Every finding on record at Auburn Village

Based on interview and record review, the facility failed to ensure timely family notification of a resident's death for 1 of 3 residents reviewed (Resident C). Findings include:On [DATE] at 12:13 P.M., Resident C's record was reviewed. Diagnoses included cancer and diseased arteries. The resident admitted to the facility with hospice services due to expected decline and had orders to not resuscitate if found without a pulse or respirations. Resident C's face sheet had a Power of Attorney (POA) listed as the 1st contact for notifications of changes in condition and a family member as his 2nd contact for notifications of changes in condition. A nurse note, dated [DATE] at 3:40 a.m., indicated the resident was observed lying in bed without a pulse or respirations. A second nurse verified he was deceased and the hospice nurse contacted. The note indicated Resident C's POA was aware of the resident's death. An on-call Nurse Practitioner (NP) note, dated [DATE] at 4:10 a.m., indicated facility staff reported Resident C had passed away and hospice notified but were not given an order to release the body to the funeral home. The NP replied with an order to release the body when hospice and family were ready. On [DATE] at 12:35 P.M., Resident C's family member was interviewed. The family member indicated family were not notified of the resident's death until 2 days after he died. The residents POA had been hospitalized and hadn't had their phone. The resident's record listed a 2nd emergency contact name and number, but the 2nd emergency contact was not notified of the death. On [DATE], the POA's voicemail on their phone was played, and family heard the message indicating the resident had passed away, was sent to the funeral home, and cremated. The family member indicated neither she, nor the rest of the family were given the opportunity to say goodbye to the resident which was very upsetting. She indicated staff must have known to call the 2nd contact because when the resident fell on [DATE], the POA was not notified but the 2nd contact was. On [DATE] at 1:01 P.M., the Director of Nursing was interviewed. She indicated staff had tried to contact the POA 3 times before notifying the funeral home but had not tried to contact the 2nd family member listed. Staff should have called all the listed contact numbers and spoken with someone prior to releasing Resident C's body to the funeral home. On [DATE] at 3:20 P.M., a current facility policy, titled Change in a Resident's Condition or Status was provided by the Administrator. The policy indicated the facility would promptly notify the resident, attending physician and representative of changes in the resident's condition and/or status. This Citation refers to Intake 3016183. 410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(2)

Based on interview and record review the facility failed to ensure respectful and dignified communication and care for 1 of 3 residents reviewed. (Resident A)A record review for Resident A's began on 10/16/25 at 9:30 AM. Diagnoses included anxiety, depression, and respiratory failure.A review of Resident A's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated the resident had a tracheostomy and ventilator. A review of Resident A's current Care Plan indicated Resident A had potential to be manipulative, exhibit attention-seeking behaviors, and display emotional overreaction to minor events. Interventions included calm, consistent communication with firm boundaries.A review of Resident A's current Care Plan indicated Resident A had a problem of an anxiety disorder. Resident A could have racing thoughts, feel overwhelmed, and stressed. Interventions included encourage Resident A to engage in deep breathing exercises, grounding techniques, and mindfulness when resident was feeling anxious. In an interview, on 10/16/25 at 9:55 AM, the Director of Nursing (DON) indicated on 9/21/25, CNA 2 had expressed concern about Resident A's respiratory distress to RN 3. RN 3 had indicated they didn't care and Resident A needed to quit yelling. CNA 2 relayed RN 3's comment to Resident A.A review of progress notes, dated 9/21/2025 at 9:54 AM, indicated Resident A continued to refuse ADL care from available CNAs, there were currently 2 aides on the floor and the other aide was providing care for another resident. Resident A DEMANDED to be changed right now, the aide that was not assigned to Resident A attempted to provide ADL care and Resident A refused. The writer attempted to explain, Resident A began screaming at staff and called the DON. Staff removed their attention as the resident was safe.In an interview, on 10/16/25 at 12:58 PM, CNA 2 indicated Resident 2 appeared they may have been choking or unable to breath well. CNA 2 indicated they expressed concern and urgency to RN 3 about breathing status. RN 3 indicated they didn't care and wasn't going to check on Resident A. Resident A had asked about what had taken place outside of the room. CNA 2 had repeated what the RN 3 had said about not caring. In an interview, on 10/16/25 at 1:09 PM, RN 3 indicated they were the charge nurse on 9/21/25 during the day shift. Resident A had been verbally upset. Resident A calmed down when CNA 2 went into Resident A's room to provide care. CNA 2 came out of the room and indicated Resident A couldn't breathe. RN 3, another nurse, and a respiratory therapist were at the nurses' station. RN 3 indicated they weren't going down there to check on Resident A. CNA 2 went back to Resident A's room. The respiratory therapist went to Resident A approximately 30 seconds after CNA 2.In an interview, on 10/16/25 at 2:10 PM, Resident A indicated RN 3 had entered the room and an upsetting exchange occurred. Resident A indicated they would call the DON, RN 3 indicated they would call her too. Resident A indicated they had anxiety, crying, was breathing fast, and needed help when CNA 2 came in.A current policy dated 10/2021, provided by the Administrator, indicated that all residents should be treated with dignity in which the staff assist with activities of daily living such as dressing, bathing, and incontinent care. All residents should be respected for their individuality, their views, and the way in which they are accustomed to conduct their lives. Staff should always treat residents with sensitivity, respect, and thoughtfulness. Staff should always treat residents in a dignified and sensitive way when performing intimate care tasks.This citation is related to intake 2624266.3.1-3(a)

Based on observation and interview, the facility failed to ensure kitchen cleanliness was maintianed. 70 of 81 residents residing in the facility ate food prepared in the kitchen. Findings include: During an observation, on 06/11/25 at 09:13 AM, there was moisture in 2 of 3 pans on drying rack, the stand mixer located in the cooking and clean storage area had yellow particles and yellow discoloration on the bowl, paddle, and on the main unit. An unlabeled fruit cup had a red liquid puddle underneath on the top drawer of the mini fridge in the south hall. Employee 9 had their hair unrestrained During an interivew, on 06/11/25 at 10:25 AM, The Dietary Manager indicated the kitchen staff needed to restrain their hair with a hairnet. During an observation, on 06/11/25 at 10:30 AM, Employee 9 took the lid off the food processor and placed it right side up on top of the toaster next to it. The top of the toaster had crumbs and dry brown particles on the top surface. The rim of the lid is an interior surface and touches the food inside the food processor. Food and liquid were transferred to the toaster by contact. During an observation, on 06/11/25 at 11:05 AM, the following was observed, in the dining room on the 200 hall brown stains were found on the floor under the coffee maker, and a dry, round, white food-like substance was found on the cabinet door next to the coffee maker. In an interview on, 06/11/25 at 10:30 AM, Employee 10 and the Dietary Manager were notified of the food and liquid from the inside of the food processor was transferred to the toaster. Employee 10 acknowledged they would have to clean the toaster and move it to a better storage location. The Dietary Manager indicated 70 of 81 residents residing in the facility ate food prepared on the facility kitchen. A current policy dated 06/12/25 provided by the Dietary Manager indicated that small appliances such as mixers and food processors should have solid food scraped into a garbage container, and to clean the outer surface with a clean cloth that has been moistened in hot, soapy water. A current policy dated 06/12/25 provided by the Dietary Manager indicated that food should be labeled with the date received, the date opened, and the date by which the item should be discarded. Once opened, these items are refrigerated and labeled with the date opened and with discard or use by date. 483.60(i)(1)(2)

Based on observation, interview and record review the facility failed to ensure dining choices were respected for 1 of 8 residents reviewed (Resident 60). Findings include: During an observation on 6/11/25 at 11:35 AM, Resident 60 was observed seated at a table in the assisted dining room with two other residents. Three staff members were seated at the table assisting the residents with their lunch. During an observation on 6/12/25 at 11:56 AM, Resident 60 was observed seated at a table in the assisted dining room with two other residents. Three staff members were seated at the table assisting the residents with their lunch. During an interview on 6/12/25 at 10:47 AM Resident 60 indicated he had notified staff during a resident council meeting he wished to dine in the main dining room, so he had the opportunity to meet more residents and increase his socialization. He indicated he had expressed to staff he would like to have the choice of where to dine. During an interview on 6/12/25 at 11:32 AM, Registered Nurse (RN) 2 indicated residents could choose which dining room they prefer to sit in. She indicated while no residents were currently aided in the main dining room, residents had been provided assistance there in the past. She indicated some residents preferred not to be assisted in front of others who were not being assisted, but ultimately, the resident could make that decision. During an interview on 6/12/25 at 1:32 PM Resident 60 indicated the Activities Director (AD) told him a few days after the resident council meeting, he was not allowed to eat in the main dining room because he required assistance, and it was a dignity issue. Resident 60 indicated he was comfortable having others observe him receiving feeding assistance. In an interview on 6/12/25 at 2:01 PM, the Activity Director indicated Resident 60 had expressed his desire to eat in the main dining room during a resident council meeting around the first week of June. She indicated the Administrator and corporate staff had told her it was a dignity issue, and he must eat in the assisted dining room. She indicated she reported to Resident 60 that he would not be able to eat in the main dining room due to dignity issues. During an interview on 6/13/25 at 10:29 AM, the Director of Nursing indicated Resident 60 was placed in the assisted dining room due to safety issues. She indicated the facility had plenty of staff available at each meal to assist each resident needing assistance to eat. She did not indicate what safety issues could not be handled in the main dining room. Resident 60's record was reviewed on 6/12/25 at 11:07 AM. Diagnoses included muscular dystrophy and major depressive disorder. A review of Resident 60's current quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated his Basic Interview for Mental Status (BIMS) score was 15 indicating he was cognitively intact and able to make daily decisions. The MDS indicated Resident 60 required assistance with eating and did not display signs and symptoms of a swallowing disorder or concerns about safety with dining. A review of Resident 60's current care plan titled Resident is independent with activities indicated the resident had a problem of independence with activities, with a goal date of 9/1/25. Interventions included ensuring activities were compatible with known interests and preferences. The care plan indicated resident interests should be established by talking with the resident as needed. A care plan intervention was added on 6/13/25 indicating Resident 60 required total assist with eating and all meals were to be in the Assisted Dining Room as the resident would allow. The care plan did not address Resident 60 having a choice of which dining area to dine in. A Quarterly Nutrition Review, dated 5/30/25, indicated Resident 60 did not display a chewing or swallowing problem and did not indicate a preferred dining location. A review of physician orders dated 11/25/24 indicated Resident 60 received a regular diet with regular/thin consistency fluids. In a Psychotherapy progress note dated 6/3/25 at 6:45 PM, Licensed Social Worker 8 indicated Resident 60 had expressed not having much going on lately and struggling with being young in the facility atmosphere. The note did not indicate the resident was requesting to eat in the main dining room for socialization. A current policy dated 10/21 provided by the Administrator on 6/16/25 at 1:38 PM indicated all residents should be consulted on any matter or activity which may impinge on their life within the facility in any way, and to have their wishes respected. 3.1-3(u)(1) 3.1-3(u)(1)

Based on observation, interview and record review, the facility failed to ensure the treatment to maintain or prevent further loss of range of motion for 1 of 1 resident reviewed (Resident 7). Findings include: In an interview, on 6/11/25 at 10:23 AM, Resident 7 indicated they were unable to participate in bingo due to limited use of their hands. On 6/11/25 at 10:25 AM, Resident 7 was observed to have contractures (rigid joints) of both of their wrists. Resident 7's record was reviewed on 6/16/25 at 9:36 AM. Diagnoses included rheumatoid arthritis (a condition that causes stiff joints) and Parkinson's Syndrome (a condition that affects movement and coordination due to stiffness and tremors). Resident 7's Quarterly Minimum Data Set, (MDS)dated 5/20/25 indicated their Brief Interview of Mental Status (BIMS) score was 2 (severe cognitive impairment). The MDS indicated Resident 7 required substantial to maximum staff assistance for eating. The MDS indicated Resident 7 was dependent on staff assistance for oral care, mobility, bathing and toileting. The MDS indicated Resident 7 had no impairment of functional range of motion to their shoulders, elbows, wrists or hands. The MDS indicated Resident 7 had no impairment of functional range of motion to their hips, knees, ankles or feet. Resident 7's care plan, dated 3/24/25, indicated the resident had limited physical mobility due to Parkinson's, Alzheimer's, rheumatoid arthritis and contracted feet. The target goal was for the resident to remain free from immobility complications including further contractures through 7/13/25. Interventions included provision of daily gentle range of motion as tolerated. Resident 7's Medication Administration Record (MAR) dated 6/1/25 through 6/17/25 did not indicate the resident had received range of motion exercises. Resident 7's Treatment Administration Record (TAR) dated 6/1/25 through 6/17/25 did not indicate the resident had received range of motion exercises. Resident 7's nurse aide task sheet did not indicate the resident had received range of motion exercises. In an interview, on 6/17/25 at 9:52 AM, the Director of Nursing (DON) indicated range of motion is documented by the nurse aides under the tasks tab. In an interview, on 6/17/25 at 11:45 AM, the DON indicated Resident 7's range of motion was not documented due to the facility not having an official restorative program. The DON indicated range of motion exercises were not documented due to range of motion was supposed to be automatically performed for all residents. The DON indicated according to a nurse aide training school, nurse aides were trained to perform range of motion during morning and evening care, therefore does not need to be recorded. The DON indicated the facility did not have an official policy for contracture care. 3.1-42(a)(1) 3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure non-medication pain interventions were implemented as ordered by the physician for 1 of 1 resident reviewed (Resident 30). Findings include: Resident 30's record was reviewed on 6/16/25 at 10:56 AM. Diagnoses included chronic pain syndrome, low back pain, right leg pain and polyneuropathy (damage to multiple nerves). Resident 30's Quarterly Minimum Data Set, (MDS) date 4/11/25, indicated the resident's Brief Interview for Mental Status (BIMS) score was 14 (no cognitive impairment). The MDS indicated Resident 30 had not been administered routine pain medication. The MDS indicated Resident 30 had been administered pain medication as needed. The MDS indicated Resident 30 frequently had pain. The pain frequently interfered with Resident 30's sleep at night. The MDS indicated Resident 30 had not been offered non-medication pain interventions. Resident 30's care plan, dated 3/10/25, indicated the resident was at risk for pain due to impaired mobility, diabetes with polyneuropathy, chronic pain syndrome, low back pain, and end stage renal disease dialysis dependent and dorsalgia (back pain). The target goal was to have no interruption of normal activities due to pain through 8/17/25. Interventions included assessment of pain, assessment of effectiveness of pain medications, documentation of probable cause of each episode of pain and removal of causes when possible. A physician order, dated 4/10/25, indicated Resident 30 could be administered 2 tablets of hydrocodone-acetaminophen (Norco) every 6 hours as needed (PRN) for moderate to severe pain. A physician order, dated 11/26/24, indicated Resident 30 could be administered 2 tablets of acetaminophen (Tylenol) every 6 hours as needed (PRN) for mild to moderate pain. A physician order, dated 11/26/24, indicated the nurse should offer non-medication pain interventions prior to administering PRN pain medications. A physician order, dated 4/1/25, indicated Resident 30 would be assessed for pain every shift. Resident 30's MAR, dated 6/1/25 to 6/16/25, indicated the resident had been administered Norco for moderate to severe pain on 20 occasions. The MAR did not indicate the resident had been offered non-medication pain interventions. Resident 30's MAR, dated 6/1/25 to 6/16/25, indicated the resident had not been administered Tylenol for mild to moderate pain. Nursing notes, dated 6/1/25 to 6/15/25, did not indicate any non-pharmacologic interventions had been attempted for Resident 30, In an interview, on 6/16/25 at 2:00 PM, Registered Nurse (RN) 4 indicated non-medication pain interventions were documented in the MAR whenever a PRN pain medication was administered. In an interview, on 6/17/25 at 9:52 AM, the Director of Nursing (DON) indicated non-medication pain interventions are recorded on the MAR when PRN pain meds are administered. The DON reviewed Resident 30's current MAR. The DON indicated non-medication pain interventions were not included in Resident 30's MAR. The DON reviewed Resident 30's physician orders and care plan. The DON indicated non-medication pain interventions were included in the resident's physician orders. The DON indicated specific non-medication pain interventions were not included in the resident's care plan. In an interview, on 6/17/25 at 11:40 AM, the DON, while referring to their phone, indicated a federal regulation did not require non-medication pain interventions. The DON indicated according to the regulation they had referred to; non-medication pain interventions could be a consideration and therefore, were not a requirement. A current facility policy, titled Pain Management, dated 11/2022, provided by the Assistant Director of Nursing on 6/16/25 at 1:54 PM, indicated a resident specific pain management care plan would be developed for each resident who has pain. The policy indicated both pharmacological and non-pharmacological interventions may be implemented. 3.1-37(a)

Based on interview and record review the facility failed to ensure massage therapy was provided for 1 of 24 residents reviewed (Resident 60). Findings include: During an interview on 6/12/25 at 10:17 AM, Resident 60 indicated he had notified facility staff of desire to receive massage therapy services for discomfort related to muscular dystrophy. He indicated he could receive the services for free at the Veterans Affairs Hospital. He indicated he had inquired about massage therapy during a Resident Council meeting. After the meeting, the facility driver had told him the facility could not assist him with transportation due to it not being a medically necessary service, but the facility might be able to offer massage in house. He indicated the conversation was several weeks ago and he had not received any further information from the facility. During an interview on 6/12/25 at 1:32 PM, Resident 60 indicated he had not received any massage therapy from facility staff or heard of any plans to be provided with this service. Resident 60's record was reviewed on 6/12/25 at 11:07 AM. Diagnoses included muscular dystrophy and major depressive disorder. A review of Resident 60's current quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 60 did not reject any care necessary to achieve his goals for health and well-being. The MDS indicated Resident 60 had limitations of range of motion in both upper extremities and required extensive physical assistance with activities of daily living. A review of Resident 60's current care plan titled Resident is Resistant to care such as wearing a gait belt indicated Resident 60 had a problem of resisting use of a gait belt with a goal date of 9/1/25. The care plan indicated Resident 60 should be allowed to make decisions about his treatment regimen to provide a sense of control. A current care plan titled resident is at risk for pain indicated Resident 60 had a problem of pain related to impaired mobility, benign prostatic hypertrophy, dorsalgia, muscular dystrophy, and irritable bowel syndrome. The care plan had a goal date of 9/1/25. Interventions included reporting complaints of pain or requests for pain treatment to the nurse. The care plan did not include interventions to relieve pain related to range of motion or massage therapy. A review of Resident Council Meeting Minutes dated 6/3/25 indicated the Nurse Practitioner spoke with Resident 60 to obtain preference and transportation related to going out to VA for massage therapy. A review of progress notes dated 5/28/25 at 1:11PM indicated Resident 60 reported persistent side neck pain for which he had received massages in the past. A review of progress notes dated 6/6/25 at 1:25 PM indicated Resident 60 was referred to Physical Therapy for ultrasound and massage therapy to address discomfort with spinal curvature. The progress note indicated Nurse Practitioner (NP) 7 would monitor his condition and adjust treatment as necessary. A review of progress notes from 6/1/25 to 6/16/25 did not include any care refusals or refusals of offers of massage therapy. A review of active physician orders for 6/12/25 did not include an order for physical therapy. A physician's order dated 5/19/25 indicated Skilled Occupational Therapy was ordered 2 times a week for 5 weeks to include therapeutic exercise, self-care, neuromuscular reeducation, therapeutic activities, wheelchair management, and safety awareness. In an interview, on 6/13/25 at 1:03 PM, the Director of Nursing (DON) indicated Physical Therapy was not providing massage therapy to Resident 60. She indicated Resident 60 was on Occupational Therapy (OT) caseload, and OT was handling the massage therapy. In an interview on 6/13/25 at 1:11 PM the Director of Therapy indicated Resident 60 had not been evaluated for massage therapy, but would be evaluated for massage therapy that day. The Occupational Therapy Plan of Care indicated therapy goals for neck pain with the initiation of manual techniques began on 6/13/25. In an interview, on 6/16/25 at 12:07 PM, Qualified Medicine Aide (QMA) 3 indicated she managed facility-provided transportation. She indicated Resident 60 had asked her about massage appointments, but she did not have an appointment for massage therapy on her schedule for him. She did not indicate passing his inquiry on to any other employee. In an interview, on 6/17/25 at 11:30 AM, the DON indicated the discussion of massage therapy was not an order and was only discussed as a possibility. The DON did not indicate the resident had been reviewed for a Restorative Program including Active and Passive Range of Motion. In an interview, on 6/17/25 at 11:40 AM, NP 7 indicated she reviewed her progress note from 6/6/25 and indicated her note appeared to be an order for a Physical Therapy referral. She indicated she did not intend to write an order, but meant to have Physical Therapy discuss massage therapy. She indicated she had not spoken with the facility about rescinding the order. A current policy titled Physician's Orders, dated 3/16, provided by the Administrator on 6/16/25 at 1:38 PM, indicated new orders should be promptly entered into the computer and carried out. 3.1-23 (a)(1)(2)

Based on interview and record review, the facility failed to ensure education about and follow public health authority recommendations during investigation of a communicable disease outbreak. This alleged deficient practice affected 1 of 3 residents reviewed (Resident M).and had the potential to affect of 68 residents residing in the facility. Findings include: An anonymous complaint to the Indiana Department of Health (IDOH), dated 6/25/24, indicated Legionella bacteria had been found in water samples collected at the facility and recommendations made to prevent disease were not being followed. Legionnaires' Disease, retrieved from CDC.gov (Centers for Disease Control) on 6/27/24, indicated Legionnaires' disease was a very serious type of pneumonia caused by Legionella bacteria. Legionnaires' disease could cause pneumonia symptoms of cough, muscle aches, fever, shortness of breath, and headache. Legionella bacteria lived in fresh water and man-made settings such as large or complex water systems found in hospitals or nursing homes. Legionella bacteria could grow in these man-made systems if the water was not properly maintained, and could become a health problem when small droplets of water, containing the bacteria, got into the air and people breathed them in. In rare cases, persons could breathe in Legionella bacteria while drinking water and it goes down the wrong pipe into the lungs. In general, Legionnaire's disease was not spread from person to person. Common water sources of Legionella bacteria include water used for showering. When Legionnaires' disease is found, it should be reported to the Local and State Health Departments promptly to allow public health officials to quickly identify and stop potential clusters and outbreaks by linking new cases to previously reported ones. Public Health Authorities are responsible for investigating cases of Legionnaires' disease which typically involves four public health fields: epidemiology, environmental health, laboratory science, and health communication. Centers for Medicare and Medicaid Services (CMS) interpretive guidelines for healthcare-associated Legionella disease indicated: The facility should contact the local/state public health authority if there is a case of healthcare-associated legionellosis or an outbreak of an opportunistic waterborne pathogen causing disease. The facility must follow public health authority recommendations which may include, but is not limited to, remediating the pathogen reservoir and adjusting control measures as necessary. On 6/27/24 at 11:09 A.M., the Maintence Director was interviewed about the facility's water management program. He indicated they had a program in place and were currently working with their water management consultant company to flush the water systems due to positive water tests for Legionella bacteria. He indicated there were no positive water tests for the Legionella species which caused disease. On 6/27/24 at 11:15 A.M., the Administrator and Maintenance Director were interviewed. The Administrator indicated they were notified by the Infectious Disease Epidemiology & Prevention Division of IDOH of a resident (Resident M) who tested positive for Legionnaires' disease when hospitalized in March 2024. He indicated the resident had discharged from the facility prior to their notification and the facility had not been notified by the hospital upon her return. He indicated the facility had been working with Epidemiologist's (Public Health workers who investigate patterns and causes of disease and injury) at IDOH and their water management company to find the source of the infection and put corrective measures in place. He indicated water samples, submitted per IDOH instruction, were found with Legionella bacteria but were not the species which caused Legionnaires' disease. He provided lab test results and map of the facility which indicated where samples had been obtained. The facility, in consultation with their water management company, had started flushing the water system 3 times per week, recorded water temperatures, chlorine levels following the water flush to monitor and raised the level of chlorine to effectively remove Legionella bacteria from the water system. He indicated the Epidemiologist at IDOH had made several recommendations, most of which they followed, but hadn't been able to install Point of Use ([NAME]) filters on their shower heads and continued to use the showers per resident's preference. The cost of replacing all the shower heads was costly and their water management consultant believed it was not necessary. On 6/27/24 at 11:52 A.M., Resident M's record was reviewed. Diagnoses included chronic obstructive pulmonary disease, diabetes, and chronic respiratory failure. She had been hospitalized [DATE]-[DATE] for pneumonia due to influenza and 3/18/24-3/27/24 for acute on chronic respiratory failure and pneumonia. Resident M had resided in a room where a positive water sample had been found for Legionella bacteria after discharging home from the facility. On 6/27/24 at 1:54 P.M., the Administrator provided copies of the water testing results and email exchanges between the facility, water management consultant company and Epidemiologists from IDOH as follows: -4/9/24: The facility was notified by IDOH of a Legionella outbreak investigation based on a resident's (Resident M) positive urine test for Legionella and diagnosis of Legionnaires' disease at the facility. The resident had spent 12 days of the 14 day incubation period at the facility which according to the CDC, prompted an outbreak investigation. IDOH requested documents from the facility and gave recommendations for implementation of immediate water precautions which were: remove ice machines from service, use bottled water for drinking, and remove showers from service until point of use filters could be installed. It was recommended the facility increase surveillance of residents and staff for symptoms of Legionnaires' disease. -4/16/24: An email, detailing a meeting which occurred in the morning with IDOH, local health department and facility staff, had included information shared about Legionella, outbreak response responsibilities of IDOH staff, consideration of notification to resident's and staff or possible drafting of a media statement, and case specific responses detailing Resident M's case. Due to the amount of time the resident spent at the facility, the case was considered, by the CDC, a presumptive healthcare-associated case which implicated the facility. The facility had provided the requested information and immediate water precautions implemented including providing bottled water for drinking, regular flushing per the water management program, cleaning and disinfecting the ice machines, checking their filters and ordering a chlorometer (device to measure amount of chlorine in the water). The facility had increased surveillance for symptomatic individuals and was waiting to implement additional water precautions depending on the water sample results. The facility had contracted with a lab and water samples were to be obtained the following day (4/17/24). -5/9/24: Water samples for Legionella, collected on 4/17/24, resulted in 12 of 35 samples positive for Legionella bacteria. -5/13/24: Lab test results were sent to the facility from the water management consulting company and meeting held between the company and facility to discuss the Legionella investigation testing and IDPH (Indiana Department of Public Health) recommendations. The water company offered their recommendations which were to increase flushing of water at all positive water sample locations for at least 10 minutes per day, at least 3 days per week; measure water temperature after hot water flush; and measure free chlorine after cold water flush for the next 2 weeks and retest. The email indicated if the department of public health changed their recommendations to mandates, the water company would recommend following their guidance. -5/14/24: An email to IDOH indicated the facility would be following recommendations per the consulting water management company. IDOH sent an email, in response, which indicated a meeting was scheduled for 5/21/24 to focus on: Immediate water precaution recommendations, including point-of-use filters, bottled water for drinking, and ice machine use, based on the initial sampling results and what the monitoring period would look like including frequency of sampling, timeline for sampling, quantity and types of samples, etc. -5/29/24: IDOH sent an email to the facility to inquire if the facility had decided on what water precautions to implement, considering the system had tested positive for Legionella; and reminder all Legionella had the potential to cause human illness. The email indicated IDOH recommendations were to install point of use filters onto showerheads currently in use and until [NAME] filters were installed, bottled water should be used for bathing. If the facility decided not to install the [NAME] filters, the bottled water was to be used for bathing and showers not used; Bottled water was to be used for drinking until the end of the response; ice machines removed from service or equipped with [NAME] or in-line filters; and increased surveillance of residents and staff for symptoms consistent with Legionnaires' disease. The email also asked if the facility had been able to conduct system remediation which could include chemical treatment, increased flushing, or replacement of plumbing components. The facility responded and indicated, with direction from their water management team, they had decided to do the following: -Increase flushing to 3x/week & test free chlorine on all of those days -Increase respiratory monitoring -Regenerate water softeners -Ordered point of use filters for ice machines -Retesting to occur once flushing period occurs for 1 month. 5/30/24: An email from IDOH indicated CDC recommended showers be restricted and bed baths used instead since the facility was unable to install [NAME] filters onto showerheads. The email provided a link to CDC recommended control measures which stated: Implementing Control Measures-implement immediate control measures to help reduce the risk of ongoing transmission and prevent exposure to systems or devices suspected to have Legionella. Examples of immediate control measures for potable water systems include: -Restricting showers (using sponge baths instead) -Installing point-of-use microbial filters 6/19/24: An email sent from the facility to IDOH had chlorine logs attached and recommendations made by the facility water management company for next steps. The facility hadn't identified any other symptomatic residents and the facility had regenerated the water softeners and installed filters on the ice machines. The facility elected not to do the sponge bathing due to resident preferences. The facility had done flushing for 10 minutes hot water followed by 10 minutes cold water, 3 days per week over the past 4 weeks, monitored chlorine levels, drained 2 of 3 hot water heaters, regenerated the water softner and disinfected all affected fixtures. The facility would continue flushing for 2 more weeks, increase draining debris from all 3 hot water tanks and replace 6 affected fixtures that had not improved in chlorine readings. On 7/1/24 at 1:45 P.M., the Director of Nursing (DON), Administrator, and Infection Preventionist (IP) were interviewed and provided a copy of the facility's infection control investigation. They indicated Resident M had been in a private room and hadn't come out of her room. She had been hospitalized multiple times for pneumonia and was symptomatic with respiratory symptoms when returning from the hospital prior to the incubation period. They had several teams meetings with IDOH, the Administrator, Maintenance Director, Director of Nursing, and water management consultant company and believed they were following recommendations to prevent transmission and exposure to Legionella. The Administrator indicated they had incorporated discussing resident's respiratory risk daily in their morning meetings, educated staff on infection control and respiratory illness (5/5/24), and consulted with the facility's pulmonologist, physician and NP (Nurse Practitioner) who had no concerns with other residents. Staff were to observe high risk residents for respiratory illness as standard practice and notify the physician, NP, resident, family and DON of changes. The DON indicated they had purchased bottled water but it was not being used for bathing or drinking. The Administrator indicated they had spoken with residents who had indicated they were not willing to have bed baths instead of showering. There was no documentation provided to indicate residents had been notified of Legionella in the water, risks of exposure to while showering and choices made to continue using the showers despite the risks. The DON and Administrator indicated all rooms, except on the vent unit, had their own bathrooms with showers. Residents on the vent unit could use the common shower room on the hall but most were provided bed baths. There were 63 private rooms with their own bathrooms and showers in the facility. The facility's water management program, dated 2024, indicated a Shower Risk Assessment indicated showers in resident rooms were a high risk location for Legionella bacteria due to stagnation of water in low use areas and aerolization of water in the showers. 6/27/24-7/2/24 confidential interviews were conducted with 12 employees including Healthcare Providers who indicated they had not received training on Legionella or other waterborne illness. None had been instructed to monitor for symptoms of pneumonia in high risk residents (vent-dependent or residing in rooms where Legionella bacteria had been found). Many of the interviewed staff indicated not knowing what Legionella was, how it could cause infection and were not told to monitor respiratory symptoms in themselves and report to their supervisor. One Healthcare Provider indicated being told water samples were negative for Legionella bacteria. This tag relates to Complaint IN00437399. 3.1-18(a)

Based on observation, interview and record review the facility failed to identify, assess and determine underlying cause of specific expressions of distress of a trauma survivor for 1 of 2 residents reviewed (Resident 3). Findings include: On 6/27/24 at 12:10 PM, Resident 3 was observed sitting in the doorway of their room in their wheelchair. Resident 3 greeted a staff member pleasantly. Resident 3 greeted this writer, then quickly looked away. Resident 3 began to speak softly in nonsensical terms while looking at the palms of their hands. Resident 3's record was reviewed on 7/1/24 at 11:36 AM. Resident 3's diagnoses included anxiety, major depressive disorder, paranoid schizophrenia, insomnia, obsessive compulsive disorder, morbid obesity, tracheostomy, (surgical opening for breathing) mechanical ventilator (breathing machine) at night. Resident 12 was a survivor of childhood sexual trauma. Resident 3's Annual Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 12 (mild cognitive impairment). The MDS indicated Resident 3 had not displayed any behaviors related to delusions, aggression or resistance of care. A progress note dated 8/23/23 at 4:07 PM indicated Resident 3 had been swearing and being sexually inappropriate. A Psychiatric Nurse Practitioner (NP) progress note dated 10/12/23 and signed 10/15/23 at 11:53 AM indicated Resident 3 had a history of sexually inappropriate comments and sexually inappropriate behaviors. Resident 3 had a history of physical and verbal aggression. Resident 3 had a history of abuse and/or neglect as a victim and as a perpetrator. A progress note dated 11/19/23 at 4:55 PM indicated Resident 3 often spoke in delusional fantasy themed conversations. A progress note dated 12/3/23 at 2:00 AM indicated Resident 3 refused their shower. Resident 3 had reported they did not want a man to assist with their shower. A progress note dated 1/6/24 at 4:16 AM indicated Resident had been verbally aggressive and had shoved their bedside table into the hallway. A progress note dated 1/6/24 at 6:10 PM indicated Resident 3 had been begging the staff to buy them alcohol. A progress note dated 1/7/24 at 6:20 AM indicated Resident 3 had made inappropriate sexual comments about a staff member's wife. A progress note dated 4/28/24 at 9:40 PM indicated Resident 3 made an inappropriate sexual comment to a staff member. A progress note dated 5/2/24 at 12:58 AM indicated Resident 3 had been making derogatory sexual comments and blaring loud music from their room. Resident 3 did not respond to redirection attempts. A progress note dated 5/2/24 at 2:53 PM indicated Resident 3 had been administered lorazepam due to increased behaviors and agitation. A progress note dated 5/15/24 at 4:35 PM indicated Resident 3 had been evaluated by the Psychiatric NP for yelling in the halls and increased behaviors. A Psychiatric NP progress note dated 11/29/23 and signed on 12/2/23 at 10:14 AM indicated Resident 3 had been obsessively focusing on their diet. A Psychiatric NP progress note dated 2/11/24 and signed 2/13/24 at 6:47 AM indicated Resident 3 had been frustrated because the resident had wanted a second meal tray before finishing their first meal. A Psychiatric NP progress note dated 5/15/24 at 7:27 PM indicated Resident 3 had been evaluated for increased delusions, hallucinations, anxiety, agitation and paranoia. Resident 3 had been yelling out and being inappropriate. A Psychiatric NP progress note dated 5/26/24 at 3:39 PM indicated Resident 3 continued to have anxiety while wearing their ventilator. Resident 3 had been prescribed lorazepam to be administered every 4 hours. A Psychiatric NP progress note dated 6/12/24 and signed 6/13/24 at 3:47 PM indicated Resident 3 had been evaluated for concerns of anxiety, depression, insomnia and a fixation on pickles. Resident 3's care plan dated 5/24/23 indicated the resident was a childhood sexual abuse survivor. The target goal was for Resident 3 to have minimal trauma related stress or anxiety by 9/24/24. Interventions included Resident 3 did not have any known triggers, avoidance of trauma related topics, providing support and assurance of safety. Resident 3's care plan dated 1/28/23 indicated the resident soaked their laundry in the sink, put their clothing on the floor and ate with their fingers. The target goal was Resident 3 would not soak their clothing in their sink through 9/24/24. Interventions included documentation of behaviors, praise for appropriate behavior, remind to use the facility laundry service. Resident 3's care plan dated 1/16/24 indicated Resident 3 refused to reduce clutter in their room. The target was for the resident to make informed choices and be aware of outcomes of resisting care by 9/24/24. Interventions included a calm approach, offer storage containers, allow the resident to maintain control. Resident 3's care plan dated 3/31/22 indicated the resident sometimes removed all the snacks from the resident pantry. The target was for the resident to have decreased behaviors by 9/24/24. Interventions included encouragement to take appropriate portions, redirection, praise for good behavior and mental health services as needed. Resident 3's care plan dated 11/7/23 indicated the resident would sometimes engage in self-gratification. The target was for the resident to be provided with privacy through 9/24/24. Interventions included positive reinforcement for appropriate behavior, encourage activities to decrease boredom, maintain safety, preserve dignity, if Resident 3 engages in self-gratification during care; immediately stop care and step away, use an opposite sex caregiver when necessary, close door and allow privacy. Resident 3's care plan dated 6/27/23 indicated the resident had a disturbed sleep pattern due to insomnia. The target was for the resident to report they feel rested through 9/24/24. Interventions included a restful environment, discouraging daytime naps, maintaining a bedtime routine and a bedtime snack. Resident 3's care plan dated 12/14/21 indicated the resident sometimes had aggressive behaviors such as throwing objects, throwing food, using racial slurs and making sexual comments. The target was for the resident to have decreased aggressive behaviors through 9/24/24. Interventions included approaching in a calm manner, alternating different staff, offering simple choices, approaching later, and providing education. Resident 3's care plan dated 1/26/22 indicated the resident was sometimes resistant to care. The target was for the resident to not have a functional decline through 9/24/24. Interventions included allowing choices, praise for appropriate behavior, avoiding power struggles, approaching later and providing education related to consequences of noncompliance. Resident 3's care plan did not address obsessive compulsive disorder or depression, interventions to identify and assess specific stressors, include pain as a possible stressor for aggression, nor include male caregivers as a possible stressor for refusal of care. In an interview on 7/2/24 at 11:56 AM, the Social Service Director (SSD) indicated they were aware of Resident 3's increased behaviors. The SSD indicated Resident 3's behaviors were reviewed in daily morning meetings and interdisciplinary (IDT) meetings. The SSD indicated specific behavioral triggers were attempted to be identified during IDT meetings. The SSD indicated Resident 3 denied specific triggers related to their history of trauma. The SSD indicated direct care staff were made aware of Resident 3's specific behaviors on daily assignment sheets. In an interview on 7/2/24 at 2:20 PM the Director of Nursing (DON) indicated Resident 3 had denied trauma related triggers. The DON indicated Resident 3 had refused to speak about their trauma history. The DON indicated they agreed stressors could be identified by other means than self-report. The DON indicated they agreed triggers could be identified by staff observances. Resident 3's Profile Care Plan Approach (used by direct care staff to provide resident care) provided by the Administrator on 7/2/24 at 2:15 PM indicated topics related to the resident's trauma should be avoided. The care plan approach did not include specific traumatic topics to be avoided. The care plan approach did not include specific stressors for aggression or resistance to care. A current facility policy dated 5/17 provided by the Social Service Director on 7/1/24 at 3:20 PM indicated the facility would identify experiences and symptoms that may indicate trauma. A current facility policy dated 2/22 provided by the Administrator on 7/1/24 at 4:10 PM indicated residents would be referred to behavioral health services in accordance with their comprehensive assessment and their plan of care. Symptoms of post-traumatic stress disorder (PTSD) can include insomnia, anxiety, and avoidance of thoughts or feelings associated with the event (NIMH, 2024). Risk factors for PTSD include exposure to traumatic events and a history of mental illness. Survivors of childhood sexual trauma have a higher prevalence of anxiety, depression and post-traumatic stress disorder, (National Center for PTSD, 2023) hoarding (and eating disorders (Journal of Eating Disorders, 2023). References National Institute of Mental Health, (nimh.nih.gov, 2024). https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd The National Center of PTSD, (ptsd.gov, 2023). https://www.ptsd.va.gov/understand/types/sexual_trauma_male.asp The Journal of Eating Disorders, (2023). https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-023-00819-7 3.1-43(a)(1)

Based on observation, interview and record review, the facility failed to conduct a thorough investigation of injuries of unknown origin for 1 of 2 residents reviewed (Resident B). Findings include: An Indiana report form, dated 1/7/24 at 12:17 p.m., indicated the local police had come to the facility for a reported assault on a dependent resident. The resident had an injury to her pubic area which had been determined to have been caused by incontinence and skin allergy. A head to toe assessment had been completed with no suspicious areas identified. On 1/10/24 at 2:43 P.M., Resident B was observed lying in bed attended by the facility wound nurse and Nurse 5. Upon hearing Nurse 5's voice, she opened her eyes, raised her eyebrows and smiled in response. Per Nurse 5, the resident was non-verbal and had the mentality of an infant due to her condition. The resident was observed to have multiple fading bruises that were brown, yellow, and green in color and were in discrete round shapes. She had 2 round bruises on her left upper arm that appeared about 1 inch long. Her right knee had 5 round shaped bruises over the kneecap. The left knee had 2 discrete round shaped bruises which appeared to be about 1/2 inch wide and 1 inch long with one bruise on the kneecap and the other to the outside of the knee. She had a round yellow bruise on the top right side of her mons pubis. There was very slight discoloration at the back of her right ankle. On her chest, were 2 round yellow bruises which were symmetrical and according to staff, was due to her shaker vest (inflatable vest attached to a machine which vibrates the chest to loosen and thin mucous in the lungs). The staff indicated the vest was getting too small for her to wear. On 1/10/24 at 10:48 A.M., Resident B's record was reviewed. The resident had resided at the facility for the past 18 months with a diagnosis of cerebral palsy and dependency on a ventilator. She was dependent on staff for all her care needs and was unable to move her body or extremities. An MAR (Medication Administration Record) dated January 2024 indicated the resident's routine weekly skin check was done on 1/3/23 by the night shift nurse. A routine weekly skin check dated 1/3/23 indicated the resident had no skin conditions noted. A progress note, dated 1/5/24 at 2:14 a.m., did not indicate any bruisign was observed. A Nurse Practitioner (NP) progress note, dated 1/5/24 at 5:01 p.m., indicated the NP visited the resident due to moisture related skin breakdown. Resident B was examined with the staff nurse and facility wound nurse present, No observations of bruising was documented. Progress notes indicated: -1/6/24 at 4:44 a.m., did not indicate any bruising was observed. -1/9/24 at 5:11 p.m., No injury was observed at time of assessment. Per resident's family member, Resident B had sensitive/friable skin and bruised easily. The facility investigation into the allegations, which included the police report, was provided by the Administrator on 1/10/24 at 11:00 A.M. The police report indicated at around 10:30 p.m. on 1/6/24, a call alleging assault of a resident had been received and police had responded to the facility. Nurse 2 and Nurse 3, nurses on duty during the visit, were interviewed. Both indicated Resident B had bruises all over her body along with other marks along her body they alleged were not normal. The officer observed bruises on the resident's ankles, knees, waistline and right upper arm and was told she had bruises on her chest. Staff indicated to the police officer, they were concerned a male resident may have gone into Resident B's room without permission due to his verbal behaviors with other residents, staff and visitors. The report indicated there was a video camera in the hallway which, based on the angle, may have shown if another resident had entered Resident B's room. On 1/10/24 at 10:42 A.M., the NP was interviewed. She indicated on Friday, 1/5/24, she was told the resident had skin breakdown. She, Nurse 5, and the facility wound nurse examined the resident and indicated the resident had some old bruises on her knees, behind one calf and above her mons pubis where her tubing sat. The resident had contractures to both upper and lower extremities and bruised easily due to fair and fragile skin. On 1/10/24 at 1:31 P.M., CNA 7 (Certified Nurse Aide) was interviewed. They indicated they provided direct care to the resident on Wednesday, 1/3/24 and had not observed any bruises on the resident. On 1/10/24 at 1:34 P.M., CNA 8 was interviewed. They indicated, on 1/5/24, they observed multiple bruises on the resident and reported it to the nurse. They indicated the resident had bruises on both knees, both ankles, top of pubic area, her right hip and right upper arm. On 1/10/24 at 3:53 P.M., Nurse 3 was interviewed. They indicated they had returned to work the evening of 1/5/24 after a week of vacation. It was reported to Nurse 3, by the CNA, the resident had several bruises. They examined the resident and observed multiple bruises on the resident's knees, ankles, arms, waist, and chest area. The bruises ranged in color and were purple, green, yellow, and brown and were in various stages of healing. The nurse reported the bruises to the DON who indicated they hadn't been aware of the bruises. On 1/6/24, the DON contacted Nurse 3, indicated the cause of the bruises was being investigated and may have occurred when given a shower the evening of 1/4/24. Nurse 3 indicated she'd never seen Resident B have bruises like those observed, while residing in the facility. On 1/10/24 at 4:22 P.M., the Administrator and DON were interviewed. The Indiana report form hadn't indicated the resident had bruises observed during the police investigators visit. The facility investigation hadn't indicated the cause, location of, or characteristics of the bruises reported by Nurse 3 and CNA 8. There were no statements collected from direct care staff who took care of the resident prior to and after the bruised areas were observed nor were other dependent resident's assessed for injuries of unknown source. There was no documentation regarding the male resident staff were concerned about and his possible wandering into the residents room. The DON bruising on the resident's chest and arms was thought to be due to the resident's too small shaker vest. She indicated the resident had severe contractures of her arms and legs and they may have been bumped while in the shower or when transferred in/out of her wheelchair. There was no documentation the shaker vest had become too small and was difficult to apply or potential for bruising to occur due to contractures when care was provided. When questioned if the video footage mentioned in the police report, was available to view, the DON indicated it had not been reviewed, but would retrieve it. The video footage was not provided prior to the survey exit. The Administrator provided a current copy of the facility policy titled Facility Abuse Prevention Guidance on 1/10/24 which stated the following: The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered .Following the discovery of any suspicious bruises, laceration or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration, or pain .An injury should be classified as an 'injury of unknown source' when all the following conditions are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time, or the incidence of injuries over time This deficiency relates to Complaint IN00425572. 3.1-28(d)

Based on interview and record review, the facility failed to ensure a resident's choice of bedtime for 1 of 3 residents reviewed (Resident P). Findings include: An Indiana report, dated 10/9/23, indicated on 10/8/23 at 8:15 p.m., Resident P had been wandering in the facility and refused to go to bed. She was put into bed against her wishes. On 10/26/23 at 10:18 A.M., Resident P's daughter was interviewed. She indicated on 10/8/23 around 8:06 p.m., the nurse caring for her mother called and indicated the resident had been going into other resident's rooms and had been taken back to her room where staff were trying to get her into bed. She tried to speak to her mother via the nurse's cell phone but the resident indicated she wanted to go home and hadn't wanted to go to bed. The nurse indicated the resident had to go to bed because of her wandering and she was transferred into bed. On 10/26/23 at 11:40 A.M., Resident P's record was reviewed. Diagnoses included vascular dementia, anxiety and depressive disorders. A significant change MDS (Minimum Data Set) assessment, dated 9/1/23, indicated the resident had severely impaired cognition. She was non-ambulatory but able to propel herself in the wheelchair. She had no mood indicators or behaviors. She was admitted to hospice services due to progressive decline in her condition. A care plan, dated 9/1/23, indicated activities the resident preferred included choosing her own bed time. The goal was to honor the resident's preferences. Interventions included: Ask the resident each evening what time she preferred to go to bed. A nurse note, dated 10/8/23 at 11:26 p.m., indicated the resident had been going into other resident's rooms on another hall. She was assisted to wheel back to her room where she was placed in bed. On 10/26/23 at 10:32 A.M., the DON was interviewed. She indicated the resident was able to choose when to go to bed and her wishes should've been honored. Staff could've offered the resident a warm drink, snack, or activity to deter her from wandering in her wheelchair. A current facility policy, titled Resident Rights, provided on 10/26/23 at 1:35 P.M., stated You have the right to choose your own activities, schedules (including sleeping and waking times), health care, and providers of health care services consistent with your interests, assessments, and plan of care This citation relates to Complaint IN00419195. 3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene procedures were performed during meal service during 1 of 3 observations. Findings include: In an observation on 7/26/23 at 11:24 AM, 14 residents were in the 300 hall dining room for lunch. During the observation, Dietary Aide 3 gloved both her hands. Dietary Aide 3 touched her glasses, moved around food containers, touched the tortillas, touched the handle of 2 utensils, then plated shredded cheese and lettuce without a utensil with both gloved hands. Dietary Aide 3 handed the 2 plates of food to another dietary aide to be served to residents. The Surveyor then intervened. In an interview on 7/26/23 at 11:28 PM, Dietary Aide 3 indicated she should have only touched food with one gloved hand. Dietary Aide 3 also indicated she should have used hand hygiene or changed her gloves after touching other items with her gloved hands. A current policy, dated 5/17, titled Hand Hygiene, was provided by the Administrator on 7/26/23 at 2:51 PM. The policy indicated hand hygiene is performed before and after handling food. The policy also indicated the use of gloves does not replace hand hygiene. 16.2-5-5.1 (f)

Based on observation, interview and record review, the facility failed to ensure food was stored, distributed, and served according to safety standards. 71 of 78 residents residing in the facility were provided meals by the facility kitchen. Findings include: On 2/14/23 at 9:00 A.M., a tour of the kitchen was completed with the Dietary Manager (DM). The following observations and interviews were made: -The dishwasher was observed with a heavy coat of limescale covering the machine from top to bottom. The bottom of the machine had 2 temperature dials for both the wash cycle and rinse cycle. The dials were covered with limescale and unreadable. The DM rubbed the limescale off both dials to get a temperature reading as she ran a load of dishes through. She opened and closed the dishwasher door several times before the wash cycle reached it's wash temperature of 165 degrees Fahrenheit (F). The dishwasher door didn't fit tightly to the base of the machine and hot water sputtered out around the door. The DM indicated they'd had repeated issues with the dishwasher and had the limescale removed on a regular schedule but hadn't known when it was cleaned last. -The DM indicated they were out of chemical strips to test for proper chemical sanitization and she would have to get some. -The reach-in refrigerator had a bag of deli ham opened and dated 2/1/23. The DM removed the package and indicated it should have been discarded 3 days after it had been opened. -A counter, across from the stove, had 2 shelves. The bottom shelf contained 3 large flat pans. Each held a variety of kitchen utensils, containers, large amounts of dried food debris and clumps of congealed cooking oil. -The stove had several burners on the right side and a grill on the left side. The grill side had positions for 3 knobs to turn on/off the grill but only had 2. The DM indicated the knob had been missing for some time and they would use one of the other knobs to turn on the grill. -A deep fryer had a tray covering the top with 2 fry baskets atop the tray. The DM indicated they usually cleaned the oil after using it to fry foods. After she moved the tray off the top, there was observed a heavy amount of floating food particles in the oil approximately 3 inches in width and clung around 3 of the 4 sides of the fryer. The oil had an odor. The DM indicated they didn't keep track of when the oil was changed and the fryer cleaned. -The walk-in refrigerator was crowded with a cart pushed into the center of the refrigerator. The cart contained 3 glasses of uncovered and undated chocolate milk. A pan holding a large pork loin was covered with saran wrap, and dated 2/9/23. The meat appeared dry with a dried on dark brown substance layered across the top of the meat along with tan colored spices. The DM indicated the pork loin had been left over from another meal. The temperature of the walk-in refrigerator was 46 degrees F. The DM indicated they kept the refrigerator temperature between 38-45 degrees F. A second temperature check of the walk-in refrigerator with the Administrator at 10:00 A.M. indicated the temperature was at 48 degrees F. He indicated the refrigerator temperature should be kept below 40 degrees. -The walk-in freezer was crowded with opened and unopened boxes sitting on the shelves and floor of the freezer. The boxes sat on their sides, upside down and upside right. The DM was unable to get to the thermometer in the freezer due to all the boxes scattered throughout. She indicated they had just received a load of food and were still organizing the freezer. During the tour of the kitchen, the DM wore a hair net that covered the top and sides of her hair but her shoulder length hair, at the back of her head remained out and uncovered by a hair net. An unidentified dietary employee came into the kitchen, crossed through the prep room and went to the walk in refrigerator to retrieve a carton of milk. He wore no hair net and had a full beard. On 2/14/23 at 11:05 A.M., an observation of the 300 hall dining room was completed. There was covered food sitting on the steamer table consisting of corned beef, cabbage, carrots, and rolls. At 11:20 A.M., the Chef and 2 dietary aides came into the dining room to serve lunch. 1 dietary aide had a tray of cupcakes sitting on top of a rolling cart. The cart had been brought from the kitchen and through the hallways uncovered. The Chef uncovered the food on the steam table and began to serve food on plates. The Chef hadn't checked the temperature of the food before serving residents. He used the same slotted spoon to serve up cabbage, and carrots, then placed a piece of corned beef over the top. He used tongs to place a roll on the plate. On 2/14/23 at 11:28 A.M., the DM was interviewed. She indicated food on the steam table should be temped prior to serving residents to ensure safe temperatures. She indicated the facility ensured the correct portion was provided to residents at each meal by using measured spoodles (a utensil-midway between a spoon and ladle that measures portions). She provided the daily diet spreadsheet. The spreadsheet indicated the amount of food to be served according to each resident's ordered diet. For lunch, residents who received a regular diet were to be provided with 3 ounces of meat and 4 ounces each of the vegetables served. She indicated the Chef should have used a 4 ounce spoodle for each vegetable served to ensure residents received the correct portions. On 2/14/23 at 12:08 P.M., the Administrator provided current facility dietary policies as follows: -Personnel Standards: Dietary personnel shall follow sanitary standards .Hair nets, covering all of the hair, must be worn at all times while on duty -Food Storage: Food storage areas shall be clean at all times .Cold foods shall be maintained at temperatures of 40 degrees F or below .Leftover food is stored and dated before being refrigerated. Leftover food is used within 3 days or discarded .Temperatures for refrigerators should be between 35-39 degrees F .Frozen Foods: All refrigerator units are kept clean and in good working condition at all times .All foods will be stored to allow adequate air circulation -Food Temperatures: The temperatures of the food items will be taken and properly recorded for each meal .All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F .Temperatures should be taken periodically to ensure hot foods stay above 135 degrees F .during the portioning, transporting and delivery process until received by the individual recipient This Federal tag relates to IN00400506. 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed in the required time frame for 4 of 4 residents reviewed. (Resident 7, Resident 8, Resident 12 and Resident 22) Findings include: 1. Resident 7's record review began on 8/11/22 at 8:49 AM. The record indicated a quarterly MDS with an ARD (Assessment Reference Date) of 6/16/22 had not been completed or transmitted within the 14 days required by the RAI (Resident Assessment Instrument) guidelines. 2. Resident 8's record was reviewed on 8/11/22 at 8:49 AM. The record indicated a quarterly MDS with an ARD of 6/28/22 had not been completed or transmitted within the 14 days required by the RAI guidelines. 3. Resident 12's record was reviewed on 8/11/22 at 8:49 AM. The record indicated a quarterly MDS with an ARD of 6/30/22 had not been completed or transmitted within the 14 days required by the RAI guidelines. 4. Resident 22's record was reviewed on 8/10/22 at 2:50 PM. The record indicated a quarterly MDS with an ARD of 7/20/22 had not been completed or transmitted within the 14 days required by the RAI guidelines. In an interview on 8/11/22 at 9:50 AM the MDS coordinator indicated the MDS should be completed and transmitted within 14 days of the ARD. A policy, dated 4/16, titled, Completion of MDS, was provided by the MDS Coordinator on 8/11/22, time unknown. The policy indicated the MDS Coordinator would determine the ARD for all MDS and notify the interdisciplinary Team 2 weeks prior to complete their assigned sections of the MDS assessments. The MDS Coordinator was to provide the date to the team that the MDS sections were to be completed. In addition, the MDS Coordinator was to transmit resident's MDS assessments to CMS at least weekly. The MDS 3.0 RAI Manual version 1.17.1, dated October 2019, was reviewed on 8/12/22 at 3:30 PM. The manual specific discussed MDS Assessment Code A0310A = 02, Non-Comprehensive Quarterly MDS on page 39. The code indicated ARD must be completed no later than the ARD of previous OBRA assessment of any type plus 92 calendar days. The code also indicates the MDS completion date must be no later than the ARD plus fourteen (14) calendar days. Furthermore, the code specified the transmission date no later than the MDS completion date plus (fourteen) 14 calendar days. 3.1-31(d)(3)

Based on interview, and record review, the facility failed to monitor side effects of medications for 5 of 5 residents reviewed. ( Resident 168, Resident 19, Resident 178, Resident 22, and Resident 32) Findings include: 1. Resident 168's record review began on August 12, 2022, at 2:45 pm. Diagnoses included [CONDITION(S)], anxiety, major depressive disorder, heart failure, and [CONDITION(S)]. The Medication Administration Record (MAR) dated August 2022 indicated the resident received [MEDICATION(S)] (antipsychotic) 75 mg at bedtime for [CONDITION(S)], [MEDICATION(S)] (blood thinner) 150 mg twice a day, vilazadone (antidepressant) 40 mg, [MEDICATION(S)] .5 mg twice a day as needed for anxiety and [MEDICATION(S)] (narcotic pain medicine) 5/325 mg every 6 hours as needed. The MAR did not indicate Resident 168 was monitored for side effects of the medications. The MAR indicated the resident received [MEDICATION(S)] .5 mg on August 9, 2022, and August 10, 2022, for a behavior issue. Niether the MAR nor the behavior monitoring record indicated the resident's behavior was being monitored. There were no diagnoses for the indication of [MEDICATION(S)], [MEDICATION(S)] or vilazadone in the record. 2. Resident 19's record review began on August 12, 2022, at 2:51 pm diagnoses included Alzheimer's disease, catatonic disorder, major depressive disorder, and dementia. The resident's physician's orders indicated the resident was to receive [MEDICATION(S)] (narcotic pain medicine) 5/325 mg 3 times a day and [MEDICATION(S)] 5 mg once every day for major depressive disorder. The physician's orders did not indicate the resident was to be monitored for side effects. There was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident 178's record review began on August 12, 2022, at 2:57 pm diagnoses included generalized anxiety disorder and unstable [CONDITION(S)]. The resident's physician's orders indicated the resident was to receive [MEDICATION(S)] (anti-anxiety) 5 mg 3 times a day for generalized anxiety disorder, [MEDICATION(S)] 5/325 mg every 6 hours for moderate to severe pain, [MEDICATION(S)] sublingual .4 mg tablets to be administered up to 3 doses every 5 minutes for chest pain, and [MEDICATION(S)] (antidepressant) 10 mg every day for major depressive disorder. The physician's order did not indicate the resident was to be monitored for side effects of medications. The physician's orders did not indicate an intervention for chest pain if 3 doses of [MEDICATION(S)] at 5-minute intervals was ineffective. During an interview on August 12, 2022 at 11:24 am RN 4 indicated residents should be monitored for side effects of antipsychotics and blood thinners. She indicated a physician's order to monitor for side effects would be included on the MAR. She indicated side effects of medications, behaviors and the effectiveness of pain medications are to be recorded on the MAR. 4. Resident 22's record review began on 8/12/22 at 3:36 PM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record (MAR) indicated Resident 22 received [MEDICATION(S)] (antidepressant) 75 mg, amount to administer: 225 mg once a morning for major depressive disorder and [MEDICATION(S)] (anticoagulant) 2.5 mg tablet twice daily for chronic [CONDITION(S)]. The MAR did not indicate Resident 22 was monitored for side effects of the medications given. 5. Resident 32's record review began on 8/12/22 at 2:43 PM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The MAR indicated Resident 32 received [MEDICATION(S)] (antidepressant) 20 mg capsule(1) twice daily on Monday, Tuesday, Wednesday, Thursday, Friday and once in the morning on Saturday and Sunday for major depressive disorder. The MAR did not indicate Resident 32 was monitored for side effects of the medication given. A policy, updated 1/2021, titled [CONDITION(S)] Medication, was provided by the Administrator on 8/12/22 at 3:25 PM. The policy indicated .ongoing documentation must include root analysis of behavioral indicators or symptoms, monitoring for efficacy and adverse consequences. The policy also indicated identified target behaviors will be monitored each shift along with individual interventions as well as supporting documentation in the clinical record. 3.1-48(a)(3)

Based on interview and record review the facility failed to ensure residents had quarterly care plan meetings for 1 of 3 residents reviewed for care plan meetings. (Resident 2) Findings include: In an interview on 8/9/22 at 10:19 AM, Resident 2 indicated he has not been invited to care plan meetings. Resident 2's record review was completed on 8/10/22 at 11:43 AM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Service Director (SSD) was interviewed on 8/10/22 at 1:30 PM. The SSD indicated residents should have at minimum quarterly care plan meetings. Resident 2 last had a care plan meeting on 1/7/22. A care plan meeting was scheduled on 3/17/2022 but the meeting was canceled. The SSD had not made any attempts to reschedule the care plan meeting. A policy titled Comprehensive care plans, dated 4/2017, was provided by the SSD on 8/10/22 at 3:53 PM. The policy indicated care plans are revised as changes in the resident's condition dictates, but no less than on a quarterly basis. 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to esure necessary eating and grooming assistance was provided to 1 of 1 resident reviewed. (Resideent 10) Findings include: During an observation on 8/9/2022 at 10:30 AM, Resident 10 was observed sitting in a wheelchair wearing a nightgown and sweater. Brown crumbs and pieces of a cookie were observed on the front of her nightgown. A partial cookie was observed on the floor near the foot pedal of the wheelchair. During an observation at 11:47 AM on 8/9/2022, observations of Resident 10 remained unchanged. At 12:45 PM on 8/9/22, Resident 10 was observed leaning forward and extending her right arm to reach a meal tray placed on a tray table positioned at an angle a few feet in front of her wheelchair. An unopened carton of milk and unopened container of juice were in the upper left corner of the tray beyond Resident 10's reach. Resident 10 was observed using a fork, piercing a serving of pulled meat, then shaking the fork. Resident 10 then placed the fork containing the meat in her left hand, pulling most of the meat off the fork until a bite sized portion remained. She extended her left arm toward the tray and when unable to reach it, tossed the meat back on the tray. Resident 10 reached for the baked potato on her tray, attempted to cut a piece with her fork several times before picking the whole potato up and using her fingers to bring it to her mouth to eat. Resident 10 attempted to tear open a packet of sour cream and began to bite it when unable to open it. In an interview at 12:56 PM on 8/9/2022 CNA 5 indicated packages should be opened, food should be cut up if needed and trays should be within reach when each tray is passed. On 8/11/22 at 10:23 AM, Resident 10 was observed sitting in her wheelchair dressed in a nightgown with one sock on her left foot and one sock (from her right foot) on the floor near her foot pedal. Resident 10's hair was disheveled and partially contained with a hair elastic. A care plan dated 4/12/2022 indicated refusals of care should be documented, and family should be notified. No care refusals were recorded in the progress notes from 8/1/2022 to 8/11/2022. A family interview conducted at 3:39 PM on 8/11/2022 did not indicate any notifications of refusals in the recent past. A policy titled Activities of Daily Living (ADLs) was received from the Director of Nursing at 9:30 AM on 8/12/22. The policy indicated residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good hygiene, grooming, and personal hygiene. 3.1-38(a)(2)(D)

Based on observation, interview, and record review, the facility failed to ensure provide professional standard of care. The deficient practice affected 3 of 3 residents reviewed. (Resident 168, Resident 174, and Resident 268). Findings include: 1. During an observation on August 9, 2022, at 11:54 am, Resident 168 was observed to have a peripherally inserted central catheter (PICC) in the right upper arm. Resident 168's record review began on August 9, 2022, at 1:40 pm, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order dated August 9, 2022, indicated the PICC should be flushed with 10 milliliters of saline twice daily and the PICC dressing should be changed weekly and as needed. A progress note dated August 10, 2022 indicated RN 11 received an order to discontinue Resident 168's PICC line. A review progress notes indicated the resident was evaluated by a physician on August 10, 2022, at 3:57 pm. A review of the admission assessment dated [DATE] did not indicate the resident had a PICC line. During an interview on August 10, 2022, at 2:50 pm, Resident 168 was alert, oriented and able to answer questions appropriately. He indicated the dressing on the PICC had not been changed since he arrived at the facility. He indicated the nurses flushed the PICC line occasionally. The PICC dressing observed was transparent with white adhesive around the edges. The date on the PICC dressing was unreadable due to the adhesive being loose and curled up around the edge of the dressing. Resident 168 pressed the curled edges of the dressing down. The date on the PICC dressing was July 30, 2022. During an interview on August 10, 2022, at 3:07 pm RN 4 indicated PICC dressings are usually changed every 7 days. During an interview on August 10, 2022, at 3:13 pm RN 11 indicated she visualized the date of July 30, 2022, on the Resident 168's PICC dressing. She indicated PICC dressings are generally changed weekly. During an interview with the DON on August 10, 2022, at 3:00 pm, she did not indicate Resident 168 was being seen by a physician. During continous observation on August 10, 2022 between 3:10PM to 4:30 PM of Resident 168's room and location, no physician was observed in the hallway, at the nurse station or to enter Resident 168's room. On August 11, 2022, at 12:03 pm the facility policy for PICC care was requested. The DON indicated there was no PICC care policy. A progress noted dated August 11, 2022, at 1:09 pm indicated Resident 168 had increased confusion and his blood pressure was 80/48. The resident was given a medication to help raise his blood pressure. A progress note dated August 11, 2022, at 2:48 pm indicated the resident's blood pressure was 89/48, an IV had been placed and he had received 500 milliliters of fluid. A progress note dated August 11, 2022, at 3:35 pm as a late entry for August 4, 2022, at 4:34 pm indicated Resident 168 was noted to have a PICC to right upper arm. A review of RN 11's employee file on August 11, 2022, at 5:37 pm indicated there was not a specific RN job description or an IV skills checklist in the employee file. A progress note dated August 11, 2022 at 3:57 pm as a late entry for August 10, 2022 at 3:57 pm indicated Resident 168's PICC dressing looked excellent on August the 4th and was in no need of a dressing change until the need to have it pulled at the time of evaluation. The same progress note indicated Resident 168 came to the facility with a PICC. The PICC had an excellent dressing, it did not require a dressing change due to the PICC being acutely placed at the hospital and was only placed a short time ago. The progress note indicated under the Assessment and Plan section, [CONDITION(S)] left lower leg: patient had a PICC with an excellent dressing on admission and had no need for change. The PICC could be removed after evaluation. The progress note was signed by RN 17 on August 11, 2022, at 11:51 and MD 1 on August 11, 2022, at 12:47 pm. In an interview on August 11, 2022, at 4:36 pm, RN 11 indicated the PICC catheter was intact, was 46 centimeters long, and a pressure dressing was applied after removal.During an interview on August 11, 2022, at 3:20 pm, the DON indicated the facility did not have a policy or procedure guide for PICC care or PICC removal. She indicated she could print a skills validation checklist if needed. She indicated medical records had the PICC measurements until the hospital documentation was scanned into the computer. She indicated medical records staff had been off work. When quiried why the PICC was not indicated on the facility matrix, admission assessment, care plan, or added to physician orders she indicated she was sure the admitting nurse was aware of the PICC due to the admitting nurse had texted the DON and mentioned a PICC. The DON indicated she did not understand the concern about Resident 168's PICC dressing due to the PICC being discontinued. During an interview on August 11, 2022, at 2:41 pm, RN 11 indicated she had received an order to remove the PICC due to non-use. She indicated she did not assess the resident's blood pressure prior to removing the PICC. She indicated the resident's shift blood pressure check was okay. She indicated she did not request Resident 168 to bear down during PICC removal, she did not use a petroleum-based dressing, and she did not assess the resident's blood pressure after the procedure. She indicated the catheter had a straight edge and was 46 centimeters long. She indicated she did not have access to the prior measurements due to the PICC information being in medical records or the DON's office. She indicated she did not refer to a policy or procedure guide prior to removing the PICC. She indicated she was not aware of a PICC removal policy or procedural checklist. She indicated she had not received training related to PICC removal or care. She indicated she had not been required to demonstrate PICC removal skills upon hire. During an interview on August 11, 2022, at 3:57 pm, LPN 15 presented a document titled Observation Detail List Report dated August 5, 2022, at 11:46 am. She indicated it was a baseline care plan she completed when the resident was admitted , however, only the IV and skin sections were completed. She indicated the initial base line care plan had to be completed within 48 hours. LPN 15 presented a document titled Event History. An entry dated August 5, 2022, at 11:10 am indicated she had notified the Nurse Practitioner (NP) about the PICC. During an interview on August 11, 2022, at 4:33 pm, Resident 168 indicated he did not feel well and had felt terrible since last evening. His skin was observed to be pale in color, he had his eyes closed and had an IV in his right forearm. During an interview on August 11, 2022, at 4:40 pm, the IP presented a document titled PICC Removal-Action/Rationale. She indicated this guide was provided for staff to use for PICC removal. She indicated the guide is available at each nurse station. The guidelines included but were not limited to having the resident bear down during removal, applying petroleum-based ointment to exit site, and measuring the catheter and arm circumference. The IP indicated the PICC Removal-Action/Rationale was to be used by RNs when removing a PICC. During a review of Resident 168's progress notes on August 12, 2022, at 12:14 pm, there was no indication Resident 168 had been evaluated by a physician on August 4 or 10th, 2022. There were no other orders regarding the PICC line. An admission assessment provided August 12, 2022 dated August 4, 2022, at 2:53 pm indicated the resident's PICC measured 46 centimeters (cm) length, 34 cm arm length, and 10 cm arm circumference. The measurements did not correlate to the IV Insertion Record. On August 12, 2022, at 9:49 am a record review of the Facility Assessment indicated IV training in-services would be provided annually. During an interview on August 12, 2022, at 11:24 am, RN 4 indicated she could not locate skill checklists at the nurse's station. She indicated she did not recall being trained to perform PICC care at this facility. During an interview on August 12, 2022, at 4:10 pm, the Administrator indicated there had been no in-services for PICC care in the last 4 months. He indicated the DON had informed him RN 11's PICC skills checklist was unavailable and must be storage. During an interview on August 12, 2022, at 12:05 pm, the DON indicated Resident 168's PICC line was assessed upon admission as the PICC was noted on the initial baseline plan of care. The initial baseline care plan was incomplete, and the bare minimum was all that was required for 48 hours. She indicated the facility did not have a policy for initial baseline care plans. The DON indicated she texted the information to RN 11 and told RN 11 what should be documented. She indicated the information was documented on the medication administration record (MAR). The DON indicated she did not understand why there was still a concern since the resident had been evaluated by the physician on Wednesday August 10, 2022. She indicated the physician reported to the DON the PICC dressing had been fine upon admission and therefore did not need to be changed prior to August 10, 2022. She indicated she could provide 4 months worth of in-service attendance records. She indicated the facility did not have a policy for obtaining physician orders. A record review of the IV Catheter Insertion Record dated July 30, 2022 indicated Resident 168's PICC measured 46 centimeters total length, 46 centimeters insertion length, 34 centimeters arm circumference, and the catheter insertion site measured 10 centimeters above the right antecubital space (the bend in the arm). A review, of the MAR dated August 2022 indicated Resident 168's PICC had not been flushed between August 4, 2022, until August 9, 2022. The MAR indicated the PICC had not been monitored between August 4, 2022, until August 9, 2022. According to Nursing 2022, the professional standard of care for PICC maintenance is to flush each lumen with 10 millimeters of saline twice daily. PICC removal professional standard of care consists of but is not limited to placing the resident in supine position, remove catheter slowly, apply light pressure for 1 minute, apply a petroleum-based ointment dressing, have the resident remain lying down for 30 minutes, and observe the resident for complications for the next 24 hours. [NAME] Hopkins Medicine, 2022 indicated some complications of PICC removal are PE and DVT. Symptoms of PE can include shortness of breath, confusion, chest pain, and low blood pressure, anxiety, and chest pain Failure to flush a PICC line can lead to complications such as occlusion of the line and/or blood clots. References Nursing (2022). https://www.journals.lww [NAME] Hopkins Medicine (2022). hopkinsmedicine.org/health/conditions-and-diseases/pulmonary- embolism 2. Resident 174's record review began on August 10, 2022, at 11:43 am. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission MDS (Minimum Data Set) indicated Resident 174's BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). A progress noted dated August 7, 2022, at 4:48 pm indicated Resident 174 had inquired about staple removal. The progress note indicated the NP was contacted and the staples were to be removed on August 8, 2022. A care plan review did not indicate Resident 174 had staples in place to the left side of his head. A review of Resident 174's physician orders did not indicate any staples were scheduled to be removed. The orders indicated Resident 174 had appointments scheduled to be seen at the wound clinic and by a urologist, but there was no note regarding staples. A progress note dated August 4, 2022, at 11:34 am did not indicate Resident 174 had staples to his head. A progress note entered by the NP dated August 4, 2022, at 3:51 pm did not indicate the resident had staples in place to his head. The NP progress note indicated Resident 174 had a normocephalic head. During an interview on August 9, 2022, at 10:10 am, indicated he had staples in place on the left side of his head. The resident indicated he was advised at the hospital the staples should be removed in 10 days. The resident was wearing a hospital wrist band dated July 24, 2022. He indicated the nurses told him they could remove the staples at the facility but would not tell him when it could be done. The laceration was observed to be well approximated with areas of dry skin in between the staples. He indicated he had asked the nurse about removing his hospital arm band and removing the staples from his head. He indicated the nurse told him she would find out when staples could be removed. Resident 174 suggested he should return to the hospital to get the staples removed. During an interview on August 10, 2022, at 2:04 pm, RN 11 indicated she was not aware of when the resident's staples were to be removed. She indicated the resident had 2 upcoming appointments this month and was likely to get the staples removed during one of the appointments or they would receive orders to remove the staples at the facility. RN 11 indicated she was not aware of a facility policy for staple removal. She indicated from prior nursing experience that staples are usually removed after 10 days. On August 10, 2022, at 4:18 pm a document titled Removing Sutures was found on the conference room table. The document was reviewed. The document did not indicate the amount of time sutures ahould be left in, but was primarily a procedure for removal. During an interview on August 11, 2022, at 11:45 am, the DON indicated the facility did not have a policy for suture removal. She indicated she had provided a policy for suture removal the previous day. On August 11, 2022, at 2:24 pm LPN 15 presented physician orders and a care plan for Resident 174. The physician orders were reviewed and did not indicate the resident had staples to his head that needed removed. A review of the care plan indicated the care plan was created on July 29, 2022. The resident's head staples were not indicated on the care plan. On August 11, 2022, at 4:50 pm LPN 15 presented progress notes for Resident 174. The progress note dated August 5, 2022, at 6:34 am was recorded as a late entry for August 4, 2022, at 11:34 am. The late progress note indicated Resident 174 was admitted to the facility with staples in place to the left side of his head. The progress note did not indicate the laceration had been measured. A progress note by the NP on August 11, 2022, at 3:51 pm was recorded as a late entry for August 4, 2022, at 3:51 pm. The entry by the NP indicated Resident 174's head was normocephalic. The NP did not indicate the resident's staples as an issue in the assessment and plan section. The NP did not indicate the resident had a head laceration with staple repair in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note by the NP dated August 11, 2022 at 3:49 pm as a late entry for August 8, 2022 at 11:12 am indicated Resident 174 had a scalp laceration with staples intact and she recommended leaving the staples in place due to delayed healing. The NP indicated she would re-evaluate the resident on August 10, 2022. The progress note was electronically signed by the NP on August 11, 2022, at 10:10 am. The NP progress note indicated the chief complaint for the visit was to evaluate a scalp laceration. The following was noted in the progress notes: Under review of systems: Line 3 indicated: Eye: Reviewed and Normal/Negative Skin: scalp laceration Under Physical exam: Line 10 indicated: Head, ear, nose, throat: Normocephalic skin: Normal temp, scalp laceration with staples, delayed Line 11: Neck: Normal appearance of the Neck wound healing noted, no symptoms of infection Under Assessment and plan: Line 1 indicated: Scalp laceration: Re-evaluate scalp laceration 8/10/22 Line 2 indicated: May remove staples to scalp if healed appropriately Under Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Line 1 indicated: S01.02XD-Laceration with foreign body of scalp, subsequent encounter A progress noted entered by the MD dated August 11, 2022, at 3:56 pm as a late entry for August 10, 2022, at 3:56 indicated Resident 174 was evaluated by the MD for an acute head wound. The MD indicated the head wound did not seem ready for staple removal on admission, but it looked good at the time of evaluation. The MD indicated the resident was seen acutely for re-evaluation of staple wound due to the wound not being stable enough for staple removal but is now stable. Head laceration with staples was not indicated in the admission information related to the MD visit. The MD indicated the resident's head was normocephalic. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the DON on August 10, 2022, at 3:00 pm, she did not indicate Resident 174 was being seen by a physician. During continous observation on August 10, 2022 between 3:10PM to 4:30 PM of Resident 168's room and location, no physician was observed in the hallway, at the nurse station or to enter Resident 168's room. According to Nursing 2022, professional standard of care for staple removal is 7 to 14 days (Nursing, 2022). Reference Nursing (2022). journals.lww.com/nursing/Removing_sutures_and_staples.23.aspx 3. During a record review on 8/10/22 at 2:10 PM, Resident 268 received hospice services begining 7/9/2022. The comprehensive care plan in the medical record dated 7/14/2022 did not address hospice services. During an interview on 8/10/22 at 2:36 PM, the Social Services Director indicated a care plan addressing hospice service should have been completed. A care plan addressing Hospice services was presented by the Social Services Director with a date of 8/10/22 at 3:40 PM on 8/10/22. A document titled Nursing Facility Agreement dated July 9, 2022, was received from the Social Services Director at 2:48 PM. The Nursing Facility Agreement, page 2, item 4.2.1 indicated the Hospice staff should have collaborated with facility staff in the care planning process including establishing how communication should be documented. A document titled Initial Baseline Care Plan on admitted d 7/9/2022 was received from the MDS Coordinator on 8/10/2022 at 5:26pm. The Initial Baseline Care Plan checklist indicated that care and services should be coordinated with Hospice team. 3.1-37(a)

Based on record review and interview the facility failed to ensure urine output was documented in 1 of 1 resident reviewed with catheter. (Resident 66.) Findings include: The record of Resident 66 was reviewed on 08/12/22 at 3:37 PM. Resident 66's record indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 66's admission Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) was a 15. This indicated the resident was alert, oriented, and able to be interviewed. The resident's Section H Bladder and Bowel assessment indicated she had an indwelling catheter (including suprapubic and nephrostomy tube). Resident 66's Care Plan indicated a problem category of indwelling catheter. The care plan specified the resident required a suprapubic catheter due to a [CONDITION(S)] bladder. One intervention indicated to document the suprapubic catheter urinary output every shift, twice a day . The intervention was dated 6/30/22. Resident's 66's Vital Report of urine output dated between 7/13/22 to 8/11/22 was reviewed. The report indicated the resident's urine output was not recorded on the following dates: 7/14/22 PM, 7/19/22 AM, 7/21/22 PM, 7/22/22 AM, 7/23/22 PM, 7/25/22 PM, 7/28/22 PM, 7/30/22 PM, 8/2/22 PM, 8/5/22 PM, 8/7/22 AM, 8/8/22 AM, 8/9/22 PM and 8/11/22 PM. In an interviewed on 08/12/22 at 2:18 PM, CNA 8 indicated Resident 66's suprapubic catheter was to be emptied every shift and output charted. She further indicated the charting does not show it was documented every shift. In an interview on 08/12/22 at 2:24 PM, RN 7 indicated Resident 66's suprapubic catheter charting did not show urine output documentation every shift every day. A Policy for suprapubic catheter monitoring/documentation of urine from Executive Director (ED) was requested on 8/12/22 at 3:00 PM. A document, revised 5/17, titled Suprapubic Catheter Care was received by the ED on 8/12/22 at 3:30 PM. The document contained no information concerning monitoring/documentation of urine from a suprapubic catheter. No further documentation was provided prior to exit from the facility. 3.1-41(a)(1)

Based on observation and interview the facility failed to ensure garbage and refuse were contained inside the dumpster for 1 of 1 observation. Findings include: An observation was made of the dumpsters with Maintenance 3 on 8/10/22 at 1:30 PM. There were plastic bags, papers, drink cups, food containers and plastic eating utensils on the ground around the dumpster. Both dumpsters had open lids with cardboard boxes sticking out of the top of one dumpster. Maintenance 3 was interviewed on 8/10/22 at 1:30 PM. Maintenance 3 indicated the maintenance staff maintained the dumpster. Maintenance 3 indicated there should not be trash lying on the ground around the dumpsters and lids should be closed. The Executive Directive (ED) was interviewed on 8/10/22 at 2:01 PM. The ED indicated there should not have been anything on the ground around the dumpster. 3.1-21(i)(5)

Based on interview and record review, the facility failed to assess, track and provide necessary care and treatment to pressure ulcers for 2 of 3 residents reviewed (Resident H and Resident J). The deficient practice resulted in Resident H and Resident J's wounds worsening and/ or becoming infected and requiring treatment with antibiotics. Findings include: 1. On 6/1/20 at 11:35 P.M., Resident H's record was reviewed. [DIAGNOSES REDACTED]. A Nurse Progress note, dated 04/28/20 at 5:45 p.m., indicated the resident was admitted to the facility. She was alert and oriented with long and short term memory intact. Skin assessment indicated she had multiple wounds and would have the wound care physician to follow. An admission MDS (Minimum Data Set) assessment, dated 5/5/20, indicated the resident had a BIMS (Brief Interview Mental Status) score of 15 which signified she had no cognitive impairment. She required extensive assistance from 2 staff for bed mobility and personal hygiene and was frequently incontinent of bowel. She had 1 Stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) and 1 surgical wound. A Care Plan, dated 4/28/20 and updated 4/30/20, indicated the resident was at risk for skin breakdown related to decreased sensory perception, bowel and bladder incontinence, bedfast, required assistance with mobility while in bed/chair, and risk for friction and shear. The goal was the resident would remain free from serious complications related to skin breakdown. Interventions included, but were not limited to, avoid shearing resident's skin during positioning, transferring, and turning; notify MD of changes; report any signs of skin breakdown; and weekly skin assessment. There was no care plan developed to address the resident's pressure ulcers identified upon admission to the facility. A Weekly Treatment (Non Pressure Ulcer) Documentation form, dated 4/29/20 at 8:11 p.m. and completed by the facility wound nurse, indicated Resident H was admitted to the facility with multiple wounds which included, but were not limited to: Wound A- located on the left lateral shin was covered with eschar (Dead or devitalized tissue that was hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) that measured 6.6 cm x 3.2 cm. A Physicians order, dated 4/29/20, was for the left lateral/outer calf to be washed with water and soap, patted dry, and Xeroform and dry dressing applied 2 times per day. A Weekly Treatment (Non Pressure Ulcer) Documentation form, dated 5/6/20 at 11:42 a.m., indicated Wound A remained with an eschar and measured 6.6 cm x 3.2 cm. Wound interventions remained effective, improvement was noted, and staff were to continue the current plan of care. There were no assessments or measurements of Wound A found between 5/6 and 5/18/20. Wound Management Documentation, dated 5/18/20 at 2:30 p.m., indicated Wound A on the left lateral/outer calf measured 7.5 cm x 5 cm. The wound bed was completely covered by black eschar and was draining light [MEDICAL CONDITION] (serum and pus) drainage. The wound healing status was noted to be stable. The resident was to be seen by the facility wound care physician on 5/19/20. An Initial Wound Evaluation and Management Summary by the wound care physician and dated 5/19/20, indicated Wound A was an unstageable pressure wound that measured 7.5 cm x 5 cm. The wound bed was 90% covered with black thick adherent necrotic tissue and 10% slough. The wound was draining light serous drainage. The wound was surgically debrided and new treatment orders given to cleanse the wound with wound wash, pat dry, apply Santyl to the necrotic wound bed, and secure with an island dressing 1 time per day. Wound B-located on Resident H's right lower abdomen, classified as a bruise, was purple in color without any open areas. The area measured 7 cm x 7.8 cm. A physician order, dated 4/29/20, was for the right lower abdomen to be washed with water and soap, patted dry, and Xeroform and dry dressing applied 2 times per day. A Weekly Treatment (Non Pressure Ulcer) Documentation form, dated 5/6/20 at 11:42 a.m., indicated Wound B remained on the resident's right lower abdomen, presented as bruising. The area measured 7 cm x 7.8 cm. There were no assessments or measurements of Wound B found between 5/6 and 5/18/20. Wound Management Documentation, dated 5/18/20 at 2:22 p.m., indicated Wound B, located on the resident's right lower abdomen measured 10 cm x 12 cm. The wound was draining light [MEDICAL CONDITION] drainage. The wound was unstageable and was 100% covered with necrotic tissue. The wound healing status was noted as stable. The resident was to be seen by the facility wound care physician on 5/19/20. An Initial Wound Evaluation and Management Summary by the wound care physician and dated 5/19/20, indicated Wound B was a Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer due to shear, under the pannus (dense layer of fatty tissue on the lower abdomen) of an obese patient. The area measured 10 cm x 12 cm and had moderate serous drainage that had a foul odor. The wound bed was 10% covered with thick necrotic tissue, 50% slough, and 40% granulation tissue. The wound was surgically debrided and new treatment orders given to cleanse the wound with wound wash, pat dry, apply Santyl to the necrotic wound bed, sprinkle [MEDICATION NAME] (anti-fungal) to the wound bed to control odor, cover with Alginate dressing and secure with an island dressing. Nurse Practitioner progress notes, dated 4/30, 5/1, 5/6, 5/8, 5/12, 5/16 and 5/18/20 indicated Resident H had been admitted with several wounds which were being monitored and treated by the facility's wound doctor. The NP progress note, dated 5/16/20 at 9:27 a.m. for the 30 day admit regulatory visit, indicated the facility wound care physician would continue to follow and treat for complicated wounds. The note indicated to refer to the wound care physician notes for further details. A review of the notes of the wound care physician indicated he had not begun treatment for [REDACTED]. 2. On 6/1/20 at 1:36 P.M., Resident J's records were reviewed. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 5/12/20, indicated the resident was in a comatose state. She was dependent on 2 staff for bed mobility, transfers, toileting and personal hygiene. She was always incontinent of bowel and bladder. Resident J was admitted with 3 unstageable pressure ulcers and other open [MEDICAL CONDITION]. Care plans, dated 5/5/20, indicated the resident had pressure wounds to her left gluteal/buttock, right heel and left heel. The goal was that she would have no complications related to skin breakdown. Interventions included, but were not limited to, monitor skin condition per protocol and monitor for signs/symptoms of infection. A Nurse Progress note, dated 5/5/20 at 6:31 p.m., indicated the resident had been admitted to the facility. A head to toe skin assessment was completed by 2 staff nurses and the facility wound nurse which included, but were not limited to the following wounds: -Pressure area to right heel which measured 1.6 cm x 2.6 cm. -Pressure area to left heel which measured 0.8 cm x 0.6 cm. -Shearing to the coccyx which measured 2.4 cm x 2.5 cm x 0.1 cm. -Shearing to the left and right side of anus had an area of excoriation that measured 4 cm x 4 cm x 0.1 cm. The documentation did not include a description of the wound bed, drainage, margins/surrounding skin, or odors. There was no documentation regarding an area to the coccyx. A Skin Integrity Observation form, completed by the facility wound nurse on 5/5/20 at 3:29 p.m., indicated Resident J had wounds which included, but were not limited to: -Left buttocks with an eschar-there were no measurements documented. -Anal: excoriation with hemorrhoids that measured 4 cm x 4 cm. -Right heel that had a thin eschar and measured 1.6 cm x 2.6 cm. The area was callused and blanchable without drainage. -Left heel that had a light brown eschar that measured 0.8 cm x 0.6 cm. The heel was blanchable and heavily callused with no drainage observed. No documentation was available for review regarding the area to the coccyx. A Physician order, dated 5/6/20, was to cleanse the left gluteal/buttock wound with water and soap, pat dry, apply [MEDICATION NAME] 1.3% cream, then normal saline moistened Kerlix with [MEDICATION NAME] covered with a large foam dressing 1 time per day. There were no other treatments ordered for the coccyx, anal, or bilateral heel wounds. A Weekly Treatment (Non Pressure Ulcer) Documentation record, dated 5/11/20 at 11:39 a.m., indicated the following wound assessments and measurements: -Left gluteal/buttock had a sloughing wound bed that measured 6.1 cm x 6.3 cm. -Right heel remained unchanged with an eschar that measured 1.6 cm x 2.6 cm. -Left heel remained unchanged with a light brown eschar that measured 0.8 cm x 0.6 cm. The record indicated current interventions for the wounds were effective and improvement was noted. There was no documentation regarding an area to the coccyx. Nurse Practitioner Progress notes, dated 5/8, 5/11, 5/13, and 5/14 indicated the resident had miscellaneous wounds and the current treatment plan should continue. A Skin Integrity Observation form, dated 5/13/20 at 11:45 p.m., indicated the resident had a necrotic area to her left buttock and left and right heels and excoriation to the anus. The documentation did not include a description of the wound bed, drainage, margins/surrounding skin, or odors. There were no orders to indicate treatments should be completed to the areas on the heels, coccyx, and anus Nurse Progress notes dated 5/13/20 and 5/14/20 indicated the resident's blood sugars had run high which required NP notification and additional insulin doses administered. A Physician order, dated 5/14/20 at unknown time, was for [MEDICATION NAME] be applied to both of the resident's heels 1 time per day. A Nurse Progress note, dated 5/18/20 at 10:02 a.m., indicated staff had been providing care to the resident when the wound on her buttocks was noted to have a foul smell. The NP was notified and orders were given to have the facility wound nurse culture the wound. The resident's coccyx wound had a foul odor which was new. At 12:34 p.m., new orders were given to administer Keflex (antibiotic) after the coccyx wound was cultured, for coccyx wound infection. At 10:24 p.m., Resident J's spouse called the facility and expressed concern that the resident now had an infection to her coccyx wound. Wound Management Documentation, completed by the facility wound nurse and dated 5/19/20 at 7:20 a.m., indicated the following: -Left gluteal/buttock wound measured 8.6 cm x 7.5 cm and was unstageable. The wound had moderate [MEDICAL CONDITION] foul smelling drainage. The wound was covered 100% with necrotic tissue and the skin surrounding the wound was dry, thin, and weepy. -Right heel wound measured 2.2 cm x 2.6 cm and was covered 100% with necrotic tissue. -Left heel wound remained unchanged with a light brown eschar that measured 0.8 cm x 0.6 cm. The resident was to be seen by the facility wound care physician on this date. An Initial Wound Evaluation and Management Summary by the wound care physician and dated 5/19/20, indicated the following: -Left gluteal/buttock wound was an unstageable pressure area that measured 8 cm x 8 cm and had a depth of 7.5 cm. The wound was surgically debrided and treatment orders given to clean the wound with wound wash, pat dry, apply a thin layer of Santyl to the necrotic area and secure with a foam dressing 4 times per week. -Right and left heels were to remain being treated with [MEDICATION NAME] applied to both heels 1 time per day. -Unstageable pressure ulcer wound was noted to the sacrum and measured 7 cm x 5.5 cm. The wound bed had 20% necrotic tissue, 30 % slough, and 50% granulation tissue. The area was surgically debrided and treatment orders given to cleanse the area with wound wash, pat dry, apply Hydrogel to the wound bed and secure with island dressing 4 times per week. There was no documentation found to indicate the facility had identified the unstageable pressure ulcer wound to the resident's sacrum prior to being treated by the wound care physician on 5/19/20. A NP progress note, dated 5/20/20 at 7:57 a.m., indicated it was a follow up visit for the resident's lab results received that showed an elevated white blood count. The resident had a wound culture of the coccyx wound completed and were awaiting the results. The resident continued on Keflex for the wound infection. A Nurse progress note, dated 5/21/20 at 3:14 p.m., indicated the resident's coccyx/buttocks were black in color, necrotic, and had a foul smell. The resident's family were insisting that she be sent to the hospital for evaluation of elevated blood sugars. An order was obtained and the resident transferred to the hospital, where she was improving. On 6/1/20 at 12:24 P.M., the facility wound nurse was interviewed. During the interview, she indicated that due to some changes in facility policies, there was no consistency with documentation of wounds or wound assessments made by staff. She indicated she tried to keep up with the facility's wounds and their assessments and tracking but this did not always occur timely and there were some wound assessments that had been completed but not documented in the resident's record. When questioned, she indicated she did not know what the facility criteria was for getting the facility's wound care physician involved in residents care despite completing rounds with this doctor every Tuesday. She indicated the facility tried to manage minor wounds themselves and would involve the wound care physician if they weren't able to manage them. She indicated she had not yet received formal training on wound care and was not wound care certified. On 6/3/20 at 1:05 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated she was not aware of the criteria set for the wound care physician to be involved in resident's care but she would try to find out. She indicated staff were expected to follow the facility's pressure ulcer policy and procedures and were all re-educated on these policies on 5/27/20 after discovery that wounds were not being assessed, monitored, and documented according to their policies and procedures. The DON indicated the facility wound nurse was, at this time, scheduled for 4 days per week to manage wounds and round with the wound care physician. On 6/3/20 at 2:00 P.M., the DON provided an addendum to the facility's wound care policy which she had just received and indicated the following: Residents with Stage 2 pressure ulcers will be referred to the wound care physician for follow up. The DON indicated residents who had a Stage 2 pressure ulcer or higher would be referred and seen by the facilities wound care physician. On 6/3/20 at 12:36 P.M., the DON provided a current copy of the facility policy titled Pressure Ulcer Prevention Protocol. The policy indicated the following: Residents will be assessed to determine their risk factor(s) for pressure ulcer development .Residents who receive treatment for [REDACTED].the plan of care will include the presence of the pressure ulcer and include the individual description of the treatment plan .the physician will be notified when the assessment indicates a lack of progress in healing .Wound Assessment Policy and Procedure: It is the policy of this facility to do a systemic, ongoing wound assessment on all wounds .A complete wound assessment will be done weekly by a licensed nurse for all wounds, ulcers, and impairments in skin integrity .wound assessments will be documented in the Weekly Pressure Ulcer Documentation Observation .the wound assessment will contain the following information: wound classification, wound location, pressure ulcer staging or description of the extent of tissue damage, description of the wound bed, drainage, margins/surrounding skin, and odor, wound measurements, and wound related pain This Federal tag relates to Complaint IN 943. 3.1-40(a)(2)

Based on interview and record review, the facility failed to assess, monitor, and treat a resident's multiple pressure ulcers for 1 of 3 residents reviewed (Resident B). The deficient practice resulted in the wounds becoming infected, resident hospitalization , and death due [MEDICAL CONDITION]. The immediate jeopardy began on 10/29/19 when Resident B was admitted to the facility with three pressure ulcers; the facility failed to identify and treat one pressure ulcer and failed to monitor and treat the other two. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on (MONTH) 7, 2020 at 12:45 PM. The immediate jeopardy was removed on 2/10/20, but noncompliance remained at the lower scope and severity of isolated , no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 2/6/20 at 12:35 P.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 11/5/2019, indicated the resident had a BIMS (Brief Interview Mental Status) score of 15 which signified he had no cognitive impairment. The resident had no refusal of care. The MDS indicated during the assessment period, bed mobility did not occur. He had an indwelling catheter and was always incontinent of bowel. Resident B was assessed to have 2 unstageable pressure ulcers which were present upon admission. A Care Plan, dated 11/11/19, indicated the resident had 2 unstageable pressure ulcers to the coccyx related to history of [DIAGNOSES REDACTED], dependent for mobility, recent hospitalization , and incontinence. The goal was the resident would have no serious complications from skin breakdown. Interventions were: Braden assessment per protocol, dietician to follow weekly, monitor for s/s infection, monitor skin condition per protocol, notify MD of changes, treatments as ordered, and turn and reposition program per protocol. Hospital discharge orders, dated 10/28/19 at unknown time, indicated in Wound Care Instructions: See attached Wound Treatment Administration Record. The attached Wound Treatment Administration Record indicated the following treatments: 1. Wound to upper coccyx/back: Cleanse with soap and water, pat dry, apply Maxsorb and border gauze twice daily and PRN (as needed). 2. Wound to rectum/coccyx: Cleanse with soap and water, pat dry, apply Iodosorb to slough area, dust with stoma powder, spray with skin prep spray and cover with [NAME]'s Butt cream. 3. Wound to right hip: Cleanse with saline, pat dry, apply Iodosorb to slough, Maxsorb to open areas, spray skin prep to intact skin and cover with bordered gauze. Hospital Wound Assessment Reports, dated 10/28/19 at 8:27 p.m., indicated measurements as follows: 1. Upper coccyx/back: Unstageable ulcer which measured 4 cm x 9 cm x 1.30 cm with slough in the base of the wound. 2. Rectum/ coccyx area: Stage 3 (Full thickness tissue loss-Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling) ulcer which measured 10.5 cm x 9 cm x unknown depth with sough in the base of the wound. 3. Right hip: Stage 3 ulcer which measured 8.5 cm x 9.5 cm x unknown depth with slough in the base of the wound. A Nurse Progress note, dated 10/30/19 at 1:54 a.m., indicated the resident had been admitted to the facility on [DATE] at 9:50 p.m. via ambulance. He was alert and oriented and able to make his needs known. He communicated by mouthed words due to having a vent/trach. His extremities were warm to touch and he had [MEDICAL CONDITION] to his lower extremities. The resident had a foley catheter that was draining light yellow urine. He had pressure wounds to the following areas: right lower buttocks which measured 8.5 cm x 1 cm; and right upper buttocks which measured 4.5 cm x 3.1 cm. the wound base was clean, non-granulation tissue. Wound edges were irregular and macerated. The note indicated the wound NP (Nurse Practitioner) was aware of the presence, location and characteristics of Resident B's wounds. The note also indicated there was a wound to the resident's coccyx and around anus, identified on 10/29/19 at 12:47 p.m. and measuremed 4.5 cm x 3.1 cm x .2 cm. There was no exudate, 75% of the wound bed was covered with slough and 25% of wound was covered by clean, non-granulation tissue. Wound edges were irregular and macerated. There was no wound documentation found for the wound on the residents right hip nor were any other areas, identified at the discharging hospital, identified at the facility. A physician's orders [REDACTED]. There was no treatment ordered for the resident's rectum/coccyx area. A review of the (MONTH) 2019 Treatment Administration Record (TAR) indicated the Z-paste was applied to the right buttocks areas bid from 11/1-11/29/19 as ordered. A review of the facility wound nurse documentation indicated the following: Wound measurements for the area identified as the coccyx, and around anus were as follows Length x Width x Depth: 10/29/2019: 4.5 x 3.1 x 0.2 no exudate, slough noted in the wound bed 11/5/2019: 4.5 x 3.1 x 0.2 serosanguinous exudate, slough noted in the wound bed. There was no note to indicate the physician had been notified of the change in exudate. 11/12/2019: 4.5 x 3.1 x 0.2 no exudate, granulation tissue noted in the wound bed. 11/19/2019: 4.5 x 3 x 0.2 light serous exudate, granulation tissue noted in the wound bed. 11/26/2019: 4.5 x 3 x 0.2 light serous exudate, granulation tissue noted in the wound bed. Wound measurements for the area identified as the lower buttocks were as follows Length x Width x Depth: 10/29/2019: 8.5 x 1 x 0.1 no exudate, slough noted in the wound bed 11/5/2019: 8.5 x 1 x 0.2 light serosanguinous exudate, slough noted in the wound bed. There was no note to indicate the physician had been notified of the change in exudate. 11/12/2019: 8.5 x 1 x 0.2 no exudate, granulation tissue noted in the wound bed. 11/19/2019: 8.4 x 1 x 0.2 light serous exudate, granulation tissue noted in the wound bed. 11/26/2019: 8.4 x 1 x 0.2 light serous exudate, granulation tissue noted in the wound bed. There were no notes to indicate a third area had been identified, measured, tracked, or treated. A review of Nurse notes indicated the following: On 11/03/2019 at 11:06 [NAME]M., Treatment was applied as ordered to the coccyx/back area. Wounds were granulating and deep. No sloughing or necrosis was observed. The nurse was unable to measure due to excessive deformities. Resident denied pain to area. Treatment was applied as ordered. On 11/05/2019 at 10:27 P.M., wounds to buttock and posterior hip were cleansed this evening and done per orders. No odor was noted. There was a moderate amount of serosanguinous drainage noted with cleansing. Skin surrounding wounds was noted to be pink and dry. There was no indication the physician had been notified of the new appearance of exudate. On 11/11/2019 at 2:07 [NAME]M., the resident continued on antibiotic therapy for [MEDICAL CONDITION] of the lower extremities, remained afebrile at 98.4, had an elevated heart rate (not measured or defined), noted from Respiratory Therapist was not completely out of his baseline normal. The resident requested the wound nurse look at his coccyx in the morning as he had some discomfort. There was no note to indicate the resident's coccyx was assessed, or the wound NP notified. On 11/11/2019 at 4:35 P.M., Interdisciplinary Team (IDT) Skin and Nutrition at Risk (SNAR) team met on 11/7 to discuss the resident's nutritional needs. Resident's weekly weight was 268.4 which was a slight increase. The resident continued on [MEDICAL TREATMENT] daily. The note indicated the wounds to buttocks remained, but there were no recommendations at that time and the team would continue to follow. On 11/15/2019 at 1:47 [NAME]M., indicated the open area remained to buttocks and posterior hip; zinc paste was applied per orders. On 11/17/2019 at 10:03 [NAME]M., indicated the IDT SNAR team met on 11/14 to discuss the resident's nutritional needs. The resident's weekly weight was 269.9 which is a slight increase. The resident continued on [MEDICAL TREATMENT] daily. The wounds to buttocks remained, but there were no recommendations at that time and the team would continue to follow. On 11/21/2019 at 7:25 [NAME]M., the wound NP was in to see the resident. His areas were clean, with a light drainage noted. There was a new order to add [MEDICATION NAME] cream to the wounds under the Z- paste. The note indicated the resident and family were aware. On 11/25/2019 at 3:58 P.M., indicated the IDT SNAR team met on 11/21 to discuss the resident's nutritional needs. The resident's weekly weight was 261.8 which was a slight decrease. The resident continued on [MEDICAL TREATMENT] daily. The wounds to buttocks remain, but there were no recommendations at that time and the team would continue to follow. On 11/28/2019 at 10:45 P.M., the resident began acting lethargic and the wife was concerned about confusion, the RT (Respiratory Therapist) mentioned this to the nurse who notified the NP. and ordered different labs including an Arterial Blood Gas (ABG). On 11/28/2019 at 10:54 P.M., the wife was concerned about the resident's recent confusion. The NP was notified and new orders were received for chest xray, an ABG, BMP, and CBC stat; ammonia, [MEDICATION NAME] acid level, and magnesium now. The note indicated wounds to buttock and posterior hip remained, treatment was done per orders. There was no note of the condition of the wounds. On 11/29/2019 at 2:09 [NAME]M., lab results were received and the NP notified. The lab was unable to obtain the ammonia level. New orders for a blood transfusion to be set up after [MEDICAL TREATMENT] on 11/30 for 1 unit of blood was received. The Resident was notified of new orders. On 11/29/2019 at 1:15 P.M., an IDT note indicated the resident's weight was 258.6 which was a slight decrease. The resident continued on [MEDICAL TREATMENT] daily. The wounds to buttocks remain. There was no note to indicate the condition of the wounds. On 11/29/2019 at 10:00 P.M., the RT told the nurse the resident had wide fluctuations in oxygenation. The nurse informed the RT/LPN of their assessment findings and information the nurse had received during report. The RT restated previous concerns. The nurse suggested the NP be notified of RT/LPN concerns and that the resident may need to be sent out to emergency room (ER). On 11/29/2019 at 10:27 P.M., the nurse called the N.P. who ordered the resident to be sent to the ER for a blood transfusion. RT called her because patients saturations were unstable. The last highest saturation was 65%. Respirations were fluctuating between 24-26. Blood Pressure was 80/50 and the resident's pulse was fluctuating between 90's -110. On 11/30/2019 at 1:47 P.M., the nurse called to receive an update on Resident B. The information received indicated the resident had been admitted to the hospital's Intensive Care Unit (ICU) and was being treated for [REDACTED]. On 11/30/2019 at 7:30 P.M., the record noted the hospital had called to notify the facility Resident B had passed. Hospital records from Hospital 1 indicated Resident B was brought to their ER via ambulance. His white blood count was (indicated an infection), blood and urine cultures were obtained. His skin had pallor, temperature was 100.2, pulse was 117, respirations were 18 and blood pressure was 80/40. When the nurse rolled Resident B onto his side, an extremely large, deep, decubitus wound with a foul odor, bloody colored exudate and necrotic tissue was observed. The note indicated the resident was leaking stool into the wound. Hospital 1 transferred Resident B to Hospital 2 due to his declining condition. Hospital records from Hospital 2, obtained on 2/7/20 at 9:00 [NAME]M., indicated upon admission to the hospital, on 11/30/19, the resident was found to be in profound septic shock. His temperature was 101.3, pulse was 120, respirations were 24, and blood pressure as 76/40. He had an extensive and unstageable sacral pressure ulcer that had a central area of eschar with a large area of surrounding redness and necrotic tissue involving the entire buttock area. In an interview on 2/06/2020 at 2:34 P.M., Resident B's family member indicated they were unaware the resident had any wounds until the resident was admitted to the hospital and he was septic from the condition of the wounds. In an interview on 2/06/2020 at 4:14 P.M., the wound NP indicated she had not been contacted about Resident B's three back, hip and coccyx wounds nor was she aware of the condition of the wounds until she was notified on 11/21/2019. She did not remeasure the wounds, but depended on facility measurements. She indicated she was not made aware of the admission wound orders for the resident. In an interview on 2/07/2020 at 10:40 [NAME]M., RN 1 indicated she had spoken with the Facility Wound Nurse about Resident B's wounds, and the concern a different treatment was needed due to the declining condition of the wounds. RN 1 indicated she did not know why the admission wound orders were not followed. In an interview on 2/07/2020 at 2:32 P.M., LPN 3 indicated the facility practice was to do a head to toe skin assessment on admission, then transcribe wound orders onto the TAR. If there was not an order for [REDACTED]. In an interview on 2/7/20 at 3:39 P.M., the Administrator and DON (Director of Nursing) indicated they were unable to answer questions regarding Resident B as both were new to the facility and not present during the resident's stay. The DON, on 2/7/20 at 3:39 P.M., provided a current copy of the facility's policy titled Pressure Ulcer Prevention Protocol. The policy indicated the following: Newly admitted or readmitted residents will have a Pressure Ulcer Risk Assessment completed upon admission weekly thereafter for the next 3 weeks after admission. Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks, which may include: daily skin checks conducted by either the CNA or Licensed Nurse to ensure early identification of potential problem areas .Residents who receive treatment for [REDACTED].the physician will be notified when the assessment indicates a lack of progress in healing .It is the policy of this facility to treat the wound according to the guidelines of the Agency for Healthcare Research and Quality, National Pressure Ulcer Advisory Panel, and current standards of clinical practice .the presence of wounds, ulcers, and/or other skin abnormalities will be indicated on the admission nursing assessment The immediate jeopardy that began on 10/29/19 was removed on 2/10/20 when the facility assessed all residents in the facility for wounds/skin impairment, continuing to inservice staff on wound/skin assessments and treatments, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced, and quailty tracking had not been completed. This Federal tag relates to Complaint IN 005. 3.1-40(a)(2)

Based on observation, interview, and resident review, the facility failed to ensure 3 of 3 residents, reviewed for Activities of Daily Living (ADL) received timely services to maintain personal hygiene and incontinence care. Residents #24, #25, and #93. This resulted in residents waiting for long periods of time in soiled briefs, clothing, and linens. Findings include: 1. Resident #24 was interviewed, at 9:38 a.m., on 5/8/13, and indicated there were times she had to sit in a soiled bed for a long period of time before staff cleaned her. She indicated "lots of times" she was asleep, but she would tell staff to wake her up and change her if she was incontinent. The resident was interviewed again, at 10:53 a.m., on 5/8/13, and indicated staff would come in when she turned her call light on, and would say they would be back, and she would tell them to wake her if she fell asleep. She indicated at times she had sat 3-4 hours in a wet brief. She indicated she did not use the bedside commode or bedpan, but would "go in my brief" then let the staff know so they could clean her. She indicated they would say they would be back because they had to look for someone to help them, then would end up waiting. She indicated this occurred at least 1 time per day, depending on who was working. CNA #3 was interviewed, at 1:38 p.m., on 5/9/13, and indicated Resident #24 was totally dependent for Activities of Daily Living (ADLs), did not get out of bed, but would sit up on the side of the bed. She indicated the resident was pretty cooperative, was incontinent and used depends and would call the CNAs after she had been incontinent to let them know she needed changed. The CNA indicated the resident required 2 staff assists for ADL care. . LPN #2 was interviewed, at 2:00 p.m., on 5/9/13, and indicated she worked 5 a.m. to 5:00 p.m, normally on West hall, and indicated Resident #24 did complain about having to wait to be changed. She indicated usually when she needed to be changed , it would be a full bed change and took awhile to clean the resident. She indicated it was almost a complete bed change every time she was incontinent. The LPN indicated the resident would say the aides were working too hard. LPN #11 was interviewed, at 2:25 p.m., on 5/9/13, and indicated Resident #24 would complain of having to wait for assistance, sometimes 20-30 minutes or longer. She indicated the resident required a 2 person assist for ADL care and it usually took 20-30 minutes to complete her care. The LPN indicated the resident sometimes had to wait 20-30 minutes if staff were working with someone else. She indicated the resident had complained of longer waits. The record for Resident #24 was reviewed, at 10:58 a.m., on 5/14/13 and indicated the resident was originally admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS, quarterly assessment, dated 2/1/13, indicated the resident scored 15 on the BIMs(Brief Interview for Memory Status), and required extensive to total assistance of 2 staff for bed mobility, transfers, toileting, and personal hygiene. The assessment indicated the resident was incontinent of bowel and bladder, and was on a toileting program. A nursing note dated 4/23/13 indicated the resident was alert and oriented and made needs known, incontinent of bowel and bladder, and ventilator dependent. Review of a social service progress note, dated 12/1/12, indicated the resident was upset because she had not been changed and had been "laying in filth" since 12 noon. The note indicated it was now 5:30 p.m. The resident also indicated her medications were late. The resident indicated her call light was answered by one of the CNAs, and the CNA told her there were a few residents ahead of her, and the resident agreed to wait. The care plans were reviewed and indicated the following: The resident required extensive to dependent assist for ADLs, originally dated 5/11/12, and most recently updated on 5/1/13; The resident was at risk for complications related to bowel and bladder incontinence, with origination date of 5/11/12, and last updated on 5/1/13. Interventions for this care plan indicated, but not limited to: provide peri care per protocol, assist with toileting as needed, and toileting program per protocol. Prompted voids. The resident was at risk for skin breakdown related to decreased mobility and bowel and bladder incontinence. The Assistant DNS was interviewed, at 12:14 p.m., on 5/14/13, and indicated the prompting program for Resident #24's toileting program was just to ask her if she needed to urinate or have a bowel movement, or if she wanted to use the bedpan. The Assistant DNS indicated the resident refused these interventions, but was just incontinent in her brief. 2. Resident #93 was interviewed, at 10:27 a.m. on 5/8/13, and indicated she had waited, in the past, 1 to 1 and 1/2 hours after turning on her call light to get care. She indicated on 5/7/13, she had turned her call light on at approximately 9:30 p.m., and LPN #4 came in her room and asked her what she needed. The resident indicated she told the nurse she needed assistance to toilet, and to "please have them hurry. " The resident indicated the nurse then turned off the call light and said she would tell the aide. The resident indicated the CNA did not come in until 10:30 p.m. She indicated when CNA #5 came in, she asked him where he had been and he indicated he had to give 2 other residents bed baths and another resident a shower. She indicated the CNA told her the nurse had not said anything to him about the resident's request for assistance. The resident indicated she held it as long as she could, but ended up being incontinent because she had to wait so long. The resident also indicated her roommate, Resident #25, had been incontinent in the bed before supper, on 5/7/13, at approximately 6:30 p.m., and the CNA told her she could eat her supper first and then they would clean her. She indicated the aide didn't come back until 10:30 p.m., so her roommate waited for 4 hours to be cleaned. The resident also indicated she had seen her roommate sit in the recliner for long hours without staff checking her to see if she was incontinent. She indicated she had seen urine puddles on the floor under her roommate's chair before. She indicated she had seen that several times, the last as recent as last week. She indicated this past Sunday(May 5, 2013) the aide put her on the bedpan(Resident #93) about 10:30 a.m., and left her on the bedpan for 2 hours. She indicated she would turn on her call light and staff would come in and say they would be right back. She indicated this happened twice on Sunday. She indicated her lunch was brought in at 12:15 p.m., and knowing she was on the bedpan, they left her to eat her lunch, so she ate her lunch laying on the bedpan. She indicated one of the staff then removed the bedpan about 1:30 p.m. She indicated she had family visit that afternoon and she told the visitors what had happened. She indicated she didn't get dressed until about 3:00 p.m. that day, and indicated she did not like to wait to get dressed that late. She indicated she had sat on the bedpan in the past, sometimes for 3 to 4 hours. She indicated one Sunday, about 1 month ago, they left her on the bedpan for about 2 and 1/2 hours. She indicated her sister went to the nursing station and there were 2 staff members sitting at the station. She indicated there was only one aide on the hall that day, and her sister talked to the nurses and told them they needed to help. LPN #2 was interviewed on 5/9/13 at 2:00 PM, and indicated Resident #93 complained about having to wait. She indicated Resident #93 was continent and could tell you when she had to use the bed pan, but had urgency so when she had to go, she couldn't wait. LPN #2 indicated over the past weekend, she had worked and it was a "rough" weekend because staff called off work. She indicated there was an issue with Resident #93 over the weekend, that she was placed on the bedpan by one CNA who then went on break, and the other CNA didn't know the resident was on the bedpan. LPN #2 indicated the resident's family complained about the incident to her later. Resident #93 was interviewed, at 9:15 a.m., on 5/13/13, and indicated staffing over the weekend was better, and she did not have long waits. She indicated about 1 and 1/2 months ago, she needed assistance to toilet, and one of the aides answered her call light, went to get a towel for the resident, but did not put her on the bedpan, and did not return for approximately 50 minutes. The record for Resident #93 was reviewed, at 10:30 a.m., on 5/13/13, and indicated she was admitted on [DATE], readmitted to the hospital on [DATE], and re-admitted to the facility on [DATE]. A quarterly Resident data collection status report, dated 5/5/13, indicated the resident used the bedpan, was continent of bladder , but dribbled, was alert, cooperative, comprehension "quick", and oriented. A Social service progress note, dated 1/26/13, indicated the resident was alert and oriented to person , place, time, and situation. Review of the care plan indicated the resident was dependent on staff for activities of daily living (ADL) with interventions including, but not limited to: assist with adls as needed, encourage and praise resident for efforts to assist in adls, hoyer lift for transfers; Also, assist with toileting as needed, bowel and bladder assessment quarterly, toileting program per protocol, prompted voids. Nursing notes were reviewed and indicated the following: 4/24/13 alert and oriented times 3 and makes needs known; 4/28/13 Alert and oriented times 3 able to make needs known, also continent of bowel and bladder; 5/12/13 alert and oriented times 3, makes needs known to staff; continent of bowel and bladder. Review of the most recent MDS, dated as signed by mds coordinator 2/7/13, indicated the resident required extensive assistance of 1 person for bed mobility, total assistance of two staff for transfers, and total assistance of 1 staff for dressing, eating, toilet use and hygiene. A concern report for corrections or requests form, dated 5/5/13, provided by the Social Service Assistant (SSA), at 1:57 p.m., on 5/13/13, included a written statement from resident #93. The written statement indicated the resident was left on the bedpan for 2 hours and ate her lunch laying down on the bedpan. She indicated her roommate, Resident #25,was given a diet soda and it wasn't even opened for her until several hours later. Resident #93 indicated she wanted to get up after lunch but had to wait until 3:00 p.m., to get ready for her family to visit. She indicated she had waited for the bedpan up to an hour on 2 other separate occasions. 3. Resident #25 was interviewed, at 10:33 a.m., on 5/7/13, and indicated the facility did not have enough staff. She indicated she had to wait 1/2 hour for care sometimes, and the last time this happened was on 5/6/13. The record for Resident #25 was reviewed at 1:35 p.m., on 5/13/13, and indicated [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated the resident was incontinent of bowel and bladder, and required total assistance of two staff for bed mobility, transfer, toileting, and extensive assistance of one person for dressing. The most recent MDS, dated 4/26/13, indicated the resident was always incontinent of bowel and bladder. Also cognitive patterns indicated the BIMs score was 12, and resident fluctuated on disorganized thinking Review of care plan, with initial date of 1/27/12, and most recent update of 2/20/13, indicated the resident required extensive assistance for activities of daily living. Review of a Social service progress note, dated 12/1/12, indicated, "concern report: When leaving visit with resident # (another resident) , resident(#25) stopped writer and stated that she had not been cleaned up all day, it was now 6pm. Writer stated she would grab some help for both residents (another resident) writer could not locate CNA, writer then went to nurses station and told nurse (name)- nurse(name)(pm nurse) overheard writer and paged CNA to nurses station. CNA #16 showed up and was told to go to room [ROOM NUMBER] and clean both residents up. Nurse(name) walked out of resident's room and stated to writer that resident had visible big brown rings surrounding bedding and resident was soiled. Nurse stated it was obvious resident was not changed during day shift..." (sic) 3.1-38(a)(3)A

Based on record review and interview, the facility failed to ensure the facility provided sufficient nursing staff to meet the needs of the residents. This affected 3 of 62 residents in the facility, Residents #24, #25, and #93. This resulted in residents waiting in soiled briefs, clothing, and linens for long periods of time for incontinence care. Findings include: Resident # 24 was interviewed, at 9:38 a.m., on 5/8/13. The resident indicated there were days when she was incontinent, and was not cleaned for hours. She indicated she would fall asleep lots of times, but told the staff to wake her if she was asleep to clean her if she had been incontinent. She indicated she never got bedsores at home, but did here. She indicated staff would come in when she turned her call light on, then turn the call light off, and tell her they would come back, but then didn't. She indicated she had laid in a wet brief for hours at times waiting for them to return. She indicated she did not sit on the bedside commode or the bedpan, but just went in her brief, in the bed. She indicated after she went, she would turn on the call light for staff so they could change her. She indicated they would say they would be right back, as she required 2 assist for her care, but then wait 2 to 3 hours at times for them to return. She indicated this happened at least 1 time per day, depending on who was working. Resident #93 was interviewed, at 10:27 a.m. on 5/8/13, and indicated she had waited 1 to 1 and 1/2 hours after turning on her call light to get care. She indicated on 5/7/13, she had turned her call light on at approximately 9:30 p.m., and nurse #4 came in her room and asked her what she needed. The resident indicated she told the nurse she needed assistance to toilet, and to "please have them hurry. " The resident indicated the nurse then turned off the call light and said she would tell the aide. The resident indicated the CNA did not come in until 10:30 p.m. She indicated when CNA #5 came in, she asked him where he had been and he indicated he had to give 2 other residents bed baths and another resident a shower. She indicated the CNA told her the nurse had not said anything to him about the resident's request for assistance. The resident indicated she held it as long as she could, but ended up being incontinent because she had to wait so long. The resident also indicated her roommate, Resident #25, had been incontinent in the bed before supper, at approximately 6:30 p.m., and the CNA told her she could eat her supper first and then they would clean her. She indicated the aide didn't come back until 10:30 p.m., so her roommate waited for 4 hours to be cleaned. The resident also indicated she had seen Resident #25 sit in the recliner for long hours without staff checking her to see if she was incontinent. She indicated she had seen urine puddles on the floor under her chair before. She indicated she had seen that several times, the last as recent as last week. She indicated this past Sunday(May 5) the aide put her on the bedpan(Resident #93) about 10:30 a.m., and left her on the bedpan for 2 hours. She indicated she would turn on her call light and staff would come in and say they would be right back. She indicated this happened twice on Sunday. She indicated her lunch was brought in at 12:15 p.m., and knowing she was on the bedpan, they left her to eat her lunch, so she ate her lunch laying on the bedpan. She indicated one of the staff then removed the bedpan about 1:30 p.m. She indicated she had family visit that afternoon and she told the visitors what had happened. She indicated she didn't get dressed until about 3:00 p.m. that day, and indicated she did not like to wait to get dressed that late. She indicated she had sat on the bedpan in the past, sometimes for 3 to 4 hours. She indicated one Sunday, about 1 month ago, they left her on the bedpan for about 2 and 1/2 hours. She indicated her sister went to the nursing station and there were 2 staff members sitting at the station. She indicated there was only one aide on the hall that day, and her sister talked to the nurses and told them they needed to help. The Assistant Director of Nursing (ADNS), who also did the nursing schedules, was interviewed at 9:50 a.m., on 5/9/13 regarding staffing. She indicated last week she asked the Administrator for more staff. Before this time, she indicated she staffed at 2 aides, 2 nurses , and 1 Respiratory Therapist(RT) on the East hall, which she indicated was mainly a hall with Tracheostomies and Ventilators. She indicated on West hall, which she indicated was mainly Tracheostomies and Ventilators, she staffed 1 nurse who came in at 5:00 a.m., and worked 12 hours, 1 nurse, who came in at 11:00 a.m., to 11:00 p.m., 1 CNA who worked 4:00 a.m., to 4 p.m., 1 QMA, who worked 6:30 a.m to 11 a.m., 2 days a week, and the other 3 days worked 6:30 a.m.to 3:00 p.m. She also indicated Respiratory Therapist (RT) were staffed around the clock, and since May 1, 2013, 2 RTs were staffed 24 hours a day. She indicated on the 200 hall, which had no Vents or Tracheostomies, there was 1 nurse, and 1 CNA staffed. The ADNS indicated she talked to the Administrator and told him more staff were needed due to the increased census and heavier acuity of residents. She indicated the Administrator agreed to hire more CNAs, and since last week, the ADNS hired 2 more CNAs, and 3 more were pending hire. She indicated her goal was to have 7 CNAs for days, and 7 for evenings/nights. CNA #8 was interviewed at 1:30 p.m., on 5/9/13, and indicated she worked mainly on West hall and indicated there were about 13 hoyer lifts (mechanical hydraulic lift for transferring residents requiring two staff) on 300 hall, but she was able to get all her work done. LPN #9 was interviewed, at 2:00 p.m., on 5/9/13, and indicated she worked mainly on West hall and there were 2 nurses working the hall about 50-60 % of the time, but it was rough when the second nurse got pulled to another hall, and there was not a second nurse. She indicated she was able to get medication passed and treatments done, but it was not easy. She indicated some of the residents did complain about staffing issues. She indicated Resident #24 usually was a full bed change when she was incontinent, and it took awhile to clean her. She indicated Resident #24 was almost a complete bed change every time she was incontinent, and would complain she had to wait for staff to assist her and would say the aides worked too hard. LPN #9 also indicated Resident #93 complained about having to wait. She indicated Resident #93 was continent and could tell you when she had to use the bed pan, but had urgency so when she had to go, she couldn't wait. LPN #9 indicated over the past weekend, she had worked and it was a "rough" weekend because staff called off work. She indicated there was an issue with Resident #93 over the weekend, that she was placed on the bedpan by one CNA who then went on break, and the other CNA didn't know the resident was on the bedpan. LPN #9 indicated the resident's family complained about the incident to her later. LPN #11 was interviewed, at 2:25 p.m., on 5/9/13, and indicated she worked mainly 200 and 300 halls. She indicated Resident #24 complained about staffing, saying she had to wait sometimes if staff were working with other residents, sometimes 20-30 minutes and has complained of longer waits before staff could help her. . LPN #13 was interviewed, at 3:00 p.m., on 5/9/13, and indicated she had worked on all the halls and staffing could vary. She indicated there was adequate staffing on dayshift, but she sometimes felt overwhelmed, but was able to get her work done. She indicated the CNAs could get their work done, but the nurses had to help them a lot. She indicated there were 2-3 aides in the building after 9 pm., and it was "kind of rough. " She indicated there was usually 1 aide after 9 pm on East, and usually 2 aides worked between South and West halls after 9:00 p.m., if everyone reported to work. She indicated the nurses had to help the aides get their work done, but it was a "constant run." She indicated when she worked on West hall, Resident #24, who was a 2 person assist for care, was incontinent, would complain she had waited a while for her call light to be answered. CNA #5 was interviewed, at 4:48 p.m., on 5/9/13, and indicated he normally worked West hall, 12 hour shifts, and there was normally 1 nurse, 1 RT, and 2 CNAs on the hall. The CNA indicated it was difficult at times to get the work done, and to get the call lights answered. The CNA indicated the residents did not sleep well, and there were a lot of call lights from 9:00 p.m. until 4:00 a.m. The CNA indicated the residents complained about having to wait for help, especially Resident #93 and Resident #24. The CNA indicated the other night Resident #93 complained about having to wait, but the CNA didn't know how long the resident had waited. The CNA indicated Resident #25 was demanding, had a ventilator, was total care, and was incontinent at times. The resident council minutes were reviewed, at 11:13 a.m., on 5/13/13, and indicated the following: April 2, 2013 meeting minutes indicated: "old business: Still not enough aids on weekends. One resident mentioned her roommate had problems and "they are being ignored." March 5,2013 meeting minutes indicated "old business: there are not enough aids during the week-ends (and other nights)" Also, "aids on weekends are good workers but not enough so those here are being overworked." January 1, 2013 minutes indicated concern regarding not been enough staff. [DATE] minutes indicated call light response time was not timely manner on weekends. November 6, 2012 call light response not timely on weekends. October 2, 2012 call light response time was not timely on weekends. The DNS was interviewed, at 1:47 p.m., on 5/13/13, and indicated the aides at night work together and start at one end of the hall and work their way down the hall, because a lot of the residents are 2 person assists. She indicated unless there was an emergency, the aides would go from one end of the hall to the other to change and check the residents. A social service progress note, dated 12/1/12, for Resident #25 indicated, "concern report: When leaving visit with (another resident) , resident stopped writer and stated that she had not been cleaned up all day, it was now 6pm. Writer stated she would grab some help for both residents (other resident) writer could not locate CNA, writer then went to nurses station and told nurse(name)- nurse(name) overheard writer and paged CNA to nurses station. CNA #16 showed up and was told to go to room [ROOM NUMBER] and clean both residents up. Nurse(name) walked out of resident's room and stated to writer that resident had visible big brown rings surrounding bedding and resident was soiled. Nurse stated it was obvious resident was not changed during day shift..." (sic) The ADNS was interviewed, at 11:05 a.m., on 5/15/13, and indicated there were heavy call lights, even at night. She indicated the facility had no system in the building to let staff know which call light came on first, so staff would answer the call lights as they saw them. She indicated the facility had residents on ventilators who turned on their call lights frequently sometimes just because they were lonely or wanted comfort. 3.1-17(a) ,

Based on observation, interview, and record review, the facility failed to re-assess and develop comprehensive care plan interventions, when residents developed risk factors and signs of dehydration, which resulted in the hospitalization of a resident (Resident #B). This deficiency affected 2 of 4 residents who were reviewed for dehydration in a sample of 4. (Resident #B, Resident #E) Findings include: 1. The closed clinical record of Resident #B was reviewed on [DATE] at 2:15 p.m. and indicated the resident was admitted to the facility from the hospital on [DATE], with [DIAGNOSES REDACTED]. The resident was transferred to the emergency roiagnom on [DATE] and expired at the hospital on [DATE]. admission orders [REDACTED]. A hospital laboratory report, dated [DATE], prior to his admission indicated the resident's blood urea nitrogen was high at 38 (normal range ,[DATE]) and the Creatinine level was high at 1.42 (normal range of 0XXX,[DATE].24) The admission dehydration risk assessment form indicated the resident was not at risk of dehydration. Physician orders, dated [DATE], indicated the resident had a "diet downgrade" and was to received nectar thick liquids instead of the previously ordered thin liquids. On [DATE] a nutrition assessment by the Registered Dietician indicated the resident's fluid needs were 2,617 ccs per day. The MDS (Minimum Data Set) Assessment, dated [DATE], indicated the resident required extensive assistance for transfer, eating and hygiene. The intake record indicated the resident received less than his estimated, 2,617 ccs of fluids, required each day between [DATE] and [DATE], and the output records indicated the resident had a decreased output of urine on [DATE] and [DATE], as follows: [DATE], intake 1300 cc, output 3,500 ccs; [DATE], intake incomplete, output incomplete; [DATE], intake 2000 ccs, output 1,800 ccs; [DATE], intake 1460 ccs, output 2,000 ccs; [DATE], intake 1600 ccs, output 2175 ccs; [DATE], intake 1200 ccs, output 1,250 ccs; [DATE], no intake recorded, incomplete output; [DATE], intake 1110 ccs, output 625 ccs; [DATE], intake 1200 ccs, output incomplete; and [DATE], intake 1280 ccs, output 500 ccs. Dietary notes, dated [DATE], indicated the resident had an admission weight of 230.3 pounds and a weekly weight of 202.4 pounds for a loss of 27.9 pounds or 12 % of total body weight since admission on [DATE]. In addition to the resident's diagnoses, he either had or developed the following risk factors for dehydration including: thickened liquids, diuretics use, decreased output, intakes below his estimated needs, weight loss and dependency for eating/drinking. Although the resident had increased dehydration risks, there was no indication he was reassessed, or that a comprehensive care plan was developed to address Resident #B's dehydration risks and hydration needs. On [DATE] at 5:15 p.m., Nursing notes indicated "Res (Resident) with (increased symbol) confusion..." On [DATE] at 10:10 a.m., nursing notes indicated the resident was found unresponsive and was transferred to the hospital at 10:45 a.m. The hospital laboratory report, dated [DATE] at 10:55 a.m., indicated the following: The resident's blood urea nitrogen was critically high at 115 (normal range of ,[DATE]); Creatinine was high at 2.7 (normal range of 0XXX,[DATE].3); Sodium was critically high at 174 (normal range of ,[DATE]); and Chloride was critically high at 128 (normal range of ,[DATE]). The emergency room report, dated [DATE], listed the resident's [DIAGNOSES REDACTED]. "1. Decreased level of consciousness 2. Severe dehydration" The short stay hospital summary, dated [DATE], indicated Resident #B had the following Diagnoses: [REDACTED]...1. Decreased level of consciousness, probably due to pneumonia. His prognosis is grim...Per family wishes supportive care will be continued with no further intervention. 2. [MEDICAL CONDITION], probably due to dehydration... 3. Acute on (sic) chronic [MEDICAL CONDITION]" Intensive Care nursing notes indicated Resident #B died on [DATE] at 17:35. The MDS (Minimum Data Set) Co-ordinator, who was assisting the new DON (Director of Nursing) was interviewed on [DATE]. The MDS Co-ordinator indicated the previous DON discontinued the facility's dehydration risk assessment and hydration program because he felt they were unnecessary and could be initiated as the nurses saw fit. She indicated on [DATE], the hydration program was restarted for all resident who received thickened liquids, were dependent on staff for drinking/eating and who were on diuretics. She indicated fourteen residents were placed on the hydration program. She indicated they were in the process of reassessing all of the residents dehydration risk factors. The MDS Co-ordinator indicated Resident #B would have benefited from being the hydration program. 2. The clinical record of Resident #E was reviewed on [DATE] at 1:30 p.m., and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE], the Registered Dietician assessed the resident and determined her fluid needs were 4,990 cc per day. The MDS (Minimum Data Set) Assessment, dated [DATE], indicated the resident had no cognitive impairment and required extensive assistance for dressing and hygiene but required only set-up assistance for eating. On [DATE], the pulmonologist noted the resident had a low grade fever. Physician order, dated [DATE] indicated the resident was place [MEDICATION NAME](an antibiotic medication) for a urinary tract infection and indicated the tracheotomy wound was to be cultured. Physician orders, dated [DATE], indicated previous antibiotics were discontinued and the antibiotic, Bactrim DS, was ordered twice daily for ten days. The February 2012, MAR (Medication Administration Record) indicated the resident's intake and output were to be monitored every shift. The intake and output records between [DATE] through [DATE] were incomplete on six of fifteen days (,[DATE],6,8,9,10,,[DATE]). On the remaining days, the resident intakes were below her estimated daily fluid needs of 4,990 ccs, for example: On [DATE], the intake was 580 cc with an output of 600 cc, On [DATE], the intake was 520 cc with an output of 300 cc, On [DATE], the intake was 910 cc with and output of 1100 cc, and On [DATE], the intake was 940 cc with an output of 1900 cc. The BMP (Basic Metabolic Panel) laboratory tests were done on [DATE] and repeated on [DATE], indicating the BUN had gone from 16 to 26 (normal range ,[DATE]) on [DATE] and was now high. The Creatinine level was 0.7 (normal range 0XXX,[DATE]) on [DATE] and was slightly higher, at 0.8, on [DATE]. On [DATE] at 2:00 p.m., the resident, who was in isolation, was visited with LPN #10 present. The resident was eating her lunch from a styrofoam portioned take-out container on a tray. The resident had no fluids on the lunch tray but did have a small soda can and water in a container on her overbed table. She indicated she would like juice and water delivered with her meal tray. The resident said the aides bring her ice water in styrofoam cups and she refills her personal insulated water glass. Resident #E indicated she can ask for fluids and felt she was getting enough to drink. The nurse indicated fluid were usually provided on the meal trays. Although the resident had an infection, had intakes below her estimated needs and had an elevated BUN, there was no documentation the resident's dehydration risks were assessed or a hydration care plan developed. This Federal tag relates to Complaint IN 686. 3XXX,[DATE](b)

Based on interviews and record review, the facility failed to provide appropriate treatment to a resident with an elevated temperature, resulting in death. This deficiency affected 1 of 3 residents, whose clinical records were reviewed following their deaths, in a sample of 7. (Resident #B) The immediate jeopardy began on 7/28/11, after the facility failed to notify the physician regarding a resident with an elevated temperature that did not respond to treatment. The Administrator, Director of Nursing and Chief Financial Officer were notified of the immediate jeopardy on 8/16/11 at 4:10 p.m. The immediate jeopardy was removed on 8/19/11, but noncompliance remained at the level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record of Resident #B was reviewed on 8/15/11 at 3:30 p.m., and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In addition, Resident #B received enteral feeding via a PEG tube (Percutaneous Enteral Gastrostomy) tube, had a supra pubic urinary catheter and had a PICC (Peripherally Inserted Central Catheter) line. On 7/8/11, Resident #B verbally requested a "Full Code" which indicated, "I request that all efforts be made to prolong my life." On 7/9/11, a Patient Transfer Form indicated Resident #B was transferred from the facility to the hospital with and increased heart rate, an increased temperature and a decreased level of consciousness. A Hospital Surgical report indicated the resident had chronic [MEDICATION NAME] and a laparoscopic cholecystectomy was performed on 7/12/11. A respiratory note, dated 7/18/11 at 2025 (8:25 p.m.), indicated Resident #B was readmitted to the facility via emergency medical services and was placed on a facility ventilator. Admission respiratory orders, dated 7/18/11, indicated, among other things, that the resident was to have respiratory assessments every six hours with vent checks. Additional admission orders [REDACTED]. The admission orders [REDACTED]. Nursing notes for 7/28/11, indicated the following: At 1:30 a.m., Resident #B's temperature was 101.6 degrees F (Fahrenheit) and she was given Tylenol and a sponge bath. At 2:30 a.m., the resident's temperature was 102.6 degrees F. "Will continue to monitor." At 3:15 a.m., the temperature was 103.4 degrees F. "Cold wet compresses applied to axilla (arm pits) & (and) groin & sponged down c (with) damp wash cloth approx (approximately) q (every) 15-20 min. (minutes) ongoing." At 4:15 a.m., the temperature was 104 degrees F. "Continuing to monitor & (and) sponge bath." At 4:35 a.m., Resident #B's temperature was 106.7. The note indicated the resident's eyes were open and she looked at staff, but she did not respond. At 4:36 a.m., the physician was paged. At 4:37 a.m., the physician called the facility and an order was received to call 911. At 4:50 a.m., Resident #B was transported to the hospital via Emergency Medical Services. There was no documentation the physician was immediately notified, when Resident #B's temperature continued to rise, after receiving Tylenol and the sponge bath. Respiratory assessments were reviewed and the resident had a respiratory assessment on 7/27/11 at 7:35 p.m. The next respiratory assessment was done on 7/28/11 at 4:25 a.m., nine hours later. A respiratory note, dated 7/28/11 at 4:30 a.m., indicated CNAs were packing the resident in ice. The note indicated the resident's heart rate was 157, the oxygen saturation rate was 85 percent, oxygen was increased to 6 liters, and saturation rates remained in the "low 90's." The note indicated the resident was "in no respiratory distress." The respiratory noted indicated Resident #B was taken by ambulance to the emergency room . The emergency room Report, dated 7/28/11, indicated Resident #B went into full arrest enroute to a Fort Wayne Hospital, Cardio [MEDICAL CONDITION] Resuscitation was initiated and the resident was rerouted to the local hospital. The report indicated the resident's temperature, upon arrival at 5:15 a.m., was 106 degrees, the pupils were fixed and... "After 14 minutes of true arrest situation with the rapid decline in her condition...Code was terminated at 06:00 hours" and the resident was pronounced dead. The report indicated the coroner was contacted because the resident was initially a victim of assault and had a recent laparoscopic cholecystectomy. The emergency room report assessment indicated "Cardiopulmonary arrest, secondary [MEDICAL CONDITION] in light of fever/recurrent multi-drug resistant organism urinary tract infections in the past." On 8/15/11 at 4:30 p.m., the DON (Director of Nursing) indicated RN #1, who had been on duty during the incident on 7/28/11, was terminated because she did not call the physician until the resident was unresponsive with a temperature of 106 degrees. She indicated the incident was reported to the ISDH (Indiana State Department of Health) on 7/29/11. On 8/16/11 at 3:30 p.m., the DON indicated Resident #B had a temperature of 101 at 1:30 a.m., Tylenol was given and an hour later the temperature had gone up. The DON indicated cold compresses should have been applied, the temperature retaken in 15-30 minutes, and the doctor called if there was no response to the treatment. The DON indicated a new policy for elevated temperature was written, shown to the Physician on 8/1/11, the Physician changed some of the wording and took a copy of the policy so it could be discussed by his partners. She indicated all the nurses had been inserviced on the policy, except one nurse, who was currently on vacation. The policy in effect at the time of the incident, entitled Observations To Report To The Physician, illegible date, provided by the DON was reviewed on 8/16/11 at 4:00 p.m., and indicated: "...The following examples of change in condition are...to provide the licensed nurse with guidelines to follow on physician notification....increases or decreases in temperature...." The immediate jeopardy that began on 7/28/11 was removed on 8/19/11, when the facility ensured new procedures were in place and staff were knowledgeable of the current policies and procedures for physician notification and respiratory assessment, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need to provide ongoing monitoring of the care provided to residents who have elevated temperatures and who require respiratory assessments. This Federal tag related to Complaint IN 325. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to safely transfer a resident using the Hoyer lift, resulting in a fall with facial bruising and hospitalization . This deficiency affected 1 of 3 residents, who used a Hoyer lift for transfers, in a sample of 5. (resident #C) Findings include: 1. During initial tour of the facility, beginning on 3/21/11 at 10:00 am, the Assistant Director of Nursing Services (ADNS) indicated Resident C had a fall when she was being transferred to her shower chair. The ADNS indicated two staff members were transferring the resident when the Hoyer lift tipped over , causing the resident to fall and hit her nose on the lift. A facility incident reporting form, dated 1/7/11, at 0615, indicated Resident C was being lifted into the shower chair, when the Hoyer tipped causing the resident to fall onto C.N.A. #1. The Hoyer lift hit the resident's nose, and the resident was sent to the local hospital for evaluation and returned to the facility. The resident was later sent back to the hospital for evaluation and found to have substantial facial bruising. The incident reporting form indicated the Hoyer lift "was used with the base at the narrow position which allowed the Hoyer to tip when weight was applied." The report indicated a policy was written and all staff were in-serviced that whenever "the Hoyer lift is used the base must be extended to allow the Hoyer to be balanced." The report further indicated the previous shower chair had been thrown away and a new one ordered that would accommodate the Hoyer base being in the wide position. The clinical record of Resident C was reviewed, on 3/21/11 at 2:33 p.m., and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated the resident required an extensive two person assist for transfers. A care plan, dated initially on 8/20/10, and updated 1/7/11, indicated the resident was at risk for falls related to decreased mobility, and a Hoyer lift was to be utilized for transfers. A nursing note, dated 1/7/11 at 6:30 a.m., indicated the resident was on the floor, and a moderate amount of red frank blood draining from the resident's nose and an abrasion noted on the bridge of the nose. The resident was sent to the hospital for evaluation, and returned. Another nursing note, dated 1/7/11 at 11:30 a.m., indicated the resident was noted to have labored breathing, and continued bleeding from the nose, and increased swelling to the face. The note further indicated the resident was sent to another hospital. A nursing note on 1/7/11 at 4:00 p.m., indicated the resident was admitted to the intensive care unit. An admission consultation note from the hospital where the resident was admitted , dated 1/7/11, indicated the resident was a chronic vent dependent resident with a tracheotomy, was evaluated for recent facial trauma due to an injury from a transfer using a lift. The examination indicated there was very dark bruising around the eyes, primarily intraorbital bilateral over the dorsum of the nose and into the cheek. C.N.A. #1 was interviewed, at 3:07 p.m., on 3/21/11, regarding the incident. The C.N.A. indicated C.N.A. #2 was assisting to transfer Resident C from her bed to the shower chair, when the Hoyer lift they were using tipped over. She indicated they were maneuvering the Hoyer lift over to the shower chair and could not widen the base of the Hoyer because if the base was widened it would not fit inside of the shower chair. The aide indicated the shower chair was too wide and the base of the Hoyer lift could not be extended around the shower chair so they narrowed the base of the Hoyer to fit under the shower chair. Review of a "Hoyer patient lifters" assembly, maintenance and specifications Manual, regarding Hoyer lifts, dated 1997, provided by the DNS (Director of Nursing Service), was reviewed on 3/22/11 at 9:50 a.m., and indicated, "Warning, lifters can tip over. Keep base widened for stability." Review of the Policy for Hoyer lifts, dated 1/13/11, provided by the DNS, was reviewed on 3/22/11 at 9:55 a.m., and indicated when using the Hoyer lift, the base must be extended to the widest position to allow the Hoyer to be balanced when weight was applied to attempt to prevent tipping of the Hoyer and potential injury to the resident. The policy indicated two employees must be present when using the Hoyer lift, and if there was an issue with a piece of equipment which would not allow the base of the Hoyer to be extended, "you need to consult with your supervisor for further instructions." The DNS was interviewed at 8:52 a.m., on 3/22/11, and indicated the old policy for Hoyer lifts was the same policy as the one signed on 1/13/11. She indicated the shower chair used for Resident C was a large plastic PVC (Polyvinyl Chloride) chair, and was "wider and bigger" then most shower chairs. She indicated she didn't realize the base of the Hoyer could not be extended to fit around the shower chair, because the shower chair was too wide. She indicated no one had made her aware of this and she didn't know the C.N.A.s were not widening the base of the Hoyer during transfers of Resident C. She indicated when the incident occurred on 1/7/11, she had a staff inservice regarding widening the base of the Hoyer for safety. Resident C was observed being transferred, from bed to wheelchair at 9:52 a.m., on 3/22/11. Two staff members assisted with the transfer, using the Hoyer lift. The ADNS operated the Hoyer lift, while C.N.A. #3 maneuvered the resident in the Hoyer lift, while moving the respiratory tubing connected to the resident's tracheostomy, and the ventilator. The base of the Hoyer lift was widened during the transfer. This federal tag relates to Complaint Number IN 735. 3.1-45(a)(2)