) to 2.5 (L) to 3.0 (L), tried repeatedly to have him do pursed lip breathing. At 0330 (3:30 a.m.) I gave PRN (as needed) [MEDICATION NAME] inhilation (sic) therapy. Resident still c/o (complained of) short of breath and O2 sat at 92%. Resident refused to use face mask while having shortness of breath and (had) rapid mouth breathing. I had to walk him through the pursed lip breathing several times. Increased the O2 to 3.5L via nasal canula (sic). Resident is very anxious .has not slept all night. There was no evidence in the Progress Notes or anywhere in the clinical record of resident B's physician being notified of his shortness of breath and rapid mouth breathing on 12/4/2015. On 12/6/2015 at 12:06 a.m., Resident B's vital signs indicated, Respirations: 24/minute. O2 Saturation: 90% (in red) (acceptable range: 91-100%). Activity: Resting .Oxygen Use: Yes - Liter flow: 2. Respirations: 24/minute Type: Mouth. Describe: Rapid. A Progress Note for Resident B, dated 12/6/2015 at 12:44 a.m., indicated, Resident frequently c/o shortness of breath. He recuses (sic) to sit up in his chair because he doesn't want his feet to be unelevated. The window will be cracked open to help with the feeling of air circulation to help calm his nerves .the resident is often confused with his [DIAGNOSES REDACTED]. On 12/6/2015 at 2:00 a.m., Resident B's vital signs indicated, Blood Pressure 191/157 mmHg (in red) (acceptable range: 98-190 mmHg/40-100 mmHg). Pulse: 68. Bounding. 02 Saturation: 91%. Activity: Low .Oxygen Use: Yes - Liter flow: 3.5. Respirations: 32/minute (in red) (Acceptable Range: 10-30 per minute). Activity: Low. Type: Mouth. Describe: Rapid. A Progress Note for Resident B, dated 12/6/2015 at 2:07 a.m., indicated, Resident is currently on 3.5 l (liters) O2 (oxygen). C/O SOB (shortness of breath), refused initial breathing tx (treatment) and inhailer (sic). After attempted deep breathing and pursed lip breathing exercise resident was unable to perform, he requested to sit up in his wheel chair. Once he moved to wheel chair his SOB increased .He has very high anxiety when these episodes occur and has a (sic) increase in his BP (blood pressure) and increase in respirations as well. There were no Progress Notes, Events, or other evidence in the record to indicate the physician or family were notified of the resident's change in condition on 12/6/2015. Resident B's Clinical Documents Progress Note (Hospital 2), dated 12/11/2015, indicated, .History of present illness: .recently here .between the dates of 11/5/2015 through 11/10/2015 for acute kidney injury superimposed on [MEDICAL CONDITION]. He also had issues with systolic heart failure during that time. On discharge .as (renal function) improved patient gradually developed worsening weight gain and fluid retention. He presented to (Hospital 1) 12/7 (sic)/2015 and was [MEDICATION NAME] .Unfortunately with aggressive diuresis at that time his creatinine continued to steadily increase .Assessment/Plan: 1. Acute kidney injury on [MEDICAL CONDITION] stage 3-4. This is most likely in relation to requirements for aggressive diuresis in light of his issues with [MEDICAL CONDITION] exacerbation

Based on observation, record review and interview, the facility failed to follow individualized care plans related to nursing assessments and notification to the physician of significant change in condition for 5 of 5 residents reviewed. This failure resulted in a delay in medical care and hospitalization for 1 resident (Resident B), and the delay in medical care for 4 residents (Residents C, D, E, and F). This Immediate Jeopardy began on 11/21/2015 when the facility failed to assess vital signs for a period between 11/20/2015 at 9:37 a.m. and 11/22/2015 at 6:51 a.m. and a 5.2 pound weight gain between 11/22/2015 and 11/23/2015 was not reported to the physician and was identified on 6/10/2016. The Executive Director, Assistant Director of Health Services, the Interim Director of Health Services, Clinical Support RN # 1, Clinical Support RN # 2, and the Medical Records Coordinator were notified of the Immediate Jeopardy at 1:42 p.m. on 6/10/2016. The Immediate Jeopardy was removed on 6/11/2016, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B's admission Minimum Data Set (MDS) assessment, dated 11/17/2015, indicated a Brief Interview for Mental Status (BIMS) score of 14; indicating he was cognitively intact. The resident had no behaviors and did not reject care. The resident required extensive, 2+ person physical assist for transfers and was non-ambulatory. The resident had an indwelling Foley catheter and received oxygen therapy. [DIAGNOSES REDACTED]. A Care Plan for Resident B indicated, Problem Start Date: 11/23/2015. I am at risk for alteration in fluid balance related to my having a fluid restriction and my [DIAGNOSES REDACTED]. Approach Start Date: 11/23/2015. Assist with fluids as needed .Observe me for s/s (signs/symptoms) fluid overload such as [MEDICAL CONDITION], distended neck veins, [MEDICAL CONDITION]. Notify my MD as needed .Weigh resident as ordered. A Care Plan for Resident B, initiated 11/23/2015, indicated, Problem: I have a [DIAGNOSES REDACTED].Approach: Administer oxygen as ordered. Monitor me for fluid excess, wt. gain, increased BP, full/bounding pulse, jugular vein distention, SOB (shortness of breath), rales, rhonchi, wheezing, [MEDICAL CONDITION], worsening of [MEDICAL CONDITION], increased urinary output .Monitor my weight per current order and notify physician as needed .Please monitor me and report signs of respiratory distress, cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse. Please monitor my intake of food and fluids A Care Plan for Resident B, initiated 11/23/2015, indicated, Problem: I have [MEDICAL CONDITION]/[MEDICAL CONDITION] .Approach: My care givers will monitor my lung sounds daily. My care givers will observe me for changes in my breathing or level of consciousness and report to my doctor Resident B's Skilled Charting - Admission Assessment, dated 11/10/2015 at 11:22 p.m., indicated the resident was alert and oriented to person, place, time and situation, did not have difficulty sleeping at night, did not use oxygen, denied shortness of breath, and did not have anxiety present. The assessment indicated Resident B's respirations were regular and unlabored, he did not have a cough, and lung sounds were clear in all fields. The resident had 1 + [MEDICAL CONDITION] in his left and right lower extremities. The resident had a Foley catheter and no urinary symptoms. The resident denied pain. Initial Nutrition Plan of Care indicated, observe weight .daily .Vitals: Pulse: 67/per minute. Respirations: 20/per minute. Blood Pressure: 146/77. O2 Saturation: 95%. Activity: Resting .Oxygen Use: No A Progress Note for Resident B, dated 11/21/2015 at 1:45 p.m., indicated, Resident has 3+ swelling to bilateral feet, Resident in recliner with feet elevated. A Progress Note for Resident B, dated 11/22/2015 at 11:41 p.m., indicated, Resident continues to have bilateral lower leg [MEDICAL CONDITION] . There were no additional assessments, events, or physician notification related to these progress notes dated 11/21-22/2015. Resident B's admission weight, dated 11/10/2015 at 11:22 p.m., was 238.4 pounds. There were no weights recorded for November 11, 12, 14, 15, 16, 17 or 21, 2015; 7 of the 27 days he was at the facility. Resident B experienced a 5.2 pound weight gain between 11/22/2015 and 11/23/2015. Resident B experienced an additional 1.4 pound weight gain on 11/24/2015; which totaled a 6.6 pound weight gain in 2 days. The resident experienced a 4 pound weight gain between 12/3/2015 and 12/4/2015. Vitals Report, dated 12/4/2015 at 11:07 a.m., indicated, Weight: 244.2 lbs (in red) .Acceptable Range: 5 percent change in weight in 30 days. There was no evidence in the clinical record that the recorded weights were re-checked, associated assessments were competed, the physician was notified, or a change of condition/event was initiated. A Progress Note for Resident B, dated 12/4/2015 at 4:35 a.m., indicated, .He c/o (complaint of) SOB at 0300 (3:00 a.m.). I tried to talk to him to calm him down, cracked his window, turned up his oxygen from 2.0 (L) to 2.5 (L) to 3.0 (L), tried repeatedly to have him do pursed lip breathing. At 0330 (3:30 a.m.) I gave PRN (as needed) [MEDICATION NAME] inhalation (sic) therapy. Resident still c/o (complained of) short of breath and O2 sat at 92%. Resident refused to use face mask while having shortness of breath and (had) rapid mouth breathing. I had to walk him through the pursed lip breathing several times. Increased the O2 to 3.5L via nasal canula (sic). Resident is very anxious .has not slept all night. There was no evidence in the Progress Notes or anywhere in the clinical record of resident B's respiratory status being assessed (lung sounds), [MEDICAL CONDITION] being assessed, or the physician or family being notified on 12/4/2015, 12/5/2015 or 12/6/ 2015. On 12/6/2015 at 12:06 a.m., Resident B's vital signs indicated, Respirations: 24/minute. O2 Saturation: 90% (in red) (acceptable range: 91-100%). Activity: Resting .Oxygen Use: Yes - Liter flow: 2. Respirations: 24/minute Type: Mouth. Describe: Rapid. A Progress Note for Resident B, dated 12/6/2015 at 12:44 a.m., indicated, Resident frequently c/o shortness of breath. He recuses (sic) to sit up in his chair because he doesn't want his feet to be unelevated. The window will be cracked open to help with the feeling of air circulation to help calm his nerves .the resident is often confused with his [DIAGNOSES REDACTED]. On 12/6/2015 at 2:00 a.m., Resident B's vital signs indicated, Blood Pressure 191/157 mmHg (in red) (acceptable range: 98-190 mmHg/40-100 mmHg). Pulse: 68. Bounding. 02 Saturation: 91%. Activity: Low .Oxygen Use: Yes - Liter flow: 3.5. Respirations: 32/minute (in red) (Acceptable Range: 10-30 per minute). Activity: Low. Type: Mouth. Describe: Rapid. A Progress Note

Based on observation, interview and record review, the facility failed to ensure administration effectively ensured the highest practicable physical, mental, and psychosocial well-being of 5 of 5 residents reviewed for quality of care. This failure resulted in a delay in medical care and hospitalization for 1 resident (Resident B), and the delay in medical care for 4 residents (Residents C, D, E, and F). This Immediate Jeopardy began on [DATE] when the facility failed to assess vital signs for a period between [DATE] at 9:37 a.m. and [DATE] at 6:51 a.m. and a 5.2 pound weight gain between [DATE] and [DATE] was not reported to the physician and was identified on [DATE]. The Executive Director, Assistant Director of Health Services, the Interim Director of Health Services, Clinical Support RN # 1, Clinical Support RNA# 2, and the Medical Records Coordinator were notified of the Immediate Jeopardy at 1:42 p.m. on [DATE]. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B's (family member), primary care giver and Power of Attorney (POA), was interviewed on [DATE] at 1:16 p.m. Resident B's (family member) indicated he was not notified that (Resident B) was not on [MEDICATION NAME] while he was at the facility and Resident B's (family member) indicated he raised repeated concerns over (Resident B's) increased lower extremity [MEDICAL CONDITION] and increasing shortness of breath to staff and was told (Resident B) was fine. Resident B's (family member) indicated the resident and family alerted staff multiple times throughout his stay that his ankles and feet were more swollen than usual and the family took the resident's recliner into him. The (family member) indicated he had never seen (Resident B) with that much swelling. Resident B's (family member) indicated (Resident B) called him [DATE] and indicated to him that he had spent the previous 2 nights and 3 days sitting up in his wheelchair and not in his recliner due to shortness of breath. The (family member) indicated, He (Resident B) said, 'I felt like I was going to drown if I laid back (in my recliner).' Resident B's (family member) indicated he was not notified by the facility of (Resident B's) additional increased swelling and increasing shortness of breath [DATE] through [DATE]. He indicated (Resident B) called him related to his decline and he requested his physician be called and he be sent to the emergency room for evaluation on [DATE]. Resident B's primary care physician was interviewed on [DATE] at 11:45 a.m. He indicated his records did not indicate that he had been notified of any changes in the resident's condition until he was called on [DATE] when the facility called because family was requesting the resident be sent to the emergency room for evaluation. The physician indicated that monitoring for fluid overload would include observing for increased swelling, shortness of breath, and weight gain. The physician indicated he would expect to be notified of a 5 pound weight gain in one day. Resident B's Skilled Charting - Admission Assessment, dated [DATE] at 11:22 p.m., indicated the resident was alert and oriented to person, place, time and situation, did not have difficulty sleeping at night, did not use oxygen, denied shortness of breath, and did not have anxiety present. The assessment indicated Resident B's respirations were regular and unlabored, he did not have a cough, and lung sounds were clear in all fields. The resident had 1 + [MEDICAL CONDITION] in his left and right lower extremities. The resident had a Foley catheter and no urinary symptoms. The resident denied pain. Initial Nutrition Plan of Care indicated, observe weight .daily .Vitals: Pulse: 67/per minute. Respirations: 20/per minute. Blood Pressure: ,[DATE]. O2 Saturation: 95%. Activity: Resting .Oxygen Use: No Resident B's Hospital Nephrology Discharge Note, dated [DATE], indicated, .Chronic SOA (shortness of air) - (at) baseline. Chronic LE (lower extremity) swelling - states at baseline .ext (extremities) trace BLE ([MEDICAL CONDITION] bilateral lower extremities) .hesitant to start .diuretic for now, but should he develop sig (significant) [MEDICAL CONDITION] or worsening breathing, a loop diuretic could be restarted Resident B's skilled nursing assessment documentation from [DATE] through [DATE] routinely indicated the resident was on a diuretic and had no side effects as a result of that diuretic. Resident B's Physician order [REDACTED]. Once a day; p.m .Fluid restriction of 1500 ml per day .Foley cath output every shift Resident B's Vitals Report indicated his intake of fluids was 1840 ml fluids on [DATE]. Resident B's Urine Output Record indicated the following: [DATE]: 1,725 mL + Large [DATE]: 1,200 mL + Large [DATE]: 1,050 mL [DATE]: 850 mL [DATE]: 850 mL [DATE]: 725 mL There was no evidence in the clinical record from [DATE] through [DATE] that the physician was notified of the decreased urine output. Physician's Progress Notes for Resident B, signed by the resident's primary care physician (PCP), dated [DATE] at 4:15 p.m., indicated, .breathing at baseline .Lungs - CTA (clear to auscultation) B (bilaterally) .Ext (extremities) - 2+ [MEDICAL CONDITION] on R (right), 1+ ([MEDICAL CONDITION]) on L (left) .[MEDICAL CONDITION] - stable - monitor for fluid overload. Daily weights. Resident B's admission weight, dated [DATE] at 11:22 p.m., was 238.4 pounds. There were no weights recorded for [DATE], 14, 15, 16, 17 or 21, 2015; 7 of the 27 days he was at the facility. Resident B experienced a 5.2 pound weight gain between [DATE] and [DATE]. Resident B experienced an additional 1.4 pound weight gain on [DATE]; which totaled a 6.6 pound weight gain in 2 days. The resident experienced a 4 pound weight gain between [DATE] and [DATE]. Vitals Report, dated [DATE] at 11:07 a.m., indicated, Weight: 244.2 lbs (in red) .Acceptable Range: 5 percent change in weight in 30 days. There was no evidence in the clinical record that the recorded weights were re-checked, associated assessments were competed, the physician was notified, or a change of condition/event was initiated. A Progress Note for Resident B, dated [DATE] at 4:35 a.m., indicated, .He c/o (complaint of) SOB at 0300 (3:00 a.m.). I tried to talk to him to calm him down, cracked his window, turned up his oxygen from 2.0 (L) to 2.5 (L) to 3.0 (L), tried repeatedly to have him do pursed lip breathing. At 0330 (3:30 a.m.) I gave PRN (as needed) [MEDICATION NAME] inhilation (sic) therapy. Resident still c/o (complained of) short of breath and O2 sat at 92%. Resident refused to use face mask while having shortness of breath and (had) rapid mouth breathing. I had to walk him through the pursed lip breathing several times. Increased the O2 to 3.5L via nasal canula (sic). Resident is very anxious .has not slept all night. There was no evidence in the Progress Notes or anywhere in the clinical record of resident B's respiratory status being assessed (lung sounds), shortness of air, or [MEDICAL CONDITION] being assessed, or the physician or family being notified on [DATE], [DATE] or ,[DATE], 2015. On [DATE] at 12:06 a.m., Resident B's vital signs indicated, Respirations: 24/minute. O2 Saturation: 90% (in red) (acceptable range: ,[DATE]%). Activity: Resting .Oxygen Use: Yes - Liter flow: 2. Respirations: 24/minute Type: Mouth. Describe: Rapid. A Progress Note for Resident B, dated [DATE] at 12:44 a.m., indicated, Resident frequently c/o shortness of breath. He recuses (sic) to sit up in his chair because he doesn't want his feet to be unelevated. The window will be cracked open to help with the feeling of air circulation to help calm his nerves .the resident is often confused with his [DIAGNOSES REDACTED]. On [DATE] at 2:00 a.m., Resident B's vital signs indicated, Blood Pressure ,[DATE] mmHg (in red) (acceptable range: ,[DATE] mmHg/,[DATE] mmHg). Pulse: 68. Bounding. 02 Saturation: 91%. Activity: Low .Oxygen Use: Yes - Liter flow: 3.5. Respirations: 32/minute (in red) (Acceptable Range: ,[DATE] per minute). Activity: Low. Type: Mouth. Describe: Rapid. A Progress Note for Resident B, dated [DATE] at 2:07 a.m., indicated, Resident is currently on 3.5 l (liters) O2 (oxygen). C/O SOB (shortness of breath), refused initial breathing tx (treatment) and inhailer (sic). After attempted deep breathing and pursed lip breathing exercise resident was unable to perform, he requested to sit up in his wheel chair. Once he moved to wheel chair his SOB increased .He has very high anxiety when these episodes occur and has a (sic) increase in his BP (blood pressure) and increase in respirations as well. The following vital signs, dated [DATE] at 8:04 p.m., indicated, Blood Pressure ,[DATE] mmHg. Pulse: 66. 02 Saturation: 95%. Resting. Oxygen Use: Yes - Liter Flow: 3.5 Liter. Activity: Low. Respirations: 26/minute. Resting. There were no Progress Notes, Events, or other evidence in the record to indicate that additional assessments related to Resident B's respiratory status and/or [MEDICAL CONDITION], follow up, or physician notification were completed. A Progress Note for Resident B, dated [DATE] at 7:48 p.m., indicated, Res.(resident) c/o SOB (shortness of breath), SpO2 recorded at 88%/3L/NC (liter/nasal cannula). Assessment revealed oxygen tubing had beside (sic) table sitting on it, Resident's w/c was also parked on top of and crushing the oxygen tubing. Additionally the oxygen line had become completely separated the water trap by the w/c rolling over it .new tubing installed .saturations hold steady at 95% A Progress Note for Resident B, dated [DATE] at 7:58 p.m., indicated, Res. stated he feels like I need to go to the hospital. Res. spoke with (family member) on the phone and states his (family member) is on the way here. Assessment completed (See vitals). There was no evidence of an assessment related to this Progress Note anywhere in Resident B's record. A Progress Note for Resident B, dated [DATE] at 8:21 p.m., indicated, Res POA (family member) arrived at the facility .POA states he wants the resident to go to the ER (emergency room ) .N.O. (new order) .to send to .ER for eval and Tx. There was no evidence of, and facility staff were unable to provide any evidence of skilled charting or nursing assessments for Resident B on [DATE] or 25, 2015 or [DATE] or 5, 2015. Daily skilled nursing assessment documentation routinely did not address/left blank [MEDICAL CONDITION] and/or lung sounds. There were no additional events or progress notes related to resident assessment of lung sounds, [MEDICAL CONDITION], or physician notification. The last documented breath sounds for Resident B were [DATE] at 11:09 a.m., which indicated, CTA (clear to auscultation). Resident B's Emergency Medical Services (EMS) Ambulance Report, dated [DATE], indicated they were dispatched at 8:38 p.m., arrived at the facility at 8:42 p.m., and arrived at the Emergency Department at 9:04 p.m. The report indicated, Pt (patient) is shorter of breath than normal .pt with obvious [MEDICAL CONDITION] globally .Respiratory: Effort: Distressed. Sounds: L: Diminished bases. R: Diminished bases. Oxygen: 3.5 lpm via NC Healthcare Provider (facility) EMS records indicated the resident did not receive any intravenous fluids or diuretic medication en route to the Emergency Department. Resident B's emergency room Record, dated [DATE] at 9:10 p.m., indicated, CC (chief complaint): (up arrow) SOB, [MEDICAL CONDITION] x 3 days. Location: chest/respiratory .Severity: severe. Duration: last ,[DATE] days. Timing: Constant .Associated signs: leg swelling .CXR (chest x-ray): [MEDICAL CONDITION] .Diagnosis; exacerbation [MEDICAL CONDITION], CRF A Hospital Emergency Department Primary Nursing Assessment for Resident B, dated [DATE], indicated, .Respiratory: Labored, Dyspnea,Increased rate, Cough - moist/nonproductive. Breath sounds: Left: Rhonchi, wheezing. Right: Rhonchi, wheezing .Peripheral [MEDICAL CONDITION]: Feet, Ankles 4+ .Neurological: Alert. Oriented x 3. Anxious .Nursing Problem List: 1. SOB (shortness of breath). 2. [MEDICAL CONDITION] .2106 (9:06 p.m.) pt sent from (facility) .increased SOB, along with [MEDICAL CONDITION] for 3 days, report states it is increasingly getting worse. Pt. has 4+ [MEDICAL CONDITION] Resident B's Hospital history and physical examination [REDACTED].He presented to the emergency department with significant shortness of breath and tight lungs. He was admitted with an exacerbation of his [MEDICAL CONDITION] and [MEDICAL CONDITION], [MEDICATION NAME], and states he is starting to feel better already Resident B's Cardiology Consultation (Hospital 1), dated [DATE], indicated, .The patient had been doing relatively well and participating in rehab at (facility). In the last 3 to 4 days, he started having some increasing shortness of breath and noted some ankle swelling. Yesterday, he became orthopneic with PND ([DIAGNOSES REDACTED] nocturnal dyspnea) and had shortness of breath at rest .came to the emergency department where he was found to have evidence of heart failure. He has received IV (intravenous) [MEDICATION NAME] and is already feeling improved Hospital 1 documentation indicated the resident required on-going Nephrology consultation/care and was transferred/admitted to Hospital 2 on [DATE]. Resident B's Clinical Documents Progress Note (Hospital 2), dated [DATE], indicated, .History of present illness: .recently here .between the dates of [DATE] through [DATE] for acute kidney injury superimposed on [MEDICAL CONDITION]. He also had issues with systolic heart failure during that time. On discharge .as (renal function) improved patient gradually developed worsening weight gain and fluid retention. He presented to (Hospital 1) ,[DATE] (sic)/2015 and was [MEDICATION NAME] .Unfortunately with aggressive diuresis at that time his creatinine continued to steadily increase .Assessment/Plan: 1. Acute kidney injury on [MEDICAL CONDITION] stage ,[DATE]. This is most likely in relation to requirements for aggressive diuresis in light of his issues with [MEDICAL CONDITION] exacerbation .2. Acute exacerbation on chronic systolic [MEDICAL CONDITION] Nephrology Clinical Consultation (Hospital 2), dated [DATE], indicated, .Assessment/Plan: .had diuresis just over 2L (at Hospital 1) given his fairly massive volume expansion Acutely decompensated systolic [MEDICAL CONDITION]. Resident B was discharged to Hospice on [DATE] and expired [DATE]. Discharge [DIAGNOSES REDACTED]. Acute kidney failure, unspecified. 2. Acute on chronic systolic ([MEDICAL CONDITION]. 3. [MEDICAL CONDITION] with (acute) exacerbation Licensed Practical Nurse (LPN) # 2 was interviewed on [DATE] at 3:06 p.m. He indicated he cared for Resident B periodically and was on duty on [DATE] when Resident B was sent to the Emergency Department. LPN # 2 indicated, (Resident B) was just not doing good .he wasn't in good condition. He had swelling issues. LPN # 2 indicated, If (a resident's) sats are not doing well, we (nursing) would put on our report sheet and in (resident) progress notes. LPN # 2 indicated daily assessments and documentation were based on the resident's primary admitting [DIAGNOSES REDACTED].# 2 indicated the physician would order parameters regarding notification. The LPN indicated, If the weight exceeds the parameters, I would send a fax .unless it says call. LPN # 2 indicated, The staff would catch a 5 pound weight gain in a day .if there's a change (in resident condition) from the norm, I don't know if that would be an event, but I would let somebody know. I would just do a progress note. The Interim Director of Health Services (DHS) and the Assistant Director of Health Services (ADHS) were interviewed on [DATE] at 4:12 p.m. The Interim DHS indicated that Resident B was being assessed related to his [MEDICAL CONDITION] because that was his admitting diagnoses. The ADHS indicated nursing staff would be charting on the renal [DIAGNOSES REDACTED]. The DHS indicated all residents were assessed daily related to their primary admitting [DIAGNOSES REDACTED]. She indicated orthopedic assessments did not include assessments of [MEDICAL CONDITION], breath sounds, or respiratory status. Both the DHS and ADHS indicated there were no policies or procedures related to monitoring for fluid overload, monitoring for changes in condition, documentation or assessment and that they relied on best (nursing) practices. The Director of Health Services (DHS) was interviewed on [DATE] at 1:50 p.m. regarding expectations for monitoring for fluid overload. The DHS indicated there was no policy and procedure related to [MEDICAL CONDITION], monitoring for fluid overload, [MEDICAL CONDITION], or [MEDICAL CONDITION]. The DHS indicated, Just monitor their intake and [MEDICAL CONDITION]. That's what I would do. On [DATE] at 4:25 p.m., the DHS indicated she probably would not document an event or change in condition for a weight change. The DHS indicated the facility relied on best practices to direct nursing staff when to do assessments, under what category to document them, and when to notify the physician of changes. The Assistant Director of Health Services (ADHS) was interviewed on [DATE] at 4:31 p.m. regarding the policy and procedure related to documenting and reporting changes in condition, events, and monitoring for fluid overload. She indicated there were no policies and procedures. The ADHS indicated, That's nursing judgement whether to do an event, a change in condition, or a progress note. On [DATE] at 12:31 p.m., the Chief Nursing Officer (CNO) provided a current copy of (facility) Guide to Event Notification Critical Thinking. She indicated that when changes in condition are observed, an event is initiated. She indicated that artificial intelligence indicated to the nursing staff when to notify the physician. The CNO indicated a section of the document which was circled and indicated the residents reviewed did not meet any of the criteria related to [MEDICAL CONDITION]. The circled documentation indicated, New Onset [MEDICAL CONDITION] Event. Notification Guidelines. Notify MD/NP immediately .for any of the following .Abrupt pt onset of [MEDICAL CONDITION] in one leg with loss of sensation. Abrupt onset [MEDICAL CONDITION] with tenderness and redness. [MEDICAL CONDITION] with sudden onset of shortness of breath, and/or chest pain. The notification guideline not circled by the CNO indicated, Weight gain of 3 or more pounds in last 7 days. On [DATE] at 10:06 a.m., the CNC indicated the facility did not have a specific policy or procedure related to change in condition. The CNC provided a current copy of (Facility) Guide to Events, which was reviewed at that time. The document indicated, .Category of Observation: Cardiovascular. Event Name: .New Onset [MEDICAL CONDITION]. Possible Reasons: Increased Or New [MEDICAL CONDITION] .Category of Observation: .Other Events: .Event Name: Other Physical Changes in Condition: Possible Reasons: Non-specified physical changes .Category of Observation: Respiratory/EENT: Event Name: Respiratory: Possible Reasons: Breathing/Respiration Changes . On [DATE] at 4:15 p.m., the ADHS was queried regarding the new onset/new documentation of Resident B's 3 + [MEDICAL CONDITION] on [DATE] at 1:45 p.m. (above) and why event/change in condition documentation was not initiated or the physician notified of the change. The ADHS indicated, It ([MEDICAL CONDITION]) depends on other factors. It could just be the time of day. On [DATE] at 4:25 p.m. the ADHS and DHS provided a copy of the current Guidelines for Weight Tracking Policy and Procedure and it was reviewed at that time. They indicated there were no additional policies or procedures related to weight tracking and/or specific to [MEDICAL CONDITION] and/or respiratory diagnoses. The Procedure indicated, .6. The weight should be recorded in the individual resident medical record. 7. Residents who have a weight that seem (sic) out of normal range shall be re-weighed to determine the accuracy of the original weight . On [DATE] at 4:36 p.m., the ADHS provided a copy of the current Physician Notification of Diagnostic Testing and Change in Condition Policy and Procedure and it was reviewed at that time. The document indicated, Purpose: To ensure the .physician is aware of all .change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care. Procedure: 1. Resident assessments for change in condition .should be completed in a timely manner. 2. The physician should be notified of .an immediate need by phone as soon as the results are known 10. Attempts to notify the physician and their response should be documented in the resident record 2. Resident F ' s Admission Nursing Assessment, dated [DATE] at 6:29 p.m., indicated, Cardiovascular: [MEDICAL CONDITION] present: Yes. Location of [MEDICAL CONDITION]: (blank). Left leg [MEDICAL CONDITION]: (blank). Right leg [MEDICAL CONDITION]: (blank) .Comments: (blank). Initial Cardiovascular Plan of Care: .Assess vital signs q (every) - 8 (hours). Administer medications per physician order [REDACTED].[MEDICAL CONDITION] chronic. Initial Infectious Disease Plan of Care: Observe vital signs per protocol .Implement isolation precautions per protocol. Administer medications per physician order. A Care Plan for Resident F indicated, Problem: I have [MEDICAL CONDITION] .Approach: .Isolation precautions to be taken for [MEDICAL CONDITION]. Follow protocol. Discipline (responsible): Administrative .Medical Records, Nursing. A Progress Note for Resident F, dated [DATE] at 3:45 p.m., indicated, admitted .alert (and) oriented x 3, mood pleasant Resident F, who was admitted [DATE] at 3:45 p.m., had no vital signs documented until [DATE] at 3:55 a.m. Resident F ' s Event - Change In Physical Condition Circumstance dated [DATE] at 9:49 p.m., indicated, Describe change in condition: admitted with 2+ - 3+ [MEDICAL CONDITION] to BLE (bilateral lower extremities) .Treatments: CHANGE IN CONDITION CIRCUMSTANCE: Follow up monitoring and vital signs x 72 hours or until resolved. On [DATE] at 3:55 a.m., Resident F's Vitals Report indicated, Blood Pressure: ,[DATE] mmHg (in red) (Acceptable Range: ,[DATE] mmHg / ,[DATE] mmHg). There were no Progress Notes, events, changes in condition, or physician notification associated with this abnormal value. The next blood pressure assessment was not until [DATE] at 7:07 p.m. A Progress Note for Resident F, dated [DATE] at 1:20 p.m., indicated, New order received .to send Resident to ER to be evaluated for decreased appetite and difficulty swallowing. Family member .very concerned about Resident's current state of health and would like her sent to ER for eval (evaluation). A Progress Note for Resident F, dated [DATE] at 6:20 p.m., indicated, resident returned from emergency room with peripheral IV (PIV) in left wrist. no s/s (signs/symptoms) infiltration noted. has normal saline running at 100 cc per hour for dehydration .is oriented to person and place. alert. asking for television to be turned on the news .non[MEDICAL CONDITION] noted in both hands. ,[DATE]+ [MEDICAL CONDITION] noted in bilateral legs The following Progress Note, dated [DATE] at 3:30 a.m., indicated, .[MEDICAL CONDITION] continues The following Progress Note, dated [DATE] at 6:46 a.m., indicated, Res. on IV .w/o issue until approx. (4:15 a.m.) at a bed check. noted cool, puffiness to L (left) bicep. IV was turned off. Site checked for blood return w/o result. Res c/o burn at placement site .Oncoming nurse was notified that the IV was shut off shortly after 0400 and was unable to determine a possible site or attempt a stick d/t incontinent episode. There was no documentation anywhere in Resident F's clinical record to indicate Resident F's left upper extremity was assessed following the [DATE] at 6:46 a.m. progress note. Resident F's Progress Note, dated [DATE] at 9:30 a.m., indicated, Speech therapist at the bedside trying to feed resident breakfast, Resident not waking up to eat. Resident F's Progress Note, dated [DATE] at 10:40 a.m., indicated, Resident not responding to family. Vital signs P - 62. B/P - ,[DATE]. O2 - 94%. A Progress Note, dated [DATE] at 11:32 a.m., indicated, Resident sent to ER per family request. There was no documentation anywhere in Resident F's clinical record to indicate the physician was notified related to the resident's decreased level of consciousness, increased [MEDICAL CONDITION], the PIV infiltration, or when the PIV was discontinued. A Progress Note for Resident F, dated [DATE] at 3:30 p.m., indicated, [MEDICAL CONDITION] continues with no draining or open areas The following Progress Note for Resident F which related to [MEDICAL CONDITION] was dated [DATE] at 5:28 a.m., and indicated, .third spacing (unusual accumulation of fluid in a transcellular space) continues w/ ,[DATE] + [MEDICAL CONDITION] to BLE, hips, and even in places in her BUE (bilateral upper extremities) . There was no evidence that Resident F ' s physician was notified of the [MEDICAL CONDITION]. On [DATE] at 3:25 p.m., CNA # 14 indicated that, prior to this date, Resident F normally helped roll and assisted with bathing and/or incontinent care and was awake and alert. CNA # 10 was interviewed on [DATE] at 9:50 a.m. She indicated, (Resident F has) been in the hospital. They sent her out yesterday because she was unresponsive. She had an IV for dehydration, but it wasn't working. It caused her to swell up like a balloon Resident F's (family member) and POA was interviewed on [DATE] at 3:35 p.m. She indicated, I kept telling them she's not eating, she's got this swelling in her legs, but nobody's responding to me .My (family member) came in around ten (10:00) a.m. said she (Resident F) was unresponsive. My (family member) said the nurse told her that when she cleaned her up earlier that morning she wasn't waking up or responding and they said she had been like that on night shift I'm here all the time. I live so close. I just don't understand why they wouldn't have called me. Resident F's (family member) indicated it was unusual for her mother to be unresponsive. She indicated, She's usually very feisty. On [DATE] at 5:10 p.m. The ADON, DON, Executive Director (ED) indicated they were not aware Resident F had been unresponsive or her IV had infiltrated. On [DATE] at 5:37 p.m., the ADHS indicated she had just gotten off the phone with RN # 7, who cared for Resident F the morning the resident went to the Emergency Department on [DATE]. The ADHS indicated the resident was sleeping normally when the nurse checked on the resident and the resident was at baseline. Registered Nurse (RN) # 7 was interviewed on [DATE] at 11:35 a.m. She indicated she worked day shift [DATE] and was assigned as Resident F's nurse that day. RN # 7 indicated she came on duty at 6:00 a.m., and first encountered Resident F at approximately 7:00 a.m. She indicated, When I went in that morning, she didn't respond when I turned and changed her. She wouldn't move her arms or help us turn her. The report I got was that she wasn't helping them (night shift) either .I assumed it (level of consciousness) was the same as when she was admitted . I knew her IV had infiltrated .there was pooling in that arm. There was third spacing .fluid filled .puffy. I called the doctor's office and left a message and she said she'd get back to me and she never did .I probably should have called the on-call .Her swelling was terrible .a lot of third spacing .her legs, her feet, all over. Her skin was cool I would just chart it (change of condition) under Progress Notes. Resident F was interviewed on [DATE] at 11:50 a.m. She was observed to be awake and alert, but hard of hearing. When queried as to how she felt, she indicated, Better. RN # 11 was interviewed on [DATE] at 2:00 p.m. regarding assessing residents with [MEDICAL CONDITION] and [MEDICAL CONDITION] who were at risk for fluid overload. RN # 11 indicated, I wouldn't listen to lungs everyday, but I would check swelling and temperature. 3. Resident E was interviewed on [DATE] at 3:12 p.m. The resident was observed wearing cotton athletic socks and open sandals with 3+ [MEDICAL CONDITION] in his bilateral lower ankles and feet. He was sitting up with his legs (hanging down) in his wheelchair. The resident indicated he had occasional lower extremity [MEDICAL CONDITION]/swelling at baseline, but worsening [MEDICAL CONDITION] since he had been in the facility. The resident indicated he had notified staff he was concerned regarding his increased [MEDICAL CONDITION] in recent weeks. Resident E's clinical record was reviewed on [DATE] at 11:10 a.m. [DIAGNOSES REDACTED]. The resident was admitted on [DATE] for rehabilitation following spinal surgery. Admission MDS assessment, dated [DATE], indicated a BIMS score of 15; indicating he was cognitively intact. The resident had no behaviors and did not reject care. The resident required extensive, 2+ physical assist for transfers and bed mobility. Resident E's Admission Nursing Assessment, dated [DATE], indicated, [MEDICAL CONDITION] present: Yes. Location of [MEDICAL CONDITION]: (blank). Left leg [MEDICAL CONDITION]: (blank). Right leg [MEDICAL CONDITION]: (blank) .Vitals: Pulse: 96/per minute. Respirations: 18 per minute. Blood Pressure: ,[DATE] mmHg There was no evidence in Resident E's clinical record that he had a care plan related to [MEDICAL CONDITION]. A Care Plan, initiated [DATE], indicated, Problem: High Risk Medications. I have potential for decreased cardiac output. Goal: My blood pressure will be maintained within normal limits. Approach: .Please monitor my blood pressure as indicated. Please observe for signs of symptoms of elevated blood pressure LPN # 16 was interviewed on [DATE] at 3:15 p.m. at Resident E's bedside. She touched resident E's foot lightly over his socked foot and indicated his [MEDICAL CONDITION] was, 3+ pitting. LPN # 16 indicated the resident had [MEDICAL CONDITION] since admission and it starting getting worse approximately two weeks ago. LPN # 16 indicated a form had been sent in to Resident E's physician to notify him/her of the resident's change in condition that day. LPN # 16 indicated that nursing staff assisted Resident E to elevate his legs during the day, pointing to a bench against the wall. During an interview on [DATE] at 3:06 p.m., Resident E indicated he was not encouraged or assisted to elevate his legs during the day and that the [MEDICAL CONDITION] in his bilateral lower extremities had become progressively worse in recent weeks. The resident indicated he had pain and tingling related to the [MEDICAL CONDITION]. During multiple random observations throughout the survey, including [DATE] at 9:59 a.m. [DATE] at 3:12 p.m., [DATE] at 3:06 p.m., and [DATE] at 11:15 a.m., Resident E was observed to have 3+ [MEDICAL CONDITION] in his bilateral lower ankles and feet, with his legs dependent (hanging down) in his wheelchair. There was no evidence in the clinical record that Resident E's lower extremity [MEDICAL CONDITION] was fully assessed or monitored, or that the physician was notified of changes. There were no events or changes in condition related to Resident E's [MEDICAL CONDITION]. Resident E did

Based on observation, record review and interview, the facility failed to provide nursing assessments, physician notification of significant change in condition, and follow physician's orders [REDACTED]. This failure resulted in a delay in medical care and hospitalization for 1 resident (Resident B), and the delay in medical care for 4 residents (Residents C, D, E, and F). This Immediate Jeopardy began on 11/21/2015 when the facility failed to assess vital signs for a period between 11/20/2015 at 9:37 a.m. and 11/22/2015 at 6:51 a.m. and a 5.2 pound weight gain between 11/22/2015 and 11/23/2015 was not reported to the physician and was identified on 6/10/2016. The Executive Director, Assistant Director of Health Services, the Interim Director of Health Services, Clinical Support RN # 1, Clinical Support RNA# 2, and the Medical Records Coordinator were notified of the Immediate Jeopardy at 1:42 p.m. on 6/10/2016. The Immediate Jeopardy was removed on 6/11/2016, but noncompliance remained at the lower scope and severity pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B's closed clinical record was reviewed on 6/8/2016 at 11:10 a.m. [DIAGNOSES REDACTED]. Resident B was admitted to the facility on [DATE] for rehabilitation following hospitalization for acute on (top of) chronic renal injury related to [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident was discharged 26 days later on 12/6/2015. Resident B's admission Minimum Data Set (MDS) assessment, dated 11/17/2015, indicated a Brief Interview for Mental Status (BIMS) score of 14; indicating he was cognitively intact. The resident had no behaviors and did not reject care. The resident required extensive, 2+ person physical assist for transfers and was non-ambulatory. The resident had an indwelling Foley catheter and received oxygen therapy. Hospital Extended Care Admitting Orders for Resident B, dated 11/10/2015 at 2:15 p.m., indicated, .Diet: 1500 ml (milliliter) fluid (restriction) .No Longer Take the following medications: [REDACTED].Discharge Instructions/Patient Education Materials: .weigh yourself every day, at the same time of day, and in the same kind of clothes. When to call your doctor: Call your doctor right away if you have any of these signs of worsening heart failure: sudden weight gain (more than 2 pounds in 1 day or 5 pounds in 1 week, or whatever weight gain you were told by your doctor). Trouble breathing related to not being active. New or increased swelling in your legs or ankles .Breathing trouble at night Resident B's Hospital Nephrology Discharge Note, dated 11/10/2015, indicated, .Chronic SOA (shortness of air) - (at) baseline. Chronic LE (lower extremity) swelling - states at baseline .ext (extremities) trace BLE ([MEDICAL CONDITION] bilateral lower extremities) .hesitant to start .diuretic for now, but should he develop sig (significant) [MEDICAL CONDITION] or worsening breathing, a loop diuretic could be restarted Resident B's Physician order [REDACTED]. Once a day; p.m .Fluid restriction of 1500 ml per day .Foley cath output every shift Resident B's written physician's orders [REDACTED]. There was no evidence in the clinical record of physician's orders [REDACTED]. Resident B's Skilled Charting - Admission Assessment, dated 11/10/2015 at 11:22 p.m., indicated the resident was alert and oriented to person, place, time and situation, did not have difficulty sleeping at night, did not use oxygen, denied shortness of breath, and did not have anxiety present. The assessment indicated Resident B's respirations were regular and unlabored, he did not have a cough, and lung sounds were clear in all fields. The resident had 1 + [MEDICAL CONDITION] in his left and right lower extremities. The resident had a Foley catheter and no urinary symptoms. The resident denied pain. Initial Nutrition Plan of Care indicated, observe weight .daily .Vitals: Pulse: 67/per minute. Respirations: 20/per minute. Blood Pressure: 146/77. O2 Saturation: 95%. Activity: Resting .Oxygen Use: No A Care Plan for Resident B indicated, Problem Start Date: 11/23/2015. I am at risk for alteration in fluid balance related to my having a fluid restriction and my [DIAGNOSES REDACTED]. Approach Start Date: 11/23/2015. Assist with fluids as needed .Observe me for s/s (signs/symptoms) fluid overload such as [MEDICAL CONDITION], distended neck veins, [MEDICAL CONDITION]. Notify my MD as needed .Weigh resident as ordered. A Care Plan for Resident B, initiated 11/23/2015, indicated, Problem: I have a [DIAGNOSES REDACTED].Approach: Administer oxygen as ordered. Monitor me for fluid excess, wt. gain, increased BP, full/bounding pulse, jugular vein distention, SOB (shortness of breath), rales, rhonchi, wheezing, [MEDICAL CONDITION], worsening of [MEDICAL CONDITION], increased urinary output .Monitor my weight per current order and notify physician as needed .Please monitor me and report signs of respiratory distress, cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse. Please monitor my intake of food and fluids A Care Plan for Resident B, initiated 11/23/2015, indicated, Problem: I have [MEDICAL CONDITION]/[MEDICAL CONDITION] .Approach: My care givers will monitor my lung sounds daily. My care givers will observe me for changes in my breathing or level of consciousness and report to my doctor Physician's Progress Notes for Resident B, signed by the resident's primary care physician (PCP), dated 11/11/2015 at 4:15 p.m., indicated, .breathing at baseline .Lungs - CTA (clear to auscultation) B (bilaterally) .Ext (extremities) - 2+ [MEDICAL CONDITION] on R (right), 1+ ([MEDICAL CONDITION]) on L (left) .[MEDICAL CONDITION] - stable - monitor for fluid overload. Daily weights. A Progress Note for Resident B, dated 11/21/2015 at 1:45 p.m., indicated, Resident has 3+ swelling to bilateral feet, Resident in recliner with feet elevated. A Progress Note for Resident B, dated 11/22/2015 at 11:41 p.m., indicated, Resident continues to have bilateral lower leg [MEDICAL CONDITION] . There were no additional assessments, events, or physician notification related to these progress notes dated 11/21-22/2015. Resident B's admission weight, dated 11/10/2015 at 11:22 p.m., was 238.4 pounds. There were no weights recorded for November 11, 12, 14, 15, 16, 17 or 21, 2015; 7 of the 27 days he was at the facility. Resident B experienced a 5.2 pound weight gain between 11/22/2015 and 11/23/2015. Resident B experienced an additional 1.4 pound weight gain on 11/24/2015; which totaled a 6.6 pound weight gain in 2 days. The resident experienced a 4 pound weight gain between 12/3/2015 and 12/4/2015.

Based on observation, interview and record review, the facility failed to ensure the privacy and dignity within a reasonable person expectation for 2 of 5 residents reviewed this deficient practice caused harm in one resident (Resident F). (Resident F's) door was open with the resident's bare feet and soiled linens on the floor visible from the hallway. Upon entering the doorway, (Resident F) was observed completely exposed, except for an adult brief. The resident's arms were crossing her chest to cover her breasts. (Residents E and F). Findings include: 1. During an observation on 6/9/2016 at 3:24 p.m., Resident F's door was observed to be open with a large pile of sheets, gowns, towels, and disposable incontinence pads, soiled with a brown, wet, foul-smelling substance on the carpeted floor at the foot of the bed. Resident F's bare feet were visible from the doorway. A bare,blue pillow was on the floor partially on top of the pile of soiled linens. Upon entering the doorway, Resident F was observed to be alone in the room, with the air mattress in the high position, legs apart, completely exposed except for an adult brief. The resident's arms were crossing her chest to cover her breasts. At 3:25 p.m., CNA #14 entered the room and indicated, My nurse was just in here. CNA # 14 indicated she left the room to answer a call light across the hall. Resident F's Admission Assessment, dated 6/5/2016 at 6:29 p.m., indicated, .Staff assist with transfer: 2 person facility staff assist .Responsiveness: Responds to commands. Level of consciousness: Alert. Oriented to: Person and Place . Resident F's clinical record was reviewed on 6/9/2016 at 2:45 p.m. [DIAGNOSES REDACTED]. Resident F was admitted to the facility on [DATE] following hospitalization for a fecal transplant. The resident was admitted to Hospice on 6/9/2016. Resident F was interviewed on 6/10/2016 at 11:50 a.m. She was observed to be awake and alert, but hard of hearing. When queried as to how she felt, she indicated, Better. 2. During an observation on 6/8/2016 at 3:12 p.m., Resident E was observed self-propelling in his wheelchair down the main hallway of the facility with his urinary catheter bag partially full of urine, exposed, and dragging on the floor under his wheelchair. The resident was assisted to his room by the Executive Director moments later and was interviewed at that time. The resident indicated he did not recall having a privacy bag for his catheter. On 6/9/2016 at 3:06 p.m., the resident was observed with his catheter tubing and bag exposed hanging on the back of his wheelchair. On 6/9/2016 at 10:20 a.m., Physical Therapist # 6 indicated Resident E required two person assist for transfers to and from his wheelchair. Resident E's clinical record was reviewed on 6/9/2016 at 11:10 a.m. [DIAGNOSES REDACTED]. The resident was admitted on [DATE] for rehabilitation following spinal surgery. Admission Minimum Data Set (MDS) assessment, dated 2/27/2016, indicated a Brief Interview for Mental Status (BIMS) score of 15; indicating he was cognitively intact. The resident had no behaviors and did not reject care. The resident required extensive, 2+ physical assist for transfers and bed mobility. The resident had a Foley catheter. A copy of the current Guidelines for the Use of Indwelling Catheter Policy and Procedure was provided by the Executive Director on 6/9/2016 at 10:41 a.m. The document indicated, A resident that does have a .catheter .all efforts should be made to maintain dignity by covering catheter bags, which may include utilizing the fig leaf (privacy) bag. A current copy of the current Resident Rights Policy and Procedure was provided by the Medical Records Coordinator on 6/8/2016 at 11:15 a.m. The policy indicated, .You have the right to personal privacy. THIS MEANS THAT: .2. When you are undergoing an examination or treatment, the staff should .maintains the privacy of your body (i.e., room door should be closed, privacy curtain should be pulled around the bed, etc.) .4. You should be granted privacy when going to the bathroom and in other activities of personal hygiene. (Note: If you need assistance, the staff should still respect your privacy.) This Federal tag relates to Complaint IN 175. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to immediately provide a resident with a wheelchair pressure relieving device who was at an increased risk for developing a pressure ulcer, resulting in a stage III coccyx pressure ulcer and a stage IV buttock pressure ulcer, for 1 of 3 resident's reviewed for pressure of 6 who met the criteria for pressure. (Resident #90) Findings include: Resident #90's record was reviewed on 10/17/14 at 1:20 p.m. Resident #90 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. An "Assessment Review and Considerations" for Resident #90 dated 8/28/14, indicated he was a potential risk for skin breakdown related to his mobility impairment and current medical [DIAGNOSES REDACTED]. A "Nursing Admission Assessment" for Resident #90 dated 8/28/14, indicated he had a post surgery chest incision. He had no pressure ulcers and had no history of skin impairment. He was at risk for developing pressure areas. He had a pressure relieving device to his bed. He was able to maintain his position in his bed and chair. He had no pain and was able to respond to pain/discomfort. The "Skin Plan of Care" documented on the form indicated the following: Resident #90 would be turned and repositioned for comfort with care. He would be provided a pressure relieving device to his bed. Consequences of refusal of treatment and/or prevention interventions would be explained. Staff would ensure adequate hydration. He would be provided vitamins and supplements per physician orders. He would be assisted with positioning in his bed and chair. He would be administered medications per his physician orders. His skin would be observed for signs of pain with skin condition. A "Skilled Charting Evaluation" for Resident #90 dated 8/29/14, indicated he had a surgical incision related to valve replacement for mitral valve insufficiency. He had no chest pain. He had no pressure ulcers. His oxygen saturation was 100% at rest. His facial color/flesh tones were normal and his nail beds were pink. A "Skilled Charting Evaluation" for Resident #90 dated 8/30/14, indicated he denied pain. He had no pressure ulcers. His oxygen saturation was 95% at rest. His facial color/flesh tones were normal and his nail beds were pink. A "Skilled Charting Evaluation" for Resident #90 dated 8/31/14, indicated he denied pain. He had no pressure ulcers. His oxygen saturation was 98% at rest. His facial color/flesh tones were normal and his nail beds were pink. A "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" dated 9/1/14, indicated Resident #90 had developed a pressure ulcer on his coccyx not present on admission. The pressure ulcer area measured 2 centimeters (cm) long by 1.5 cm wide. The area was red with no signs or symptoms of infection and surrounding tissue was intact. A "Change In Condition" for Resident #90 faxed to the physician on 9/1/14, indicated Resident #90 had developed a 2 cm long by 3 cm wide coccyx pressure ulcer and the nurse requested an order to apply [MEDICATION NAME] to the wound and change every 3 days. A "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" dated 9/2/14, indicated Resident #90's coccyx pressure ulcer had 3 different measurements including a red area measuring 10 cm long by 8 cm wide by 0.1 cm deep, a black/purple area measuring 6 cm long by 4.6 cm wide, by 0.1 cm deep, and a open area measuring 2 cm long by 1.5 cm wide by 0.1 cm deep. The wound margins were irregular and surrounding tissue was black/purple/red. The wound treatment was [MEDICATION NAME] and [MEDICATION NAME]. Preventive interventions were to turn and reposition him. There was pain at the wound bed. A "Skilled Charting Evaluation" for Resident #90 dated 9/2/14, indicated his chest incision was well approximated with no drainage and no chest pain. He had a pressure ulcer. His oxygen saturation was 92% at rest and his nail beds were pink. A "Change In Condition" for Resident #90 faxed to the physician on 9/2/14, indicated Resident #90's coccyx pressure ulcer was 10 cm by 8 cm, red and non-blanchable, with a purple black area in the center of that area that was 6 cm by 4.6 cm , with an open area in the center of that area that was black/purple. The nurse requested an order to add [MEDICATION NAME] to the [MEDICATION NAME] order. A "Skilled Charting Evaluation" for Resident #90 dated 9/3/14, indicated his chest incision was well approximated with no drainage and no chest pain. He had stage II coccyx pressure ulcer. His oxygen saturation was 98% at rest. His facial color/flesh tones were normal and his nail beds were pink. A "Skin Impairment Circumstance, Assessment and Intervention" for Resident #90 reviewed by the Interdisciplinary Team (IDT) on 9/3/14, indicated he had recent coronary artery bypass graft surgery. He did not have a history of skin impairment. He had developed a stage II pressure ulcer on his coccyx with suspected deep tissue injury. Pain was present. His treatment included [MEDICATION NAME] and [MEDICATION NAME] to the area. He was compliant with care plan interventions. He was compliant with turning and repositioning and/or treatment interventions. His prevention update indicated treatment had been implemented and to turn him. Resident #90's admission Minimum Data Set (MDS) assessment dated [DATE], indicated he was understood and had the ability to understand others. He was moderately impaired in his skills for daily decision making. He required extensive assistance of 2 plus persons for bed mobility, transfers, dressing, toileting, and hygiene. He had functional limitation his his range of motion in both of his lower extremities. He used a wheelchair for mobility. He was at risk for developing pressure ulcers. He had a surgical wound. His skin and ulcer treatment included a pressure relieving device for his bed and surgical wound care. He had participated in 255 minutes of Occupational (OT) Therapy and 245 minutes of Physical Therapy (PT). A physician's orders [REDACTED]. [MEDICATION NAME] would be applied and covered with a sacral [MEDICATION NAME] dressing. A "Skilled Charting Evaluation" form for Resident #90 dated 9/6/14, indicated he had no chest pain. He had stage II coccyx pressure ulcer. His oxygen saturation was 95% at rest. His facial color/flesh tones were normal and his nail beds were pink. A "Skilled Charting Evaluation" form for Resident #90 dated 9/10/14, indicated his surgical incision was well approximated with no drainage or chest pain. He had a stage III coccyx pressure ulcer. His oxygen saturation was 94% at rest. His facial color/flesh tones were normal and his nail beds were pink. A "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" dated 9/10/14, indicated Resident #90's stage III coccyx pressure ulcer measured 13 cm long by 10.2 cm wide by x 0.3 deep. There was pain. The wound bed was beefy red with slight yellow slough. The wound margin was irregular with red surrounding tissue. The treatment was [MEDICATION NAME] and [MEDICATION NAME]. Preventive interventions included an air loss mattress was ordered. Medical interventions included a Wound Clinic evaluation. A "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" dated 9/10/14, indicated Resident #90 had developed a right lower hip area pressure ulcer that was not present on admission. The pressure ulcer measured 5 cm long by 2.8 cm wide. The area was black/purple in color. There was pain. A physician's orders [REDACTED]. He would receive [MEDICATION NAME] 875 milligrams (mg) everyday for 10 days. He would be seen by the Wound Clinic. He would be turned every 2 hours. A "Change in Condition" for Resident #90 dated 9/10/14, indicated he had a new pressure area that was black/purple in color, located on his right lower hip next to his buttock. An order was requested for [MEDICATION NAME] and skin prep to be changed every 3 days and as needed. The area measured 5 cm by 2.8 cm. On 9/11/14, the physician's response to the "Change in Condition" faxed 9/10//14. He indicated he had seen the resident on 9/10/14, and had ordered for him to be seen at the Wound Clinic. A "Resident First Conference Notes" dated 9/10/14, indicated the following: Pressure reduction devices: mattress and cushion. A "Skin Impairment Circumstance, Assessment and Intervention" for Resident #90 reviewed by the IDT on 9/12/14, indicated he had a stage I pressure ulcer to his right lower hip next to his buttock. Other contributing factors indicated he did not like to lay down or turn side to side. His prevention update indicated a speciality surface for his bed (low air loss mattress), treatment had been implemented, moisture would be applied to keep his skin supple, fluids would be encouraged, and the Wound Clinic would evaluate and treat him. An OT Daily Treatment" note dated 9/15/14, indicated the following: "Patient with gel foam cushion replaced with (name brand) multi cell bladder cushion with increased disbursement of pressure for buttocks. Patient with multiple decubitis ulcers related immobility and unable to complete self pressure relief due to sternal precautions." An initial local "Wound Clinic History and Physical" note for Resident #90 dated 9/17/14, indicated he was wheelchair bound due to the inability to use his legs secondary to his [DIAGNOSES REDACTED]. His wound measurements indicated his coccyx pressure ulcer measured 5 cm long by 6.6 cm wide by 0.4 cm deep. His right buttock ulcer measured 2.5 cm long by 1.6 cm wide by 0.2 cm deep. The wounds were debrided. His Assessment/Plan indicated [MEDICATION NAME] would be used in the wounds. An Allevyn sacral pad would be placed over the sacral area and an ABD pad would be placed over the deeper wound on the buttock. A Wound Vac was ordered for the deeper wound, believed necessary for filling in the depth of the wound. He was encouraged to increase his nutrition and to offload the wounds. He was expected to do well. He would be seen for a followup in 1 week. A local "Wound Clinic Progress" note for Resident #90 dated 9/26/14, indicated his coccyx pressure ulcer measured 5 cm long by 5 cm wide by 0.1 cm deep. His right buttock ulcer measured 2.5 cm long by 3.2 cm wide by 0.7 cm deep. The wounds were debrided. His Assessment/Plan indicated he would continue the Wound Vac. He would need to offload the pressure ulcer areas. He should only be up in his wheelchair for meals approximately 45 minutes at a time. Otherwise he would need to be in bed and off of the areas. He would be seen for a followup in 1 week. A Skin Plan Of Care for Resident #90 indicated he had pressure ulcers present on his buttocks and coccyx related to impaired mobility. He was at risk for breakdown because of his [DIAGNOSES REDACTED]. His interventions included an air mattress on his bed to reduce the risk of further breakdown and to aide in healing his wound. He was being seen by the Wound Clinic doctor weekly for wound care and any changes in treatment. He currently had a Wound Vac appliance on his right buttock wound to aide in healing. The nursing staff changed the dressing every Monday, Wednesday, and Friday and would monitor the dressing every shift. The nursing staff would monitor monitor the Wound Vac canister every shift and document the amount of drainage. The nurse would continue to complete a full skin assessment weekly to observe for changes in skin integrity. He would be encouraged to have good nutritional intake and drink adequate fluids. His Plan of Care would be reviewed by 12/22/14. A Skin Plan Of Care for Resident #90 indicated he often was noncompliant with turning and repositioning every 2 hours per his physician's orders [REDACTED]. He was supposed to only be up in his wheelchair for meals, no more than 45 minutes. At times, he choose to stay up in his wheelchair for longer periods than 45 minutes. The nursing staff encouraged him to be off of his bony prominence's as much as possible. He had been given the information of the risk of not laying down and being turned often, and he voiced understanding. The nursing staff would continue to provide wound care and preventative skin care per his physician's orders [REDACTED]. His Care Plan would be reviewed by 12/29/14. A local Wound Clinic "Nursing Wound/Ulcer Assessment" for Resident #90 dated 10/15/14, indicated his coccyx pressure ulcer measured 2.3 cm long by 1.5 cm wide by 0.1 cm deep. His right buttock wound measured 3.8 cm long by 2.4 cm wide by 2.8 cm deep. The note indicated his wounds were improving with no necrotic areas noted. An interview with RN #17 on 10/14/14 at 11:50 a.m., indicated Resident #90 had a stage III pressure ulcer on his coccyx and a stage IV pressure ulcer on his right buttock, he acquired in the facility. On 10/16/14 at 3:30 p.m., Resident #90 was observed lying on an air mattress on his left side with pillows behind his back and under his head. He indicated he had received the air mattress after he had developed his pressure ulcers and the air mattress was comfortable. He had a trapeze bar above his head and indicated he used it for exercise. He indicated he turned in bed every 2 hours with the assistance of staff. He indicated he believed he developed pressure ulcers on his buttock because he had spent a lot of time sitting up in his wheelchair when he should have spent more time in bed. He indicated he went to a local Wound Care Center weekly. He indicated he was participating in therapy and the therapy staff were going to help him build his strength. He indicated therapy staff had helped him stand which he hadn't done in a long time. He indicated he had not sat in a wheelchair at home. On 10/17/14 at 9:10 a.m., Resident #90 was observed seated upright in his wheelchair on a seat cushion in the dining room. He had a Wound Vac bag hanging on the back of his wheelchair. On 10/17/14 at 10:27 a.m., Resident #90 was observed receiving wound care in his bedroom from the Assistant Director of Health Services (ADHS) and RN #5. RN #5 held resident on his left side and the DHS provided him with his right buttock Wound Vac dressing change near his hip. The Wound Vac container was replaced and the Wound Vac set on 150 mm/hg. The right buttock pressure ulcer was approximately the size of a half dollar in circumference. The wound bed was deep, pinkish/red in color. The surrounding skin was pinkish/white and no odor was noted. RN # 5 provided him with the coccyx ulcer dressing . The wound edges were irregular. The wound bed was red/beefy looking. The surrounding skin was pinkish/white and then surrounding tissue around that pinkish/red. No odor noted. He tolerated the procedure well and denied having any pain. On 10/17/14 at 1:40 p.m., Resident #90's wife indicated when he first arrived at the facility he often sat up in his wheelchair, going outside and different areas of the building. She indicated she believed he developed the pressure ulcer because he had spent so much time sitting up in his wheelchair. On 10/21/14 at 9:35 a.m., Resident #90 was lying in bed on his left side. Resident #90 was queried how long he had a wheelchair cushion in his wheelchair. He indicated he didn't know but therapy staff would know because they had ordered it. He indicated he could not recall if he had any pressure relieving device in his wheelchair prior to that one. On 10/21/14 at 2:03 p.m., Certified Occupational Therapy Assistant (COTA) #6 indicated Resident #90 was admitted to the facility with his own wheelchair. She indicated the wheelchair did not have a pressure relieving cushion and he spent a lot of time up in his wheelchair. She indicated he had started to get some breakdown on his buttock and she had informed the Therapy Manager she believed Resident #90 would benefit from a (name brand) cushion to relieve pressure off of his buttock. COTA #6 left the room and returned with the printed "OT Daily Treatment" note for Resident #90 dated 9/15/14, to provide information of when the (name brand) cushion had been ordered. After reviewing the note she indicated maybe Resident #90 had received a gel foam cushion prior to the (name brand) cushion but she did not know what date that would have been placed in his wheelchair. On 10/21/14 at 2:21 p.m., the Therapy Manager indicated Resident #90 was admitted to the facility with his own wheelchair. He indicated he did not remember what date Resident #90 had a gel foam pressure relieving cushion placed in his wheelchair prior to the (name brand) cushion. He indicated it would have been within the first week or two of admission. He indicated it would have likely been himself or COTA #6 who had provided him with a gel foam cushion out of the stock supply. He indicated he had ordered the (name brand) pressure relieving cushion for Resident #90's wheelchair because a staff member in morning meeting had mentioned he was getting pressure ulcers and a (name brand) cushion was better than a gel cushion. He indicated there was no protocol related to providing a resident with a wheelchair seat cushion. He indicated Resident #90 had not used a wheelchair cushion at home so the cushion was new to him when he received it. He indicated Resident #90 was currently in OT and PT and had been since admission. On 10/21/14 at 4:45 p.m., the Therapy Manager indicated he was unable to locate any therapy documentation when Resident #90 received a gel foam pressure relieving cushion for his wheelchair prior to receiving his (name brand) cushion. No documentation was available Resident #90 had a pressure relieving device in his wheelchair until the "Resident First Conference Notes" dated 9/10/14. The facility was unable to provide any information Resident #90 had any pressure relieving device in his wheelchair prior to the "Resident First Conference Notes" dated 9/10/14. The "Pressure Prevention Guidelines" provided by the Director of Health Care Services on 10/21/14 at 5:00 p.m., indicated the following: "Purpose: To maintain good skin integrity and avoid development of pressure ulcers. Procedure: Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include but not be limited to: ...Place on pressure reduction support surface (bed - chair). Obtain an advanced pressure reduction cushion for wheelchair...." 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review the facility failed to provide a restorative Passive Range Of Motion (PROM) program for a resident with limited range of motion resulting in the resident experiencing a decline in joint mobility for 1 of 4 residents who met the criteria for a contractures without a splint device in a total sample of 15 (Resident #1). Finding include: During observation on 10/15/14 at 10:46 a.m., Resident #1 was laying in bed, both of the resident's right and left wrist and fingers were curled in towards the resident's chest. Resident #1 did not have a splint device in place. Interview with Resident #1's family member on 10/15/14 at 2:29 p.m., indicated they visit the resident almost daily. Resident #1's family member indicated the resident stayed in bed all of the time. During observation on 10/16/14 at 10:06 a.m., Resident #1 was laying in bed, both of the resident's right and left wrist and fingers were curled in towards the resident's chest. Resident #1 did not have a splint device in place. During observation on 10/17/14 at 10:00 a.m.., Resident #1 was laying in bed, both of the resident's right and left wrist and fingers were curled in towards the resident's chest. Resident #1 did not have a splint device in place. Review of the record of Resident #1 on 10/20/14 at 11:45 a.m., indicated the resident's [DIAGNOSES REDACTED]. The record of Resident #1 indicated the resident was admitted to the facility on [DATE]. Review of Resident #1's careplan's dated, 4/11/14 to 9/14/14, indicated no plan of care related to the resident's contractures or PROM program. The Occupational Therapy (O.T.) initial assessment for Resident #1, dated 3/3/14, indicated the following: "The patient has shown a clinical need for PROM and positioning intervention for reduced risk of contractures and promote optimal skin integrity while in long term care. Therapy is necessary for PROM and positioning intervention. Without therapy the resident is at risk for contractures and skin breakdown. The discharge plans was to remain in the skilled nursing facility with a Restorative Nursing Program (RNP). The Range of Motion assessment for Resident #1 indicated the following: the right upper extremity had 75 % of normal range, the right lower extremity had 75% of normal range of motion, the left upper extremity had 75% of normal range of motion, the left lower extremity had 75% of normal range of motion." All the Range Of Motion (ROM) was completed passively with contractures of digits, however able to range digits to table top position for good hygiene. " "Patient with fixed bilateral inversion contractures of ankles." "Changing and maintaining body positron functional limitation, current status has been documented based on patient is in a persistent vegetative state and requires O.T. to establish RNP for decreased risk of contractures." The assessment was electronically signed by the Therapy Manager. The O.T. progress and discharge summary for Resident #1, dated 4/16/14, indicated the following: Goal #1- "The goal for ROM was the resident would achieve 75% ROM for wrists and digits while rest of joints are also at 75% PROM or better in prep for RNP." The start date of the goal status, dated 3/3/14, was the resident demonstrated 75% PROM for bilateral shoulders, elbows, knees, and hips. The resident had bilateral hands PROM at approximately 50% for digits and wrists. "Bilateral ankles with fixed contractures. The end of goal status, dated 4/16/14, indicated the goal was met and the resident demonstrated 75% PROM all major joints such as the hips, knees, shoulders, elbows and approximately 75% PROM for wrist and digits. The resident will have overall Bilateral lower extremities and bilateral upper extremities ROM RNP established to decrease risk of further contractures development. Education with staff related to PROM to be completed daily. The discharge summary was electronically signed by the Therapy Manager. The change in condition form for Resident #1, dated 8/7/14, indicated the resident's family were requesting an increase in [MEDICATION NAME] (skeletal muscle relaxant) due to the resident's muscles have gotten very stiff and unable to bend legs worse than usual. The Minimum Data Set (MDS) assessment for Resident #1, dated 8/14/14, indicated the following: bed mobility- total dependence of two people, transfer- total dependence of two people, walk in room- activity did not occur, functional limitation in ROM of upper and lower extremities- impairment on both sides and Restorative Nursing Program for PROM- none. During observation and interview on 10/20/14 at 11:45 a.m., CNA #7 and CNA #8 was repositioning Resident #1 in bed. CNA #7 indicated the resident did not get out of the bed except on shower days. When queried what PROM exercises were done for the resident, CNA #8 indicated when they repositioned the resident in bed they tried to move the resident's fingers,. CNA #8 indicated the resident could not move his wrist or ankles. CNA #8 indicated the resident did not wear any splints. CNA #8 demonstrated PROM on the resident's fingers on left and right hand. The resident fingers on both hands were able to be moved very little with the assistance of CNA #8. CNA #8 attempted to move the resident's wrist on both hands and indicated she was unable to and attempted to move both of the resident's ankles and indicated she was unable to. Interview with MDS coordinator #1 on 10/20/14 at 2:04 p.m., indicated she was unable to find documentation that Resident #1 received PROM exercises. Interview with the Assistance Director Of Health Services (ADHS) on 10/20/14 at 2:40 p.m., indicated Resident #1 did not have a restorative program for PROM. Interview with the Therapy Manager on 10/20/14 at 4:15 p.m., indicated the facility did not have a Restorative Nursing Program. The Therapy Manager indicated the facility was going to have one at one time but the program did not get started. The Therapy Manager indicated he did education with the nursing staff on how to do PROM for Resident #1 and would look for documentation on the training was and who was trained. The Therapy Manager indicated when the resident was discharged from therapy the resident was able to move his wrist. Interview with Resident #1's family member on 10/21/14 at 10:22 a.m., indicated when the resident lived at home, PROM was done by the family twice a day. The family member indicated they had never seen the facility staff provide PROM to the resident except when the resident was receiving therapy. The family member indicated the resident use to be able to move his wrist and now he could not. The family member indicated the resident's fingers, legs and knee joints have "deteriorated" since admission to the facility. Interview with the ADHS and Therapy Manager on 10/21/14 at 11:10 a.m., when queried who was responsible for the contractures prevention and management program, the Therapy Manager indicated it would be collaborative effort of the staff to put a program in place. The ADHS indicated the facility did not currently have a contractures prevention and management program in place. Requested for the ADHS and the Therapy Manager to do a joint assessment on Resident #1 as to see the resident's current joint mobility. During observation on 10/21/14 at 11:20 a.m., ADHS did a joint assessment on Resident #1 with the Therapy Manager present. The following was observed: The ADHS indicated the following: she was unable to move the resident's left wrist, the resident's neck had 75% PROM, the digits on the left hand had less than 50% PROM, the resident's left elbow had less than 50% PROM, the resident's left shoulder had less than 50% PROM, the resident's left hip was less than 50% PROM, the ADHS indicated she was unable to move the resident's left knee, the resident's toes on the left foot had less than 50% PROM, the ADHS indicated she was unable to move the resident's left ankle. The ADHS indicated the following for the right side- she was unable to move the resident's right wrist or right ankle, the resident's digits on the right hand was at 10% PROM, the right shoulder, elbow, hip, knee and toes were 75% PROM. The Therapy Manager agreed with the ADHS assessment of the resident's joint's. During the observation the resident's joints could be heard popping and the resident had some facial grimacing. Interview with MDS Coordinator #1 on 10/21/14 at 3:10 p.m., indicated she was responsible to put a Restorative Program in place. MDS Coordinator #1 indicated there was not specific program in place because of the specific criteria for a restorative program. Interview with the Therapy Manager on 10/21/14 at 3:50 p.m., indicated he was unable to find any documentation of training for staff related to PROM. Interview with CNA #12 on 10/22/14 at 10:30 a.m., indicated there was no specific PROM exercises for Resident #1. When queried if the facility provided any guidance for Resident #1's PROM limitations, CNA #12 indicated no. CNA #12 indicated normally when she gave the resident a bed bath she would try to bend his knee's, but they did not move much. CNA #12 indicated she was unable to move his hands wrist or feet. Interview with CNA #2 on 10/22/14 at 10:37 a.m., indicated there was no specific PROM exercises for Resident #1. CNA #2 indicated she did not bend the resident's knee's but did place a pillow between his legs. CNA #2 indicated she could move his arms when she washed him, but he was stiff. CNA #2 indicated she did not know if Resident #1 could move his toes. CNA #2 indicated the resident's hands were in a fist and she had not attempted to move them. Interview with CNA #7 on 10/22/14 at 11:05 a.m., indicated there were no guidelines on how far to move Resident #1 during PROM. CNA #7 indicated the facility had talked about putting a Restorative Range Of Motion program in, but they never did. CNA#7 indicated she moved the resident's arms up and down. CNA #7 indicated she could move his knee's and hands very little. The "Contracture Prevention and Management Program" provided by the Director Of Health Services (DHS) on 10/21/14 at 10:10 a.m., indicated the purpose was to prevent or reduce contractures and deformity, and/or preserve range of motion of residual limb to allow for use of prosthesis if needed through eh provision of range of motion, stimulation of circulation, and muscle strengthening exercises. The procedure included, but were not limited to, complete the initial restorative assessment to establish a baseline of residents with potential or actual range of motion limitations, determine the type of exercises required based on the assessment and the resident's abilities, determine the goal of the range of motion activity, enter the resident specific interventions and goals on the Restorative/Functional Maintenance Plan interventions and goals and approaches. Inform care giving team of the plan. Document daily participation and/or number of minutes that interventions are provided. 3.1-42(a)(2)