Every finding on record at Barrington of Carmel, The

Based on observation, interview and record review, the facility failed to ensure residents sitting at the same table were all served before assisting other residents for 12 of 17 residents observed for dining. Finding includes: During an observation, on 6/7/23 at 12:18 p.m., the cook carried two plates to a table of six residents sitting against the wall by the windows. The cook then carried two more plates to another table of six residents sitting at the entrance of the dining room. During an interview, on 6/7/23 at 12:20 p.m., Certified Nursing Assistant (CNA 2) indicated not all residents sitting at one table were served at the same time. During an interview, on 6/7/23 at 12:24 p.m., CNA 3 indicated one cook and two servers were preparing the food and serving the meal to the residents. The plates came out at different times and not all tables were served at the same time. During an interview, on 6/7/23 at 12:49 p.m., Server 4 indicated lunch was first come first served for the residents. The plates were delivered in no particular order, and they normally did not pass one table at a time. During the resident council meeting, on 6/7/23 at 2:05 p.m., the residents indicated they waited a long time for their meals and the tables did not get their food at the same time. One resident indicated she had to watch the other residents eat while waiting for her food. A current policy, titled Resident Rights, not dated and received from the Associate Executive Director on 6/8/23 at 2:54 p.m., indicated .The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility .All residents will be treated equally regardless of age, race, ethnicity, religion, culture .The resident has a right to be treated with respect and dignity The facility did not have a dining policy at the time of the exit conference. 3.1-3(t)

Based on observation, interview and record review, the facility failed to notify the MD (medical doctor) about a greater than 5% weight loss in 3 days according to the order for 1 of 2 residents reviewed for nutrition. (Resident 7) Finding includes: During an interview, on 06/07/23 at 1:34 p.m., Resident 7's daughter indicated the resident was getting food which was against her gluten-free diet, and it was giving her diarrhea. The record for Resident 7 was reviewed on 06/08/2023 at 9:35 a.m. Diagnoses included, but were not limited to, moderate protein-calorie malnutrition, celiac disease (an immune reaction to eating gluten), age-related physical debility, unspecified dementia, and need for assistance with personal care. A physician's order, dated 05/19/2023, indicated to weigh the resident every Monday during the day shift. A care plan, dated 04/10/2023, indicated the resident was at risk for malnutrition and the facility was to report a significant weight loss of greater than 5% of body weight in 1 month to the MD. The resident's weights were: a. On 05/29/2023, the resident's weight was 104.4 pounds. b. On 06/01/2023, the resident's weight was 98.8 pounds which was a significant weight loss of 5.4% in 3 days. A progress note, dated 06/2/2023 at 8:52 a.m., indicated the facility notified the RDN (Registered Dietary Nutritionist). Her weight was recognized as a 1.8% weight loss in 30 days. The EHR (Electronic Health Record) did not indicate the facility re-weighed the resident after there was a significant weight loss. The progress notes did not indicate the facility contacted the MD. During an interview, on 06/09/23 at 11:56 a.m., the ADON (Assistant Director of Nursing) and the RDN indicated the facility would re-weigh the resident to ensure there was not an error. A current policy, titled Notification of Changes, dated as reviewed in 2022 and received from the Assistant Executive Director on 06/08/2023 at 3:14 p.m., indicated .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification .Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status A current policy, titled Weight Monitoring, dated as reviewed in 2022 and received from Assistant Executive Director on 06/09/2023 at 10:57 a.m., indicated .Weight Analysis: The newly recorded resident weight should be compared to the previously recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure a Registered Nurse was in the facility for 8 hours during a 24-hour period for 2 days of the second quarter reviewed for sufficient staffing. (March 11 and 12, 2023) Finding includes: A Payroll-Based Journal (PBJ) Staffing report, for the second quarter of 2023, indicated the facility failed to have licensed nurse coverage for 2/11, 2/12, 2/19, 2/25, 2/26, 3/4, 3/11, 3/12, 3/18, 3/19, 3/25 and 3/26/2023. During an interview, on 6/8/23 at 10:15 a.m., the Director of Nursing (DON) indicated she did not believe the facility went twelve days without Registered Nurse (RN) coverage. They always work with at least two nurses each shift. The facility scheduled a RN daily. During an interview, on 6/8/23 at 10:20 a.m., the Facility Scheduler indicated she normally scheduled a RN daily and did not know why a RN was not on the schedule. During an interview, on 6/8/23 at 11:18 a.m., the DON indicated the facility did not have RN coverage for the weekend of 3/11 and 3/12/23. They should have had RN coverage and did not know why an RN was not on the schedule. During a record review, on 6/8/23 at 11:20 a.m., the actual worked staffing schedule indicated there was no RN coverage for 3/11 and 3/12/23. A current policy, titled Nursing Services and Sufficient Staff, not dated and received from the DON on 6/8/23 at 2:51 p.m., indicated .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the high practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans .The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week .The facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week 3.1-17(b)(3)

Based on interview and record review, the facility failed to ensure staff knew how to monitor residents for the serious side effect of EPS (extrapyramidal side effects) which can be caused by antipsychotic medications for 2 of 5 residents reviewed for unnecessary medications (Resident 14 and 4). Findings include: 1. The record for Resident 14 was reviewed on 6/8/23 at 9:54 a.m. Diagnoses included, but were not limited to, psychotic disorder with hallucinations due to a known physiological condition, Parkinson's disease, and dementia without behavioral disturbance. A physician's order, dated 5/22/23, indicated quetiapine (an antipsychotic) 25 mg (milligram) give one half tablet at bedtime related to the psychotic disorder with hallucinations due to a known physiological condition. A physician's order, dated 5/22/23, indicated to monitor for the antipsychotic medication side effects of dry mouth, constipation, blurred vision, disorientation, confusion, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, EPS symptoms, tremors, disturbed gait, increased agitation, restlessness and involuntary movements of the mouth or tongue. A care plan, dated 5/24/23, indicated the resident was at a risk for behavior problems related to the psychotic disorder with hallucinations. The interventions included, but were not limited to, administer medications as ordered and monitor for side effects and effectiveness. The MAR (Medication Administration Record), dated 5/22/23 through 5/31/23, indicated LPN 5 had observed for antipsychotic side effects including EPS on 5/23/23, 5/24/23, 5/25/23 and 5/31/23 and LPN 6 on 5/26/23. The MAR did not include if the resident had any of the side effects being monitored. The MAR, dated 6/1/23 through 6/7/23, indicated LPN 5 had observed for antipsychotic side effects including EPS on 6/3/23, 6/4/23 and 6/7/23 and LPN 6 on 6/2/23 and 6/5/23. The MAR did not include if the resident had any of the side effects being monitored. During an interview, on 6/8/23 at 11:14 a.m., the MDS (Minimum Data Set) Coordinator indicated the side effect monitoring was on the MAR. If the MAR triggered any side effects, then an AIMS (Abnormal Involuntary Movement Scale) would be initiated. During an interview, on 6/8/23 at 11:37 a.m., LPN 5 indicated when monitoring for antipsychotic medication side effects they would look for behaviors, any changes in bowel habits, dryness of mouth or eyes, increased thirst, and mental changes. LPN 5 did not know what EPS was. When asked to look at the MAR for an explanation of EPS, LPN 5 indicated they still did not know what EPS was. During an interview, on 6/9/23 at 9:50 a.m., LPN 6 indicated for antipsychotic medications the side effects to monitor included dry mouth, increased confusion, restlessness, and to look for worsening behaviors. LPN 6 did not know what EPS was and stated they would have to figure it out. LPN 5 and LPN 6 had signed the MAR, for May 2023 and June 2023, to indicate they had monitored for EPS, and they did not know what EPS included. An In-Service attendance record dated 3/22/23 at 1:30 p.m., for antipsychotic medication conducted by the pharmacy did not include LPN 5 and LPN 6. The facility in-service handout for Monitoring for Adverse Effects of Antipsychotics, dated 2023, indicated to observe for EPS and consider the use of objective rating tools such as an AIMS assessment. Symptoms to monitor included, but were not limited to, tremors, muscle rigidity, shuffled gait, painful and acute muscle contracture commonly in the neck, eyes and trunk, restlessness, fidgeting, pacing, and rocking. The current Nursing Drug Handbook indicated quetiapine could cause EPS. Consider stopping the medication for signs or symptoms of tardive dyskinesia (a type of EPS with stiff jerky movements of the face and body which could not be controlled and could be permanent). Another extrapyramidal side effect was NMS (neuroleptic malignant syndrome which was a rare reaction to antipsychotic medications which causes a high fever, muscle stiffness, sweating, fast or abnormal heartbeat, quick breathing). NMS could cause kidney failure, heart and lung failure, lack of oxygen in the body, and infection in the lungs. 48385 2. The record for Resident 4 was reviewed on 06/08/23 at 10:46 a.m. Diagnoses included, but were not limited to, morbid (severe) obesity due to excess calories, essential (primary) hypertension, weakness, dyspnea, depression, hypothyroidism, age-related physical debility, muscle weakness (generalized), and unsteadiness on feet. A physician's order, dated 03/09/2023, indicated quetiapine (an antipsychotic) 25 milligram tablet, take 1/2 tablet (12.5 milligrams) by mouth daily for a mood stabilizer. A care plan, dated 03/20/2023, indicated the resident received a psychotropic medication and was at a risk for adverse consequences. The interventions included, but were not limited to, administer medications as ordered and monitor for side effects and effectiveness. The MAR did not include if the resident had any of the side effects being monitored. During an interview, on 06/09/23 at 10:09 a.m., the Administrator indicated the facility did not complete routine AIMs testing, and they only did this if needed after monitoring for side effects. During an interview, on 06/09/23 at 11:06 a.m., LPN 6 indicated they monitored for adverse effects of antipsychotic/antidepressant medications such as dry mouth, constipation, and restless. When asked what EPS symptoms were, LPN 6 did not know what Extrapyramidal (EPS) was or what the side effects were. An AIMS assessment was not located in resident's medical record. A current policy, titled Use of Psychotropic Medication, undated and received from the MDS Coordinator on 06/08/2023 at 11:56 a.m., indicated .residents who receive a psychotropic medication will have Abnormal Involuntary Movement Scale (AIMS) test performed if triggered by anti-psychotic monitoring 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure a resident received privacy during an assessment for 1 of 2 residents reviewed for privacy. (Resident 2) Finding includes: During an observation, on 06/08/22 at 12:42 p.m., the Psychiatric Nurse Practitioner (NP 2) was observed in the dining room, during the mid day meal, asking Resident 2 questions. The questions which were asked in the dining room, with other residents, dietary staff and a CNA present, were about her sleep patterns, her mood, whether the resident was happy or sad, if she was better on [MEDICATION(S)] (an antidepressant) and if she was participating in activities. During an interview, on 06/08/22 at 12:46 p.m., NP 2 indicated the dining room was not an appropriate area to ask those questions. During an interview, on 06/09/22 at 9:21 a.m., the Director of Nursing indicated NP 2 was a new nurse practitioner, new to a health care environment and was not aware she should not have interviewed the resident in the dining room. It was not appropriate to assess the resident in the dining room. A current facility policy, titled Confidentiality of Personal and Medical Records, undated and provided by the facility on 06/09/22 at 8:30 a.m., indicated .Employees should not discuss resident information in public or semi-public areas 3.1-3(o) 3.1-3(p)(2)

Based on observation, interview and record review, the facility failed to implement the comprehensive person-centered care plan interventions documented in a fall care plan for a resident who was at high risk for falls for 1 of 12 residents reviewed for care plans (Resident 22). Finding includes: On 05/24/2021 at 11:47 a.m., the resident was observed sitting in her wheelchair, at the dining table, wearing white tube socks. On 05/25/2021 at 9:57 a.m., the resident was observed sitting in her wheelchair, participating in activities, wearing white tube socks. On 05/26/2021 at 11:46 a.m., the resident was observed sitting in her wheelchair, at the dining table, wearing white tube socks. On 05/26/2021 at 4:35 p.m., the resident was observed sitting in her wheelchair, at the dining table, wearing white tube socks. The record for Resident 22 was reviewed on 05/25/2021 at 2:02 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Fall Risk Assessment, dated 04/28/2021, indicated the resident was intermittently confused, had 1 to 2 falls within the last three months and had decreased muscular coordination. She was at high risk for falls and had a fall on 04/27/2021. She was standing in her room at the time of the fall. A Fall Risk Assessment, dated 04/29/2021, indicated the resident was intermittently confused, had 3+ falls within the last 3 months and had decreased muscular coordination. She was at high risk for falls and had a fall on 04/29/2021. She was in her wheelchair at the time of the fall. A Fall Risk Assessment, dated 05/20/2021, indicated the resident was disoriented to person, place and time at all times, had 3+ falls within the last 3 months and had decreased muscular coordination. She was at high risk for falls and had a fall on 05/20/2021. She was observed on her mat next to her bed and slipper-socks .were not present. The comprehensive person-centered care plan related to falls, dated 04/16/2021 to present, indicated the resident was at high risk for falls due to dementia, history of falls and immobility. Interventions included, but were not limited to, assist the resident to wear non-slick footwear. During an interview, on 05/28/2021 at 9:53 a.m., the Infection Control Preventionist Nurse indicated nursing should be following and implementing all care plan interventions. A current facility policy, titled Comprehensive Care Plans, undated and provided by the Executive Director on 05/28/2021 at 9:00 a.m., indicated .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment .8. Qualified staff responsible for carrying out the interventions initially and when changes are made 3.1-35(f) 3.1-35(g)(2)

Based on observation, interview and record review, the facility failed to ensure an expired medication was removed and disposed of from a medication refrigerator for 1 of 1 medication refrigerators observed. Finding includes: During an observation of the medication refrigerator, on [DATE] at 9:49 a.m., with LPN 1 a Pneumococcal Vaccine stored in the refrigerator door had an expiration date of [DATE] on the medication storage box. During an interview, at that time, LPN 1 indicated the vaccine had not been used and should have been discarded because it was expired. A current facility policy, titled Medication Storage, dated ,d+[DATE] and provided by the Executive Director on [DATE] at 9:00 a.m., indicated .8. Unused Medications .all medications rooms are routinely inspected .for outdated .medications .and are destroyed A current facility policy, titled Storage of Medications dated ,d+[DATE] and provided by the Executive Director on [DATE] at 9:00 a.m., indicated .4. The facility shall not use .outdated .drugs or biological's 3.,d+[DATE](o)

Based on observation, record review and interview, the facility failed to ensure a resident was provided care to prevent the development of multiple stage 2 to stage 4 pressure ulcers due to the resident being left on a bedpan for an undetermined amount of time. The facility also failed to provide wound care to the pressure ulcers as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: During the initial tour observation on 9/27/18 at 5:10 a.m., Resident B was in bed on an air mattress. At 5:13 a.m., RN 2 arrived to assist CNA 1 to turn the resident. The resident had a foam dressing on her left hip dated 9/25/18, and left isheal area dated 9/25/18. A very large dressing, without a date, made up of abdominal pads and tape was loose and coming off the large area on the coccyx and hip that was a Stage 4 pressure ulcer. During the observation, the resident indicated the sores on her bottom were caused by the bedpan. She indicated she had been placed on the bedpan and fell asleep. She had no idea how long she was on the bedpan or the exact date this had occurred. During an interview with the Administrator and the Director of Nursing on 9/27/18 at 6:02 a.m. , the DON indicated Resident B had been left on a bedpan for an undetermined amount of time, the wound was very invasive and was caused from a bedpan. At that time, the Administrator indicated the facility could not determine who had put the resident on the bedpan. During an observation on 9/27/18 at 6:49 a.m., with the Director of Nursing (DON) and LPN 3, the DON was completing a treatment to the resident's legs. There was a spray bottle of wound cleaner, a spay bottle of skin prep, a tube of [MEDICATION NAME], packages of 4 x (by) 4 dressings, 2 packages of Kerlix, and a box of [MEDICATION NAME] lying on the bed. After the leg treatment, the DON placed the items that were on the bed onto a 4 tiered wheeled stand that had been brought into the room with supplies and a computer on the top. The 4 x 4 dressings, the spray skin prep and the Kling package were placed directly onto the keyboard of the computer. At 7:00 a.m., LPN 3 washed a bedside table and placed a chux on it. She then arranged supplies for the dressing change to the residents bottom on the table. She retrieved the spray bottle of skin prep, and 4 x 4 dressings from the computer keyboard and placed them on the clean field. She then placed the remainder of the supplies onto the clean field. The two dressings on the left gluteal and left lateral area were dated 9/25/18. The left gluteal wound was a stage 3 pressure ulcer approximately (approx.) 2 x 5 centimeters (cm), with a small amount of slough (dead tissue) in the wound bed. The 2nd left gluteal pressure ulcer was a Stage 2 pressure ulcer approx. 0.5 x 0.5 cm. The wound treatment was completed to both areas. The resident was then turned onto her right side. The dressing to her bottom was loose and was not dated. At that time, during interview, the DON indicated the dressing was abdominal pads and should not have been. The wound on the bottom was an arc shape starting approximately (approx.) 5 centimeters to the left of the intergluteal cleft (crevice of the buttock) and continuing approx. 9 cm to the right. The wound bed was red with moderate drainage, and had an area of slough and tunneling at 1 o'clock. The wound bed was approx. 3 centimeters long and approx. 3 centimeters deep. The treatment to this area was completed. The residents right buttocks had two pressure ulcers. The wound most lateral was an unstageable ulcer, approx. 3 x 4 cm and the wound bed was black necrotic (dead) tissue. The treatment was completed to this area. The pressure ulcer most medial to the intergluteal cleft was circular approx. 3 x 3 x 2 cm with slough and moderate amount of yellow drainage. The wound had an area of tunneling between 4 and 5 o'clock. The treatment was completed to this area. The record for Resident B was reviewed on 9/27/18 at 12:27 p.m. [DIAGNOSES REDACTED]. The resident was on hospice services. A facility investigation, dated 8/30/18, indicated Resident B was left on a bedpan for an undetermined amount of time and received stage 2 pressure ulcers. There was no staff person identified or confessed to putting the resident on the bedpan. One CNA was terminated for not following the CNA assignment sheet since the resident should have been turned and repositioned every two hours. The resident indicated she was not sure who or what time, maybe after dinner, she was put on the bedpan and that she fell asleep. The next day the hospice aide informed LPN 3 at 11:30 a.m., the resident was on the bedpan. LPN 3 assessed the resident's buttocks and indicated a new skin area was observed to the left and right buttock and the tip of bottom area from the bedpan. The entire wound measured 18 cm x 2 cm. The wound was a deep purple bruise that was not blancheable. On the upper right side of wound was a stage 2 pressure ulcer that measured 4 cm x 2.5 cm. A stage 2 on the upper right buttocks was a partial thickness wound with scant drainage with a red wound bed. On the lower right buttock a small fluid filled raised area 1.1 x 1.1 cm that was a stage 2, with slight drainage. The investigation summary indicated CNA 4 was assigned to the resident during the night shift on 8/30/18. The summary indicated the CNA stated she had not put the resident on the bedpan and no other staff interviews indicated who had placed the resident on the bedpan. The resident's CNA assignment sheet for the night of the incident indicated the resident was to be turned and repositioned every 2 hours from side to side and to be checked and changed every 2 hours as well. A Counseling Documentation Form indicated CNA 4 did not follow the care instructions and she did not complete any charting for the night. .If (name of CNA) would of followed this instruction, the resident would not have experienced skin breakdown .Due to severity of misconduct and resulting outcome with skin breakdown, (name of CNA)'s employment with The Barrington will be terminated on 9/7/18 An 8/20/18 MDS (Minimum Data Set) Assessment indicated the resident was at risk for pressure ulcer development, and currently had no pressure ulcers and preventative measures were in place. The resident was extensive assist of 2 people for bed mobility, including turning and repositioning and toilet use including the use of the bedpan. The MDS also indicated the resident was cognitively intact. A plan of care with a start date 6/14/18 indicated the resident was as risk for skin breakdown due to decreased mobility, weakness and fragile skin. Approaches included, but were not limited to, assist with frequent position changes, wound care as ordered, keep skin clean and dry. A plan of care dated 6/14/18 indicated the resident needed extensive assist of 2 staff with toileting and turning and repositioning. A Braden Scale dated 8/24/18 indicated the resident was bed fast, had limited mobility, had a problem with friction and sheering, needed moderate to maximum assist with moving and had not sensory deficit which would limit ability to feel or voice pain or discomfort. A plan of care dated 8/30/18 indicated actual skin integrity problem of unstageable pressure ulcer to top center buttocks, now open, 2 on left buttocks and 1 on right side of buttocks. Approaches included, but were not limited to, wound and dressing change as ordered. Observe for treatment effectiveness and report concerns to physician and hospice. A physician order [REDACTED]. Place calcium alginate on the wound bed. Apply skin prep to the peri wound. Then cover with OPTIL[NAME]K (non-adhesive super absorbent wound dressing) every morning. A nursing note dated 9/16/18 indicated the resident had multiple wounds to the buttocks and surrounding areas. The wounds had drainage, slough/eschar (black necrotic) and odor. The resident's largest area was 22 cm by 4 cm by 2.5 cm. The resident did complain of pain and discomfort from the treatment. A 9/24/18 skin evaluation form indicated a Stage 3 pressure ulcer to the buttock, that was 14.2 x 2.2 x 2.5 cm, with purulent and foul smelling drainage. The wound edges had undermining and a sinus tract. The form indicated the area had opened up into two separate areas. Second area to left buttocks measured 4.2 x 3.4 and had necrotic tissue covering the wound bed with a scant amount of drainage. A skin evaluation form dated 9/24/18 indicated a wound to the right upper buttocks that was 3.8 x 2.3 x 0.2 cm that was covered in necrotic tissue with slough around the edges. From the observation on 9/27/18 and review of the skin evaluation forms, not all the pressure areas were assessed and documented as observed. There was not a separate skin evaluation form for left buttock, isheal and right medial gluteal wound for follow up assessment. The Treatment Administration Record for (MONTH) (YEAR) indicated the dressing change for the entire buttocks, which is listed as one order, was not completed on 9/26/18. A nursing note dated 9/26/18 indicated the nurse was notified by staff the hospice nurse usually did wound care on this day. It was confirmed that hospice would not be in and wound be in on Friday 9/28/18. The replacement nurse and ADON (Assistant Director of Nursing ) notified that dressing needed completed. A nursing note dated 9/27/18 at 11:08 a.m., indicated Hospice was contacted and indicated they had been in the prior day but had not provided wound care. The treatment was completed this a.m. During an interview on 9/27/18 at 2:07 p.m., the DON indicated the buttock dressing was not changed on 9/26/18 as ordered. She indicated the shift nurse knew that hospice was in and they would change the dressing, but today hospice was contacted and the dressing was not changed on 9/26/18 by hospice. She also indicated the dressing that was observed on 9/27/18 during the dressing change, did not follow the physician orders [REDACTED]. There were ABD (abdominal dressing) pads covering the wound. She was also informed of the dressing items such as spray wound cleanser, 4 x 4 gauze, Kerlix wrap, and skin protectant spray being on the bed and then moved to the 4 tier cart and then placed onto the clean field. She indicated at that time, there was so much going on, she did not identify this. A policy titled Bedpan .Offering/Removing was provided by the Administrator on 9/27/18 at 9 a.m., and deemed as current. The policy indicated: .1. Review the resident's care plan to assess for any special needs of the resident .5. Do not allow the resident to sit on a bedpan for extended periods. (Note: This is not only uncomfortable to the resident, it also causes skin breakdown A policy titled Wound Treatment Guidelines was provided by the DON on 9/27/18 at 2:30 p.m., and deemed as current. The policy indicated: 1. Wound treatments will be provided in accordance with physician orders, including the .type of dressing, and frequency of dressing change .6.The facility will follow specific physician orders [REDACTED]. A policy titled Clean Dressing Change was provided by the DON on 9/27/18 at 2:30 p.m., and deemed as current. The policy indicated: .Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. physician's orders [REDACTED].Mark with intial and date . This federal citation is realted to Complaints IN 221 and IN 614. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to ensure coordination of care between hospice care provisions and facility care provisions for 1 of 1 resident reviewed for hospice services. (Resident B) Findings include: During the initial tour observation on 9/27/18 at 5:10 a.m., Resident B was in bed on an air mattress. At 5:13 a.m., RN 2 arrived to assist CNA 1 to turn the resident. The resident had a foam dressing on her left hip dated 9/25/18, and left isheal area dated 9/25/18. A very large dressing, without a date, made up of abdominal pads and tape was loose and coming off the very large area on the coccyx and hip that was identified as a Stage 4 pressure ulcer. During an observation on 9/27/18 at 7 a.m., with the Director of Nursing (DON) and LPN 3, the left gluteal and left isheal dressings werre observed to be dated 9/25/18. The dressing to the residents large area on her bottom was loose and was not dated. The wound on the bottom was an arc shape starting approximately (apx.) 5 centimeters to the left of the intergluteal cleft, just above the coccyx, and continuing apx. 9 cm to the right. The wound bed was red with moderate drainage, and had an area of slough and tunneling at 1 o'clock. The wound bed was apx. 3 centimeters long and apx. 3 centimeters deep. The residents right buttock had two pressure ulcers. The wound most lateral was an unstageable ulcer, apx. 3 x 4 cm. The wound bed was black necrotic (dead) tissue. The treatment was completed to this area. The pressure ulcer most medial to the intergluteal cleft was circular apx. 3 x 3 x 2 cm with slough and moderate amount of yellow drainage. The wound had an area of tunneling between 4 and 5 o'clock. The record for Resident B was reviewed on 9/27/18 at 12:27 p.m. [DIAGNOSES REDACTED]. The resident was on hospice services. A plan of care dated 8/30/18 indicated an actual skin integrity problem of unstageable pressure ulcer to top center buttocks, now open, 2 on left buttock and 1 on right side of buttock. Approaches included, but were not limited to, wound and dressing change as ordered, and observe for treatment effectiveness and report concerns to physician and hospice. A physician's orders [REDACTED]. The Treatment Administration Record for (MONTH) (YEAR) indicated the dressing change for the entire buttocks, listed as one order, was not completed on 9/26/18. A nursing note dated 9/26/18 indicated the nurse was notified by staff, the hospice nurse usually did wound care on this day. It was confirmed that the hospice nurse would not be in on 9/26/2018, but would be in on Friday 9/28/18 instead. The note also indicated the replacement nurse and ADON (Assistant Director of Nursing ) was notified the dressing needed completed. A nursing note dated 9/27/18 at 11:08 a.m., indicated hospice was contacted and indicated they had been in the prior day but had not provided wound care. During an interview on 9/27/18 at 2:07 p.m., the DON indicated the buttock dressing was not changed on 9/26/18 as ordered. She indicated the shift nurse knew that hospice was in and they would change the dressing, but today hospice was contacted and the dressing was not changed on 9/26/18 by hospice. She indicated she would not assume Hospice changed dressing anymore. Resident B's (Name of Hospice) binder was reviewed on 9/27/18 at 2:30 p.m. There was no plan of care in the binder. LPN 3 indicated at that time during interview, there was verbal communication with the hospice nurse when they come for resident visit regarding whether they completed the dressing changes. There was no specific plan or care to delineate who was responsible for the dressing changes. A (Name of Hospice) plan of care was provided by the DON on 9/27/18 at 2 p.m., with a fax date a time to facility of 9/27/18 at 1:52 p.m. This plan of care had no delineation of services for wound care. A facility plan of care for hospice serviced dated 9/3/18 did not delineate who was providing wound care. During an interview with the DON on 9/27/18 at 2:35 p.m., she indicated communication with hospice was verbal related to dressing changes. She indicated there was no written plan of care to coordinate the care services. A (Name of Hospice) Residential Hospice Care Agreement for Services to Residents of Nursing Facilities made on (MONTH) 3, (YEAR) and signed by the facility Executive Director was provided on 9/27/18 at 2:50 p.m., and deemed as current. The agreement indicated: .2. Responsibility of Facility (d) Coordination of Care .(i) General .Facility and Hospice shall communicate with one another regularly and as needed .(ii) Design of Plan of Care .Facility shall coordinate with Hospice in developing a Plan of Care for each Hospice Patient . (b)Professional Management Responsibility .(iii) Coordination and Evaluation. Hospice shall retain responsibility for coordinating, evaluating and administering the hospice program, as well as ensuring the continuity of care of Hospice Patients, which shall include coordination of Facility Services .(e) Provision of Information. Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Facility Services under this agreement is in accordance with the Hospice Patient's Plan of Care .and care coordination. A policy titled Wound Treatment Guidelines was provided by the DON on 9/27/18 at 2:30 p.m., and deemed as current. The policy indicated: 1. Wound treatments will be provided in accordance with physician orders, including the .type of dressing, and frequency of dressing change .6.The facility will follow specific physician orders [REDACTED]. This Federal citation is related to Complaints IN 221 and IN 614. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was allowed to exercise her right to choose when to go to bed for 1 of 3 residents reviewed for exercising resident rights (Resident B). Finding includes: During a phone interview on 7/25/18 at 4:21 p.m., (Name of family member) indicated he was called on the phone on 6/22/18 at 10:45 p.m., and told by a nurse it took three people to take his (family member) to her room and she was being transferred to (Name of Hospital) because they could not handle her behavior. He indicated the resident remembered what happened to her at the facility the night she was transferred to the hospital. Resident B told the family members there was three large African American women on her trying to take her to the bathroom when she did not want to go. They were digging their nails into her arms to hold her down. On 7/25/18 at 6:22 p.m., the record for Resident B was reviewed. [DIAGNOSES REDACTED]. A progress note, dated 6/22/18 at 10:58 p.m., indicated, Resident refused to accept medications from evening shift nurse. Writer assisted other nurse with attempting to persuade resident to take medications and to get out of her wheelchair to go to bed. Resident continued to refuse to take any medications or to get out of her wheelchair. Resident's lower bilateral extremities continue to be extremely [MEDICAL CONDITION]. Resident was informed by writer (nurse) that she needs to elevate her legs due to the swelling and to get in bed to relax for the night. Resident began to yell in the hallway. 'Leave me alone, I don't want to go to bed. I want to go up there to watch tv!' CNA staff member assisted resident to her bedroom along with two nurses. Resident was assisted in taking off her clothes and shoes and assisted to bed. While attempting to assist resident to bed resident attempted to kick staff and bite staff on the arm if staff attempted to hold onto resident due to resident's unsteady gait. Once resdent (sic) was in bed she was offered her evening medications again. Resident refused again to take any medications. Resident stated she would throw the water in the bed if the nurse tried to give her medications. Resident then quickly attempted to get out of bed but quickly fell back onto bed due to inability to stand on her feet due to the increased swelling. Writer contacted ADON (Assistant Director of Nursing) at 2200 (10:00 p.m.) who informed writer to contact 911 and to send to ER (emergency room ) for behavioral issues and non-compliance with physical aggression. Writer (nurse) called 911 at 2205 (10:05 p.m.). Writer (nurse) notified (Name of family member) at 2208 (10:08 p.m.). EMS (Emergency Medical Services) arrived at 2221 (10:21 p.m.) for pickup to transport to (Name of Hospital). An ER Nursing Documentation form from (Name of Hospital), dated 6/22/18 at 11:09 p.m., indicated the resident presented to the ED from the facility by the EMS for behavioral problems. An ER Physician Exam from (Name of Hospital), dated 6/23/18 at 12:23 a.m., indicated .Triage Chief Complaint: other Additional Triage Comments: Pt (Patient) to ED (Emergency Department) per (by) EMS from (Name of Facility). Pt. would not stay in bed and became combative with staff and attempted to bite several staff members when attempted to give pt her meds During a phone interview on 7/26/18 at 2:54 p.m., LPN 1 indicated Resident B was content in her wheelchair propelling herself around the hallway in circles for hours after dinner on the evening of 6/22/18. Resident B propelled herself around to the North nursing station around the time the CNA's were getting ready to leave for the end of their shift. LPN 1 indicated she told Resident B she needed to get out of her wheelchair and go to bed to elevate her legs, but the resident refused. She explained to her again why she needed to lay down and she refused again. LPN 1 explained a third time why Resident B needed to lay down and the resident refused again. LPN 1 indicated due to the resident's legs having 3+ [MEDICAL CONDITION], fluid seeping from her lower legs and she had blisters on her lower legs, she used her nursing judgement and told the resident she was going to put her to bed, so she could elevate her legs. Resident B did not want to go to bed and when LPN 1 tried to push her wheelchair forwards to take her to her room, she planted her feet on the ground to stop the wheelchair from going forward, so LPN 1 and CNA 2 turned the wheelchair around and pulled the wheelchair backwards to get the resident into her room. LPN 1 indicated Resident B was screaming in the hallway to leave her alone, she didn't want to go to bed, she wanted to watch TV. LPN 1 indicated one person had to hold one of her arms while another person was taking the other arm out of the sleeve of her shirt and putting it into the sleeve of the gown, then the opposite arm had to be held by someone, while another person took the second arm out of her shirt sleeve and placed it inside the gown sleeve. She indicated it was difficult to get her gown on because Resident B was moving her head trying to bite them, flailing her arms in the air and she was screaming Help me, Help me. LPN 1 indicated CNA 2 and 3 also helped take the resident's clothes off. She indicated she and CNA 2 placed the resident in bed. The resident was hitting, kicking and trying to bite them while they were transferring her to bed. LPN 1 indicated LPN 4 asked the resident if she wanted her medication for the second time that evening and Resident B refused her medications and kicked LPN 4. LPN 1 indicated the resident jumped out of bed, but she fell back into the bed because her legs were so [MEDICAL CONDITION] she could not stand on them. LPN 1 indicated this situation was a mess. She had never seen this resident aggressive and agitated like this before. During a phone interview on 7/27/18 at 12:40 p.m., LPN 4 indicated she worked the split assignment at the facility in the evening from 6:00 p.m. to 10:00 p.m., on 6/22/18, the night this resident was sent out to the hospital. She tried to offer Resident B her medications approximately between 7:30 p.m. to 8:00 p.m. and the resident refused her medications. She was passing her other medications when a CNA came to get her and told her there was a problem with Resident B. She told her she was being non-compliant while they were trying to provide her bedtime care to her. She indicated she went into the resident's room and she was in the bed screaming and LPN 1 was trying to calm her down by talking to her, but the resident was getting more agitated with her. She offered her medication to her again and she refused it. She was hitting, kicking and trying to bite the staff. She was yelling. She indicated the resident would not have taken the medication at that time when she offered them to her anyway because she was to far gone. LPN 4 indicated someone had made her mad and she was aggressive and combative, so there was no way she would have taken that medication. She indicated the resident keyed in on (Name of LPN 1) because she upset her. The resident told LPN 1 Don't touch me. She told LPN 4 Don't touch me, get off me. The resident was swinging, trying to ward her off, but she did not physically touch the resident at any time. During an interview on 7/27/18 at 4:15 p.m., the DON indicated the staff should have honored the resident's wishes and left her in her wheelchair. This Federal tag relates to Complaint IN 653. 3.1-3(u)(1)

Based on interviews and record review, the facility failed to ensure a resident was not forced to go to her room, was not physically restrained while ADL (Activities of Daily Living) care was provided, then forced to go to bed against her will for 1 of 3 residents being reviewed for abuse (Resident B). Resident B had abrasions to her arms and had a bruise to her back and buttock after being forced into her room, then into her bed and she was forced to change into her nightgown from her clothes after she refused to do all these more than once. Finding includes: During a phone interview on 7/25/18 at 4:21 p.m., (Name of family member) indicated he was called on the phone on 6/22/18 at 10:45 p.m., and told by a nurse it took three people to take his (family member) to her room and she was being transferred to (Name of Hospital) because they could not handle her behavior. He indicated the resident remembered what happened to her at the facility the night she transferred to the hospital. Resident B told the family members there was three large African American women on her trying to take her to the bathroom when she did not want to go. They were digging their nails into her arms to hold her down. Resident B indicated four huge men came and rescued her and they told the three women to get their hands off her. The family member indicated Resident B told the same story at the hospital regarding the facility staff holding her down on 6/23/18, 6/24/18, and 6/25/18. He indicated Resident B was having nightmares regarding the treatment she received at the facility on 6/22/18. On 7/25/18 at 6:22 p.m., the record for Resident B was reviewed. [DIAGNOSES REDACTED]. A progress note, dated 6/22/18 at 10:58 p.m., indicated, Resident refused to accept medications from evening shift nurse. Writer assisted other nurse with attempting to persuade resident to take medications and to get out of her wheelchair to go to bed. Resident continued to refuse to take any medications or to get out of her wheelchair. Resident's lower bilateral extremities continue to be extremely [MEDICAL CONDITION]. Resident was informed by writer (nurse) that she needs to elevate her legs due to the swelling and to get in bed to relax for the night. Resident began to yell in the hallway. 'Leave me alone, I don't want to go to bed. I want to go up there to watch tv!' CNA staff member assisted resident to her bedroom along with two nurses. Resident was assisted in taking off her clothes and shoes and assisted to bed. While attempting to assist resident to bed resident attempted to kick staff and bite staff on the arm if staff attempted to hold onto resident due to resident's unsteady gait. Once resdent (sic) was in bed she was offered her evening medications again. Resident refused again to take any medications. Resident stated she would throw the water in the bed if the nurse tried to give her medications. Resident then quickly attempted to get out of bed but quickly fell back onto bed due to inability to stand on her feet due to the increased swelling. Writer contacted ADON (Assistant Director of Nursing) at 2200 (10:00 p.m.) who informed writer to contact 911 and to send to ER (emergency room ) for behavioral issues and non-compliance with physical aggression. Writer (nurse) called 911 at 2205 (10:05 p.m.). Writer (nurse) notified (Name of family member) at 2208 (10:08 p.m.). EMS (Emergency Medical Services) arrived at 2221 (10:21 p.m.) for pickup to transport to (Name of Hospital). An ER Nursing Documentation form from (Name of Hospital) dated 6/22/18 at 11:09 p.m., indicated the resident presented to the ED from the facility by the EMS for behavioral problems. Skin assessment noted the resident's skin was warm and she had abrasions noted to her arms. An ER Physician Exam from (Name of Hospital) dated 6/23/18 at 12:23 a.m., indicated .Triage Chief Complaint: other Additional Triage Comments: Pt (Patient) to ED (Emergency Department) per EMS from (Name of Facility). EMS state pt coming in for diarrhea and concerned about possible mistreatment of [REDACTED]. Staff called to state pt. was no (sic) having issues with diarrhea and was being sent to ED for behavioral issues this evening. Pt. would not stay in bed and became combative with staff and attempted to bite several staff members when attempted to give pt her meds. Pt very cooperative with EMS and upon arrival An Adult Assessment Intervention form from (Name of Hospital) dated 6/23/18 at 6:24 a.m., indicated Resident B had a bruise to her right upper back and her right buttock. She had a skin tear to her right lower extremity. During a phone interview on 7/26/18 at 2:54 p.m., LPN 1 indicated Resident B was content in her wheelchair propelling herself around the hallway in circles for hours after dinner on the evening of 6/22/18. Resident B was not LPN 1's resident at that time, she was LPN 4's resident, because LPN 4 had the split assignment from 6 p.m. to 10 p.m., then at 10 p.m., this resident became LPN 1's resident. She indicated the CNAs were getting ready to leave for their shift, when this resident propelled herself around to the North nursing station. LPN 1 indicated she told Resident B she needed to get out of her wheelchair and go to bed to elevate her legs, but the resident refused. She explained to her again why she needed to lay down and she refused again. LPN 1 explained a third time why Resident B needed to lay down and the resident refused again. LPN 1 indicated due to the resident's legs having 3+ [MEDICAL CONDITION], fluid seeping from her lower legs and she had blisters on her lower legs, she used her nursing judgement and told the resident she was going to put her to bed, so she could elevate her legs. Resident B did not want to go to bed and when LPN 1 tried to push her wheelchair forwards to take her to her room, she planted her feet on the ground to stop the wheelchair from going forward, so LPN 1 and CNA 2 turned the wheelchair around and pulled the wheelchair backwards to get the resident into her room. LPN 1 indicated Resident B was screaming in the hallway to leave her alone, she didn't want to go to bed, she wanted to watch TV. LPN 1 indicated one person had to hold one of her arms while another person was taking the other arm out of the sleeve of her shirt and putting it into the sleeve of the gown, then the opposite arm had to be held by someone, while another person took the second arm out of her shirt sleeve and placed it inside the gown sleeve. She indicated it was difficult to get her gown on because Resident B was moving her head trying to bite them, flailing her arms in the air and she was screaming Help me, Help me. LPN 1 indicated CNA 2 and 3 also helped take the resident's clothes off. She indicated she and CNA 2 placed the resident in bed. The resident was hitting, kicking and trying to bite them while they were transferring her to bed. LPN 1 indicated LPN 4 asked the resident if she wanted her medication for the second time that evening and Resident B refused her medications and kicked LPN 4. LPN 1 indicated the resident jumped out of bed, but she fell back into the bed because her legs were so [MEDICAL CONDITION] she could not stand on them. LPN 1 indicated this situation was a mess. She indicated she had never seen this resident aggressive and agitated like this before. Resident B argued with her son and husband, but she was usually compliant and sweet when LPN 1 took care of her. She indicated some of the other residents were alarmed about her and were coming down to her doorway checking on her to make sure she was alright, because of how agitated she was that night. She indicated after she was placed to bed, she called the ADON (Assistant Director of Nursing) and told her how the resident was acting. The ADON called her back and told her the DON (Director of Nursing) said to send her out 911 to the hospital for her behavioral problems and non-compliance. She indicated she called 911, then prepared her paperwork. LPN 1 indicated when the Paramedics and Firemen arrived the resident was a totally different person, she was nice to the men and she pointed her finger at LPN 4 and told the Paramedics and the Fireman that she was the one who held her down. LPN 1 indicated Resident B was usually in bed before she took over her care at 10:00 p.m., so this was out of character for her. LPN 1 indicated if she looked back on this incident and if there was anything she would change it would be she would call the resident's family to see if they could come in to try to get her to go to bed, because her husband was usually here in the evening, but he was not on this day and she would have left her in the wheelchair if she was not ready to go to bed. During a phone interview on 7/27/18 at 12:40 p.m., LPN 4 indicated she worked the split assignment at the facility in the evening from 6:00 p.m. to 10:00 p.m., on 6/22/18, the night this resident was sent out to the hospital. She tried to offer Resident B her medications approximately between 7:30 p.m. to 8:00 p.m. and the resident refused her medications. She was passing her other medications when a CNA came to get her and told her there was a problem with Resident B. She told her she was being non-compliant while they were trying to provide her bedtime care to her. She indicated she went into the resident's room and she was in the bed screaming and LPN 1 was trying to calm her down by talking to her, but the resident was getting more agitated with her. She offered her medication to her again and she refused it. She was hitting, kicking and trying to bite the staff. She was yelling. She indicated LPN 1 ran out of the resident's room and she said to LPN 4 she was not going to be beat on like that. She indicated the resident would not have taken the medication at that time when she offered them to her anyway because she was to far gone. LPN 4 indicated someone had made her mad and she was aggressive and combative, so there was no way she would have taken that medication. She indicated the resident keyed in on (Name of LPN 1) because she upset her. The resident told LPN 1 Don't touch me. LPN 4 indicated LPN 1 said while she was still in the room, I don't have to take this abuse, I'm not going to take this abuse. LPN 1 left the room and went to call someone regarding the resident. She thought she called the DON. She indicated she could see steam coming out of LPN 1's ears, but she could not say what she wanted to say to the resident. When the Paramedics got there the resident told them that all of them in the room, which was LPN 4 and two CNA'S jumped on her and tried to make her take her medication and she did not want to take it. She indicated when the Paramedics walked into the room the resident started asking them to come over to her and was reaching her hand out to them. One of the Paramedics went over to the resident and knelt down in front of her and took her hand and she pleaded with him to please help her because 3 or 4 of them jumped on her. LPN 4 indicated the resident broke down crying pleading with him to help her and get her out of there. She and the two CNA'S had told the Paramedics that she would not take her medication they were trying to get her to take. She indicated the resident went from an irate person to someone pleading for help. LPN 4 indicated she had not even punched the resident's medication out of the card because she had refused it earlier. She told LPN 4 Don't touch me, get off me. The resident was swinging, trying to ward her off, but she did not physically touch the resident at any time. LPN 4 indicated LPN 1 told her the DON said to send the resident out to the hospital. While LPN 1 was on the phone there were 2 CNA's at the foot of the bed and she was also at the foot of the bed. Resident B was starting to calm down. She indicated she did not think the resident was escalating enough to be sent out to the hospital. She thought if she was left alone for a while, she would have calmed down and went to sleep. She indicated LPN 1 got scratched by the resident. She indicated LPN 1 tried to show the resident her clothes and the bed was wet and she needed changed, but the resident did not care. Her whole demeanor changed when the Paramedics and the Firemen showed up, like they were there to rescue her. During an interview on 7/27/18 at 4:15 p.m., the DON indicated the staff should have honored the resident's wishes and left her in her wheelchair. A current policy titled Abuse: Screening, Training, Prevention, Identification, Investigation, Protection and Reporting undated, provided by the Administrator on 7/25/18 at 5:45 p.m., indicated Policy Statement: It is the responsibility of this community to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of property. Policy Interpretation and Implementation: 1. Our community does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving that the resident, family members, legal guardians, sponsors other residents, friends or other individuals. 2. To assist with the recognition of incidents of abuse, the following definitions of abuse are provided: i. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Mental abuse is the use of verbal or nonverbal conduct, which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Includes harassment, threats of punishment or withholding of treatment or services .6. Identification: The goal is to train staff to identify signs of potential abuse and/or neglect. Types of abuse: Physical Description: Non-accidental physical force or battery .What to look for: Abrasions .Bruises on face, lateral arm, and posterior torso .Type: Mental and/or Verbal Description: Verbal or nonverbal acts that inflict mental distress, pain or anguish through intimidation and humiliation or other conduct. Examples include: harassing a resident .hovering over a resident with the intent to intimidate, threatening, isolating from social activities .What to look for: Anxiety .Mood changes This Federal tag relates to Complaint IN 653. 3.1-27(a)(1)

Based on interviews and record reviews, the facility failed to ensure residents were weighed daily as ordered for 2 of 3 residents being reviewed for daily weight monitoring (Residents B and F) and the facility failed to ensure residents non-pressure wounds were assessed to follow the progress of healing of the wounds for 1 of 3 residents being reviewed for non-pressure wounds (Resident B). Findings include: 1. On 7/25/18 at 6:22 p.m., the record for Resident B was reviewed. [DIAGNOSES REDACTED]. a. Resident B's weights: The Electronic Treatment Administration Record, dated (MONTH) (YEAR), was reviewed and the orders included, but were not limited to, the following orders: 6/20/18-Daily Weight The weights for Resident B were reviewed and these were the dates and the weights documented for her 6/15/18-156 pounds (lb) 6/16/18-157 lb 6/17/18-158 lb 6/18/18-165 lb No further weights were found documented after 6/18/18 in the resident's record. A progress note, dated 6/20/18 at 11:00 a.m., indicated .Resident display weight gain, 3 + [MEDICAL CONDITION], blood fluid blister on back of leg. Resident display increase confusion. A progress note, dated 6/20/18 at 3:15 p.m., indicated Resident assessed this am while in bed. Voiced concern regarding BLE (bilateral lower extremities); stated they are bigger than they ever have been and painful. Remains on antibiotics for pneumonia .Wound care apt (appointment) today at (Name of Hospital) at 1230 (12:30 p.m.) A progress note, dated 6/21/18 at 3:52 p.m., indicated .3+ [MEDICAL CONDITION] noted on top of both feet .[MEDICAL CONDITION] noted around inner thighs and back of thighs. new orders received from NP (Nurse Practitioner) Resident B was admitted to the hospital on [DATE]. She had a [DIAGNOSES REDACTED]. Her Chest X-ray, dated 6/23/18 at 1:10 a.m., indicated cardiac enlargement with diffuse (spread over a wide area) interstitial (the tissue and space around the air sacs of the lungs) opacities (represents the result of a decrease in the ratio of gas to soft tissue in the lung), which may represent interstitial [MEDICAL CONDITION] related to [MEDICAL CONDITION]. During an interview on 7/27/18 at 2:00 p.m., the DON (Director of Nursing) indicated she could not find any more weights documented in the resident's record. b. Resident B's Wound Assessments: A Nursing Assessment for Resident B, dated 6/15/18 at 4:24 p.m., indicated she had bruises on her admission skin assessment. A progress note, dated 6/15/18 at 7:27 p.m., indicated the resident had the following skin issues: she had scattered bruising on her bilateral hands from previous IV placements and scattered bruising on her bilateral lower extremities with [MEDICAL CONDITION]. A progress note, dated 6/21/18 at 3:52 p.m., indicated, Resident agitated during early part of day shift. Resident refused to let nurse on staff change wraps on leg. left leg wrapping saturated with serous fluid .Resident complained of pain from wraps. Resident refused any pain medications. Resident insisted on nursing staff to call son and schedule appointment with doctor so the doctor can change dressings. Resident requested multiple times that staff call MD office. (Name of family member) in to visit resident. (Name of family member) and writer able to redirect resident and allowed staff to change dressings. Both wounds healing well. Resident complained of pain with touch at site. Drainage noted Resident B was treated at the wound center once a week for her bilateral lower extremity wounds. There were no wound assessments found in the resident's record. Wound Assessments, dated 6/5/18 and 6/20/18, were faxed to the facility from the (Name of Hospital Wound Clinic) on 7/27/18 at 2:12 p.m. A Wound Clinic physician progress notes [REDACTED]. She had the following skin conditions to her bilateral legs: Right lateral lower leg had an ulcer with mixed fibrous and granular tissue. The wound was related to [MEDICAL CONDITION]. There was a moderate amount of serosanguineous (drainage, which contains blood and the liquid part of the blood) drainage. The tissue loss was full thickness (Subcutaneous fat may be visible with exposed bone, tendon or muscle). Slough (necrotic or avascular in the process of separating from viable tissue. Usually soft, moist, and light in color and may be stringy) or eschar (thick, leathery necrotic or divitalized tissue, frequently black or brown in color) may be present on some parts of the ulcer bed. Often includes undermining (destruction of tissue or ulceration that extends under the skin edges, so that the pressure ulcer is larger at its base than at the skin surface) or and tunneling (passageway of tissue destruction under the skin surface, with an opening at the skin level from the edge of the wound) with exposed subcutaneous (fat layer exposed). The wound bed was beefy red granulation (pink-red moist tissue that fills an open wound when it begins to heal) and had slough. The wound measured 1.0 x 0.7 x 0.1 cm (centimeters). Therapist Comments: The resident and the husband were unable to tell the date the ulcer appeared. The stated they did not know it was there. Date of Onset: 6/20/18 Left medial lower leg was a former blister site. The wound was related to [MEDICAL CONDITION]. Tissue loss was full-thickness wound with exposed subcutaneous. There was moderate amount of serous (clear, thin and watery plasma drainage) drainage. The periwound was [DIAGNOSES REDACTED]tosus (reddened). The wound bed was beefy red granulation with pink granulation. The wound measured 4.0 x 3.2 x 0.1 cm. Date of onset 6/15/18. Therapist Comments indicated the resident returned to the wound clinic without a dressing intact. During an interview on 7/27/18 at 4:15 p.m., the DON indicated she did not have any wound assessments for this resident for her BLE wounds to show to indicate the facility was monitoring the progression of healing. She indicated the only wound assessments she had for this resident were the ones faxed over from the St. Vincent Wound Clinic earlier that afternoon. 2. The record review for Resident F was completed on 7/27/18 at 3:36 p.m. [DIAGNOSES REDACTED]. The Electronic Treatment Administration Record, dated (MONTH) (YEAR), was reviewed and the orders included, but were not limited to, the following orders: 6/8/18-Daily weights for [MEDICAL CONDITIONS] The weights for Resident F were reviewed and these were the dates and the weights documented for him: 6/8/18--168 pounds (lb) through 6/18/18--162 lb (A loss of 6 pounds 10 days) 6/8/18--168 lb 6/9/18--168 lb 6/10/18--169 lb 6/11/18--163 lb 6/12/18--163 lb 6/13/18--163 lb 6/14/18--163 lb 6/15/18--160 lb 6/16/18--162 lb 6/17/18--163 lb 6/18/18--162 lb No weight was taken on 6/19/18 6/20/18--160 lb No weight was taken on 6/21/18 6/22/18--160 lb through 6/30/18--161 lb (A gain of 1 pound in 8 days) 6/22/18--160 lb 6/23/18--160 lb 6/24/18--163 lb 6/25/18--163 lb 6/26/18--164 lb 6/27/18--160 lb 6/28/18--161 lb 6/29/18--160 lb 6/30/18--161 lb No weight was taken on 7/1/18 7/2/18--168 lb through 7/7/18--164 lb (A loss of 4 pounds in 5 days) 7/2/18--168 lb 7/3/18--163 lb 7/4/18--162 lb 7/5/18--164 lb 7/6/18--164 lb 7/7/18--164 lb No weight was taken on 7/8/18 7/9/18--160 lb No weight was taken on 7/10/18 7/11/18--163 lb through 7/13/18--167 lb (A gain of 4 pounds in 4 days) 7/11/18--163 lb 7/12/18--165 lb 7/13/18--167 lb No weight was taken on 7/14/18 7/15/18--169 lb through 7/20/18--174 lb (A gain of 5 pounds in 5 days) 7/15/18--169 lb 7/16/18--167 lb 7/17/18--166 lb 7/18/18--165 lb 7/19/18--170 lb 7/20/18--174 lb On 7/18/18, the resident received an order to start [MEDICATION NAME] 20 mg daily No weights was taken on 7/21/18 or 7/22/18 7/23/18--176 lb through 7/27/18--167 lb (A loss of 9 pounds in 4 days) 7/23/18--176 lb 7/24/18--174 lb 7/25/18--171 lb 7/26/17--162 lb 7/27/18--167 lb On 7/25/18, the resident received an order for [REDACTED].>No further weights could be found documented in his record. During an interview on 7/27/18 at 2:00 p.m., the DON indicated she could not find any more weights documented in the resident's record. This federal tag relates to Complaint IN 653. 3.1-37(a)

Based on record review and interview the facility failed to monitor [MEDICAL CONDITION] levels for 1 of 5 residents reviewed for unnecessary medications (Resident 5), and failed to monitor heart rates as ordered by the physician for a hypertensive medication for 1 of 5 residents reviewed for unnecessary medications (Resident 23). Findings include: 1. The record for Resident 5 was reviewed on 5/31/18 at 1:50 p.m. [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. In an interview with the ADON (Assistant Director of Nursing), on 06/05/18 at 11:37 a.m., she indicated she was unable to provide a [MEDICAL CONDITION] laboratory result. 2. The record for Resident 23 was reviewed on 06/01/2018 at 1:28 p.m. [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. Hold this medication for a heart rate less than 60 beats per minute. A current care plan for cardiovascular disease indicated the resident was at risk for complications from hypertension. Approaches for this care plan included, but were not limited to, monitor vital signs as ordered. During an interview with the Director of Nursing on 06/04/2018 at 10:16 a.m., she indicated there was no documentation of heart rate monitoring for this medication and the physician's orders [REDACTED]. 3.1-48(a)(3)

Based on record review and interview the facility failed to attempt a gradual dose reduction on 2 [MEDICAL CONDITION] medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 23) Finding includes: The record for Resident 23 was reviewed on 06/01/2018 at 1:28 p.m. [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. The original start date for the [MEDICATION NAME] was 01/01/2015 and the original start date for the [MEDICATION NAME] was 07/02/2016. A current care plan indicated the resident used antidepressant and antianxiety medications. Approaches for this care plan included, but were not limited to, the facility staff and resident's physician will routinely evaluate reductions in dosing to ensure the resident's ongoing need for these medications. During an interview, with the Director of Nursing on 06/06/2018 at 1:00 p.m., she indicated she could not provide a documented gradual dose reduction for either the [MEDICATION NAME] or [MEDICATION NAME] within the last twelve months. 3.1-48(b)(2)

Based on interview and record review, the facility failed to ensure a resident was informed of an X-ray result to enable him to participate in decisions about his medical care for 1 of 1 resident reviewed for making decisions about resident healthcare (Resident D). Finding includes: Resident D's record was reviewed on 4/5/18 at 1:04 p.m. [DIAGNOSES REDACTED]. On 1/31/18 at 9:36 p.m., a CNA notified a nurse the resident was lying on the floor in his room. He was laying on his right side with his electric wheelchair on the side of him. The nurse assessed him. He sustained a laceration to his right eyebrow. The nurse and three CNA's assisted the resident to bed. The laceration was cleaned and steri strips were placed over the laceration after it was cleaned. He denied hitting his head. Neurological assessments were started. A Radiology Report dated 2/1/18, indicated Resident D's X-ray of his right shoulder was a limited study. There was a finding for a suspicious for minimally displaced fracture involving the distal clavicle. The progress notes were reviewed from 2/1/18 to 2/7/18 and there was no documentation, which indicated the resident knew about the X-ray results from the 2/1/18 X-ray of his right shoulder until 2/7/18. The resident complained about right shoulder pain on 2/7/18 and a nurse called the NP and reported the X-ray results from 2/1/18. During a confidential interview on 4/5/18 at 5:41 p.m., the anonymous interviewee indicated Resident D was given his right shoulder X-ray result dated 2/1/18, by one of the facility nurses, then he approached the DON (Director of Nursing) regarding the results. During an interview on 4/6/18 at 3:50 p.m., the resident indicated he had fallen out of his manual wheelchair when he was trying to pick something up off the floor. He got the results of the first shoulder x-ray (2/1/18) from someone around 2/7/18, but he could not remember who and he went to the DON (Director of Nursing) and talked to her about it because it did not say it was broken, but his right shoulder still hurt. He got another x-ray done and it showed a [MEDICAL CONDITION] scapula bone and he went to see a specialist. During an interview on 4/6/18 at 5:17 p.m., the DON indicated this resident was his own responsible party. The DON indicated she did not remember Resident D coming to her to talk to her about his shoulder x-ray result. She indicated she talked to him frequently about issues he had and about ordering medications in the mail. This Federal tag relates to Complaint IN 560. 3/1-4(c)

Based on interview and record review, failed to ensure a residents treatment for [REDACTED]. (Residents B and D). Findings include: 1. On 4/5/18 at 1:45 p.m., the DON (Director of Nursing) was observed changing Resident B's left heel pressure ulcer dressing. The resident had an allevyn foam island dressing on her left shin dated 4/3/18. The DON indicated she was not sure what days her dressing was to be changed. She indicated she had a skin tear on her left shin. Resident B's record was reviewed on 4/5/18 at 4:44 p.m. [DIAGNOSES REDACTED]. a. A progress note dated 3/26/18 at 1:19 p.m., indicated Resident B had two skin tears to her left shin. The first one measured 5.0 cm (centimeters) and the second one measured 3.0 cm The flesh was showing, but there was no bleeding. The NP (Nurse Practitioner) assessed the wounds and gave new orders for treatment. Steri-strips were applied to both wounds, Xeroform applied then wounds covered with Tesla dressing. The wound dressings were to be changed every other day. A Skin Evaluation Form dated for 4/5/18 at 2:31 p.m., indicated the resident had a skin tear to her left shin, which measured 5.0 x 1.0 cm. There was no original order found for Resident B's skin tear dressing to her left shin on the ETAR (Electronic Treatment Administration Record). An order was received on 4/5/18 at 2:26 p.m., after the dressing to the left shin with a date of 4/3/18 was brought to the DON's attention. During an interview at 5:20 on 4/5/18, the DON indicated she had the original order for Resident B's left shin skin tear on her desk as a yellow copy, but it never got transcribed to the ETAR (Electronic Treatment Administration Record) for the nurses to sign off they did the dressing change. The DON indicated the nurses had been doing the dressing change to the left shin as ordered, but they have not been documenting it on the ETAR. 2. Resident D's record was reviewed on 4/5/18 at 1:04 p.m. [DIAGNOSES REDACTED]. A progress note dated 1/31/18 at 9:36 p.m., indicated Resident D was found lying on his side and he had a laceration to his right eyebrow. After laceration was cleaned, steri-strips was placed on the laceration. No measurements were noted in the record regarding the laceration. A progress note dated 2/1/18 at 3:26 p.m., indicated the resident sustained [REDACTED]. The residents electronic record lacked further or assessments regarding his laceration and skin tear to his LUE (left upper extremity). During an interview on 4/6/18 at 5:20 p.m., the DON indicated there were no further skin assessment sheets for Resident D. The laceration and skin tear was not measured until they were healed. A current policy titled Skin Tears-Abrasions an Minor Breaks, Care of dated 9/2013, provided by the DON on 4/6/18 at 4:39 p.m., contained the following, Purpose: The purpose of this procedure is to guide the prevention and treatment of [REDACTED]. Preparation: 1. Obtain a physician's orders [REDACTED]. Assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stage .Documentation: 9. When an abrasion/skin tear/bruise is discovered complete a Report of Incident/Accident This Federal tag relates to Complaint IN 560. 3.1-37(a)

Based on interview and record review, the facility failed to complete a fall intervention (Resident C) and failed to complete the neurological assessments to monitor for mental status changes after residents' falls for 2 of 3 residents being reviewed for accidents (Residents C and D). Findings. 1. Resident C's record was reviewed on 4/6/18 at 2:35 p.m. [DIAGNOSES REDACTED]. A progress note dated 2/6/18 at 5:14 p.m., indicated the resident was found on the shower bathroom floor lying face down. She was assisted off her face onto her side so that she could be assessed for injuries. She had a laceration to the right eye with a significant amount of blood and with facial swelling. She was sent to the ER (emergency room ) by 911. Vital signs were not able to be obtained due to the resident's position. A progress note dated 2/7/18 at 4:50 a.m., indicated the resident had facial bruising noted to the right eye and steri-strips, which were intact. Resident C complained of pain with scheduled pain medications given. She continued to transfer herself and her gait was unsteady as well as her balance. She was at the nurses station at this time in her wheelchair. A progress note dated 2/8/18 at 4:37 a.m., indicated there was marked bruising to right eye and swelling and steri strips intact. A progress note dated 2/8/18 at 5:09 P.M., indicated bruising surrounding the resident's eye remained purple and dark in color redness to inner eye. Steri strip in place. A progress note dated 2/9/18 at 6:32 a.m. indicated steri strips to the right brow was intact with bruising spreading down around the jaw bone. The resident had a care plan dated 1/10/18, which addressed the problem Resident C had the potential for falls related to weakness, decreased safety awareness and unsteadiness. The goal for the resident was to not have any fall related injuries while in the health center through the next three months. The interventions included, but were not limited to, .2/7/18--Orthostatic BP (blood pressure) every shift times 3 days. The EMAR (Electronic Medication Administration Record) dated (MONTH) (YEAR), lacked documentation of Orthostatic BP results. During an interview on 4/6/18 at 1:45 p.m., the DON (Director of Nursing) indicated this residents interventions for her last fall was orthostatic BP's to be completed every shift times three days. She indicated on 2/9/18, an agency nurse signed off she did the orthostatic BP's, but failed to document them. She indicated there were 3 blood pressure not documented in the EMAR. During an interview on 4/6/18 at 3:00 p.m., the DON indicated this resident did not have a Neurological Assessment tool completely filled out for her fall on 1/31/18, but it was documented in her progress notes that her neurological checks were within normal limits for those shifts following her fall for 72 hours. These were the dates and times for the 72 hours following the fall there was incomplete documentation regarding the neurological checks. 2/7/18 from 6 a.m. to 6 p.m.--No documentation indicating the neurochecks were within normal limits. 2/7/18 from 6 p.m. to 6 a.m.-- No documentation indicating the neurochecks were within normal limits. 2/8/18 from 6 p.m. to 6 a.m.-- No documentation indicating the neurochecks were within normal limits. (There was no documentation at all in the resident's record for this shift.) 2/9/18 from 6 p.m. to 6 a.m.-- No documentation indicating the neurochecks were within normal limits. (There was no documentation at all in the resident's record for this shift.) During an interview on 4/5/18 at 3:00 p.m., the DON indicated the resident's Neurological Assessment tool for her 2/6/18, fall had holes in it because the neurological checks were not documented on the tool, but they were documented in the progress notes. The nurses indicated in the nurses notes the neurological checks were within normal limits 2. Resident D's record was reviewed on 4/5/18 at 1:04 p.m. [DIAGNOSES REDACTED]. On 1/31/18 at 9:36 p.m., a CNA notified a nurse the resident was lying on the floor in his room. He was laying on his right side with his electric wheelchair on the side of him. The nurse assessed him. He sustained a laceration to his right eyebrow. The nurse and three CNA's assisted the resident to bed. The laceration was cleaned and steri strips were placed over the laceration after it was cleaned. He denied hitting his head. Neurological assessments were started. During an interview on 4/6/18 at 3:00 p.m., the DON indicated this resident did not have a Neurological Assessment tool filled out for his fall on 1/31/18, but it was documented in his progress notes that his neurological checks were within normal limits for those shifts following his fall for 72 hours. These were the dates and times for the 72 hours following the fall there was no documentation regarding the neurological checks. 1/31/18 from 6 p.m. to 6 a.m.--No documentation indicating the neurochecks were within normal limits. 2/02/18 from 6 a.m. to 6 p.m.--No documentation indicating the neurochecks were within normal limits. 2/02/18 from 6 p.m. to 6 a.m.--No documentation indicating the neurochecks were within normal limits. 2/03/18 from 6 a.m. to 6 p.m.--No documentation indicating the neurochecks were within normal limits. A current policy titled Neurological assessment dated (MONTH) 2010, provided by the DON on 4/6/18 at 4:39 p.m., contained the following, Purpose: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated. General Guidelines: 1. Neurological assessments are indicated: a. Upon a physician order; 2. Following an unwitnessed fall; 3. Following a fall or other accident /injury involving head trauma; or d. When indicated by resident's condition .Steps in the Procedure: 3. Perform neurological checks with the frequency as ordered or per falls protocol .Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All abnormal assessment data findings obtained during the procedure, 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason (s) why and the intervention taken. 6. The signature and title of the person recording the data This Federal tag relates to Complaint IN 560. 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify the residents' Medical Doctors and/or Nurse Practitioners regarding the results of radiology reports for follow-up for 1 of 2 residents being reviewed for timeliness of X-ray result reporting (Resident D). Findings include: Resident D's record was reviewed on 4/5/18 at 1:04 p.m. [DIAGNOSES REDACTED]. On 1/31/18 at 9:36 p.m., a CNA notified a nurse the resident was lying on the floor in his room. He was laying on his right side with his electric wheelchair on the side of him. The nurse assessed him. He sustained a laceration to his right eyebrow. The nurse and three CNA's assisted the resident to bed. The laceration was cleaned and steri strips were placed over the laceration after it was cleaned. He denied hitting his head. Neurological assessments were started. A Radiology Report dated 2/1/18, indicated Resident D's X-ray of his right shoulder was a limited study. There was a finding suspicious for minimally displaced fracture involving the distal clavicle. This report result was faxed to the facility on [DATE] at 9:33 p.m. This report was not called to the NP (Nurse Practitioner) until 2/7/18. During a Daily Conference exit on 4/5/18 at 5:38 p.m., with the Administrator, DON and ADON, the DON indicated she would provide the X -ray tracking, policy and the X-ray results the next morning. As of the end of the exit conference on 4/6/18 at 6:17 p.m., the facility had not supplied the information needed to demonstrate how they tracked the laboratory and diagnostic results. This Federal tag relates to Complaint IN 560. 3.1-49(e)(2)

Based on interview and record review, the facility failed to have a shoulder X-ray dated and signed by a Physician and scanned into the electronic record for 1 of 2 residents being reviewed for diagnostic tests filed in medical records (Resident D). Finding includes: Resident D's record was reviewed on 4/5/18 at 1:04 p.m. [DIAGNOSES REDACTED]. A Radiology Report for Resident D's right shoulder X-ray dated 2/1/18, indicated his X-ray of his right shoulder was a limited study. There was a finding suspicious for minimally displaced fracture involving the distal clavicle. This report result was faxed to the facility on [DATE] at 9:33 p.m. This radiology report was not signed or dated by a Physician or NP (Nurse Practitioner) indicating one or the other had seen it and it was not scanned into the resident's electronic record as of 4/6/18. During an interview on 4/5/18 at 3:15 p.m., the DON (Director of Nursing) indicated the right shoulder X-ray was probably in a stack of papers to be scanned into the computer in medical records. She could not explain why the 2/7/18, right shoulder result was signed and dated by a NP and scanned into the electronic record, but the 2/1/18, was not. During an interview on 4/5/18 at 3:20 p.m., the DON, she indicated if a Physician or NP would have been notified, one of them would have signed off on the 2/1/18, X-ray. This Federal tag relates to Complaint IN 560. 3.1-49(e)(4)

Based on observation, interview and record review, the facility failed to ensure residents' Wanderguard bracelets were checked for placement as ordered for 2 of 3 residents reviewed for accident hazards (Residents C and D). Findings include: 1. On 2/26/18 at 3:52 p.m., Resident C's wanderguard was checked for placement with the DON in attendance. His wanderguard bracelet was not observed to be on, at that time. The DON indicated he was supposed to have it on his right wrist or wheelchair. She was observed looking at the resident's bilateral wrists and ankles and the resident's wheelchair. The DON indicated the wanderguard bracelet was placed on the bottom of his wheelchair, but the wanderguard alarm would not sound, so they moved it up on his wheelchair and that was where she thought it was located. CNA 4 indicated the resident had the wanderguard bracelet on his right wrist prior to her going to lunch at 11:00 a.m, then she indicated he Probably cut it off again. The DON instructed her to go ask LPN 5 where his wanderguard bracelet was located. CNA 4 talked to LPN 5 and when she returned she indicated LPN 5 indicated he must have cut it off again. CNA 4 indicated Resident C cut his wanderguard bracelet off before with nail clippers and LPN 5 took the nail clippers away from him. She and the DON was searching his room for the bracelet. The entire time the staff members were searching for the bracelet the DON asked the resident what he did with the bracelet and he indicated to her he did not know where it was and asked if they had found it yet. CNA 4 looked in a small black bag in a black cloth square tote in the bathroom and was observed removing a small pair of scissors from the small black bag. She gave the scissors LPN 5. At that time, LPN 5 indicated Resident C had cut his wanderguard bracelt off in the past with nail clippers and she had to take the nail clippers away from him, but he had not attempted that it in a while. She indicated she did not know what happened to his wanderguard bracelet today because he had it on every time she checked. The record review for Resident C was completed on 2/26/18 at 2:30 p.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], indicated the resident had severe cognitive impairment. He had behavioral symptoms of wandering, which occurred one to three days during that 7 day assessment period. His functional status indicated he required extensive assist of one person for transfers and limited assist of one person for locomotion on the unit, locomotion off the unit only occurred once or twice during this assessment period with one assist. Elopement Risk assessment dated [DATE], indicated the score was 9, which indicated he was a high risk. The resident's Electronic Treatment Administration Record dated (MONTH) (YEAR), included, but was not limited to the following orders: 12/10/17--Resident to wear wanderguard due to exit seeking (Discontinued on 1/31/18 due to order clarification) 1/31/18--Resident to wear wanderguard related to exit seeking on day shift 1/31/18--Resident to wear wanderguard related to exit seeking on night shift 2/9/18--Check placement of wanderguard every shift 2/15/18--Take resident to exit doors of unit to ensure wanderguard activates door alarm every Thursday. The following dates and times were not documented for the resident's wanderguard being worn: 2/1/18 on the day shift 2/4/18 on the night shift 2/6/18 on the night shift 2/8/17 on the night shift 2/10/18 on the night shift 2/21/18 on the day shift No documentation found for the evening shift for the month of (MONTH) (YEAR) A progress note dated 12/4/17 at 5:50 p.m., indicated resident had behaviors this shift. Resident was found trying to exit unit . A progress note dated 12/10/17 at 3:46 p.m., indicated Resident displayed exit seeking behaviors this shift. Resident observed by staff through window after exiting north door by nurses station. Resident immediately brought back onto unit and easily re-directed . New behavior reported to Administrator, DON .N.O. (new order) for wander guard obtained A Nursing Home Psychiatric Subsequent Visit Form dated 12/15/17, indicated the resident had behaviors of exit seeking, agitation, cursing at staff and calling them names. He was asked about ways to get outside and he was observed on that date trying to cut off his wanderguard. He had increased confusion, looking for his (family member) and wanting to go to the bottom floor. A progress note dated 12/31/17 at 1:12 p.m., indicated Resident was in dining room trying to go outside. Writer went in to redirect resident and resident once again became agitated because writer would not let him go outside A progress note dated 12/31/17 at 5:58 p.m., indicated, Writer went into the dining room and resident had a butter knife and was trying to cut the wander guard off. Writer took away knife and talked to resident A progress noted dated 2/15/18 at 2:34 p.m., indicated Resident was exit seeking .Resident sat at nurses station for several minutes, then was propelling self down hallway towards exit doors. Wanderguard was activated, and resident was assisted back to nurses station A progress note dated 2/17/18 at 2:38 p.m., modified on 2/17/18 at 8:40 p.m., indicated Resident has been found wondering (sic) around unit this shift but in a pleasant mood. CNA brought resident from therapy area and stated that resident was exit seeking A progress note dated 2/21/18 at 5:28 p.m., modified 2/22/18 at 11:42 a.m., indicated Resident exited unit today. Wonder (sic) guard activated door alarm as resident left unit. Staff immediately attempt to redirect resident. Resident non-compliant . After several attempts, resident came back onto unit During an interview on 2/26/18 at 5:45 p.m., the Administrator indicated Resident C did not elope from the facility on 12/10/17. He indicated the resident held the door open for the 15 seconds until the North exit door unlocked then he wheeled himself outside in his wheelchair. The staff went to check who set the North exit door alarm off and seen Resident C going out the North door, so staff went outside to get him and they brought him back in. 2. The record review for Resident D was completed on 2/26/18 at 4:45 p.m. [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE], indicated the resident was cognitively impaired. His functional status indicated: bed mobility he required extensive assist with one person assist, transfers were limited assist with one person assist, locomotion in and out of his room was supervision with one person assist. An Elopement Risk assessment dated [DATE], indicated the resident's score was 11, which indicated the resident was a high risk for elopement. The resident's ETAR dated (MONTH) (YEAR), included, but were not limited to, the following orders: 2/8/18--Check placement of wanderguard every shift for day shift 2/8/18--Check wanderguard is in working order everyday. 2/8/18--Walk resident to exit doors of units to ensure wanderguard activates door alarm every Thursday. 2/8/18--Check placement of wanderguard every shift for night shift. The following dates and times were not documented on the ETAR for the resident's wanderguard being checked every shift: 2/25/18 on the night shift No documentation found for the evening shift for the month of (MONTH) (YEAR). During an interview on 2/26/18 at 2:04 p.m., the DON indicated the courtyard doors were not wanderguard alarmed, so if someone who wore a wanderguard wandered out those doors, the staff would not necessarily know the resident was out there, but she hoped the staff would see the resident outside. She indicated the double doors coming into the skilled unit were wanderguard alarm protected. The front doors to the Plaza were not wanderguard alarmed because that was considered part of the assisted living side, not the skilled side. The Elopement Risk Assessment form undated, contained the following, To Be Completed on Admission And Quarterly By the Charge Nurse. Instructions: Upon admission and quarterly (at a minimum), and when significant changes are noted thereafter assess the resident status in seven clinical areas, below (1-7) by assigning the corresponding score which best describes the resident should be considered an ELOPEMENT RISK. Prevention protocols should be followed and documented on the Care Plan. A current policy titled Resident Elopement was undated, provided by the Administrator on 2/26/18 at 3:00 p.m., contained the following, Resident Assessment: .Based on the comprehensive assessment, determine if a risk of elopement exists and care plan accordingly. If at any point a potential risk of elopement is identified, develop interventions and care plans immediately. This Federal tag relates to Complaint IN 372. 3.1-45(1)

Based on observation, interview and record review, the facility failed to ensure preventative interventions were in place to prevent a new pressure ulcer to the right heel for 1 of 3 residents (Resident #31) and lacked an appropriate assessment of a pressure ulcer for 1 of 3 residents (Resident #89) reviewed for pressure ulcers. Resident #31's right heel pressure ulcer progressed from a Stage II to an Unstageable wound requiring antibiotics for [MEDICAL CONDITION] to the wound and bone was present in the wound bed. Findings include: 1. During an interview on 5/5/16 at 11:35 a.m., the Director of Nursing (DON) indicated Resident #31 had an acquired (began at the facility) pressure ulcer on the right foot, which was an Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the ulcer bed) Note: Until enough slough or eschar is removed to expose the base of the ulcer, the true depth and therefore stage, cannot be determined. Stable (dry, adherent, intact without erytherma or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed) ulcer and is now a Stage 4 and a wound vac (a technique that uses a vacuum dressing to promote healing in wounds) was started this week. Resident 31's record was reviewed on 5/9/16 at 8:42 a.m. [DIAGNOSES REDACTED]. An IDT team note dated 5/7/16, indicated the resident had an open area to the right heel, which measured 4.8 x 4.2 x 0.2 cm. He had a wound vac to the wound bed. The wound base was being treated with a piece of white foam over the bone and black sponge to granulation tissue with the wound vac set at 125 mmHg continuous pressure as the primary dressing. A small amount of bloody drainage was noted on the old dressing. The right heel wound originated from a rug burn when the resident used his heels as leverage when he was using his wheelchair for locomotion. He was followed by a wound clinic. He used Multipodus boots to the right heel for pressure relief after the wound was formed. Physician orders [REDACTED]. 4/26/16--[MEDICATION NAME] (an antibiotic medication) 875 mg (milligrams)-125 mg one tablet by mouth twice daily for 14 days for [DIAGNOSES REDACTED]. 5/6/16--Apply duoderm (a protective dressing) to surrounding tissue of wound on right heel prior to applying wound vac. 5/10/16--Use NPWT (Negative-pressure wound therapy-cleanse wound on the right heel with Normal Saline. Apply white foam over bone, then black sponge to granulation tissue and set it at 125 mmHg (millimeters of mercury) continuous pressure as the primary dressing to the wound. Change the wound vac three times a week for [DIAGNOSES REDACTED]. The resident had a Care Plan dated 1/12/16, which addressed the problem he actually had impaired skin integrity and had an unstageable area to his right heel. Approaches indicated 1/12/16--1. Wound care/dressing change as ordered. See Physician orders. 2. Provide pressure relieving devices (bed, chair cushion and boots to bilateral feet). 3. Turn and reposition every two hours and as needed The resident had a Care Plan dated 4/28/16, which addressed the problem he had [MEDICAL CONDITION] to his right heel. Approaches indicated 4/28/16-- .2. Administer antibiotics as ordered. Observe for side effects and effectiveness and report concerns/worsening symptoms to physician promptly. 3. Implement & (and) maintain appropriate precautions as outlined per CDC (Centers for Disease Control) guidelines as indicated. 4. Augumentin 875 mg-125 mg tablet ([MEDICATION NAME]-potclavulanate), 1 tablet PO (by mouth) BID (twice daily) daily for 12 days, dx (diagnosis) [MEDICAL CONDITION] to the right medial heel Resident #31's notes for the following dates indicated the following: 11/4/15-- A Skin Evaluation note indicated the resident had an unstageable pressure ulcer to the right heel. The treatment was protective dry dressing applied and heelz up pressure relief device in place. He had a reoccurring reddened right heel, he was already on a pressure reducing mattress with his heels elevated while in bed and turn every two hours and as needed. The pressure ulcer measured 2.0 x 1.5 x 0 cm (centimeters). The wound edges were approximated (the edges of the wound were brought together without areas of separation. 11/11/15--A Skin Evaluation note indicated the resident had a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Note: This stage soul not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation.) pressure ulcer to his right heel. The treatment was [MEDICATION NAME] (a debridement medication) change every day. The tissue type was [MEDICATION NAME] (sheet of cells that covers a body surface or lines a body cavity). The drainage was a light amount. The pressure ulcer measured 2.0 x 1.5 x 0.1 cm. 11/11/16 at 3:41 p.m., IDT (Interdisciplinary Team) note dated 11/11/16 at 3:41 p.m., indicated the heels up intervention was considered ineffective because the resident developed an open area to his right heel, so the MD was notified and the heels up was discontinued and an order for [REDACTED].>IDT wound note dated 12/10/15, indicated the pressure ulcer on the resident's right heel had a red wound base and the surrounding tissue had a yellow scab. The wound was a Stage II. The treatment was [MEDICATION NAME] and the resident wore heel protectors at all times. 12/12/15--A Skin Evaluation note indicated the resident had a Stage II pressure ulcer to the right heel. The treatment was [MEDICATION NAME] change every day. The tissue type was [MEDICATION NAME] with no drainage. The wound measured 0.3 x 0.3 x 0.1 cm. IDT wound note dated 12/17/15 at 12:20 p.m., indicated the foam heel boots order was changed to while the resident was in bed, so he could maintain his independence with locomotion in his wheelchair. 12/30/15--A Skin Evaluation note indicated the resident had a reddened area on the right heel with a dark discoloration, the area was blanching when palpated. The treatment was to wrap the wound with kerlix and apply a foam boot to the right heel when in bed. The skin condition indicated it was a bruise. The wound edge was pink and surrounding healthy skin. Tissue type was 100% granulation (Pink-red tissue that fills an open wound when it begins to heal). IDT wound note dated 1/2/16, indicated the pressure ulcer on the right heel was not healed and continued to improve. The wound base was red. The surrounding tissue to the right heel was red from a rug burn from when the resident used his heels as leverage when he was propelling his wheelchair himself. The right heel treatment was changed to wrap the right heel with kerlix to help cushion the heel when he was propelling himself. [MEDICATION NAME] was the treatment. 1/8/16--A Skin Evaluation note indicated the resident had a Suspected Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and sheer. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissues) pressure ulcer. The description was dark purple discoloration referred to as the distal right heel wound. The tissue type was [MEDICATION NAME]. The ulcer measured 4.8 x 5.8 x 0.1 cm. 1/8/16--A Skin Evaluation note indicated the resident had a Stage II pressure ulcer to his right heel described as an open area to the right heel referred to as the proximal wound. The tissue type was [MEDICATION NAME]. The wound measured 0.2 x 0.2 x 0.1 cm. 1/15/16--A Skin Evaluation note indicated the resident had an Unstageable pressure ulcer to his right heel described as 40% black eschar (Thick, leathery necrotic or devitalized tissue, frequently black or brown in color) and 60% granulation. The tissue type was necrotic/Eschar The wound measured 6.2 x 5.8 x 0.1 cm. The treatment was [MEDICATION NAME] change every day. IDT note dated 1/16/16, indicated the pressure ulcers on the right heel around the proximal and the distal heel open areas have integrated and will be referred to as a right heel unstageable pressure ulcer. The right heel pressure ulcer measured 6.2 x 5.8 cm. The right heel presented with 40% black eschar and 60% granulation. The right heel wound originated from a rug burn when the resident used his heels as leverage when he was propelling his wheelchair. Treatment was not effective and was changed to [MEDICATION NAME] daily, foam boots continued to be used to relieve pressure from the heels when the resident was in the bed only. A Podiatry note dated 1/20/16, indicated the chief complaint was Resident #31 was seen for an evaluation and treatment of [REDACTED]. Nursing stated the resident had this wound for about a month. The wound was treated with [MEDICATION NAME] alginate. The ulcer was located to the right posterior medial heel. Mostly soft black eschar open at the distal aspect, moderate amount of serosanguineous drainage, no odor, mild surrounding erytherma, . The wound measured 3.7 x 5.0 cm. The Podiatrist was unable to determine the depth. [DIAGNOSES REDACTED]. treatment plan: [REDACTED]. Waffle boot to be ordered by nursing to offload pressure on heel. Patient was not cooperative with floating his feet and has been wearing foot pillows to protect heels and feet. Needs waffle boot to offload heel pressure right foot. IDT wound note dated 1/27/16 at 9:20 a.m., indicated the resident was seen by the podiatrist on 1/27/16, and an order to keep the black eschar dry with [MEDICATION NAME] application twice a day and to wear heel protectors at all times to prevent pressure to affected heel. A Podiatrist note dated 1/27/16, indicated the chief complaint was the resident was seen for an evaluation of a right heel ulcer being treated with [MEDICATION NAME]. The ulcer was located to the right posterior medial heel. The wound tissue was 100% black eschar. The wound measured approximately 4.0 x 5.0 cm. Unable to determine the depth. The wound was unstageable. The [DIAGNOSES REDACTED]. Care Plan: Discontinue [MEDICATION NAME] to heel wound. Apply providone/iodine ([MEDICATION NAME]) swab to heel wound twice a day and cover with 4 x 4 , wrap with kerlix. The resident received new heel protectors today that offload pressure on heels. The patient was to wear these bilateral heel protectors at all times. X-ray ordered to r/o (rule out) osteomylitis. Arterial Doppler BLE (bilateral lower extremity) ordered to asses arterial status. IDT wound note dated 2/3/16 at 11:47 a.m., indicated the findings of the arterial Doppler revealed disseminated [MEDICAL CONDITION] disease, which put the resident at compromised healing to the right heel. Results of the Doppler and effects of arterial insufficiency to healing of the right heel were discussed with his wife. He continued to wear the heel protectors at all times to prevent pressure to the affected heel. 2/6/16--A Skin Evaluation note indicated the resident had an Unstageable pressure ulcer to his right heel described as 100% black eschar. The wound measured 6.2 x 5.8 x 0.1 cm. The tissue type was necrotic/eschar. The treatment was to apply [MEDICATION NAME] twice a day to the right heel, then wrap with Kerlix. 3/5/16--A Skin Evaluation note indicated the resident had an Unstageable pressure ulcer to his right heel described as 100% black eschar. The wound measured 5.2 x 4.9 x 0.4 cm. The tissue type was necrotic/eschar. The treatment was to apply [MEDICATION NAME] two times a day to right heel, wrap with kerlix. 3/20/16--A Skin Evaluation note indicated the resident had an Unstageable pressure ulcer described as 100% black eschar. The tissue type was necrotic/eschar. The wound measured 5.0 x 4.2 x 0.4 cm. The treatment was cleanse with normal saline, apply Santyl, then Hydrogel dressing and wrap with Kerlix. 3/24/16--A Skin Evaluation note indicated the resident had an unstageable pressure ulcer to the right heel described as 10% black eschar and 90% yellow slough. The tissue type was necrotic/eschar. The wound measured 4.9 x 4.0 x 0.4 cm. The treatment was cleanse with normal saline, apply Santyl, then Hydrogel dressing and wrap with Kerlix. 3/30/16--A Skin Evaluation note indicated the resident had an unstageable pressure ulcer to the right heel described as 10% black eschar, 40% granulation and 40% yellow slough. Tissue type was necrotic/eschar. The wound measured 4.7 x 3.8 x 0.4 cm. The treatment was cleanse with normal saline, apply Santyl then Hydrogel dressing and wrap with Kerlix. 4/5/16--A Skin Evaluation note indicated the resident had a Stage 4 pressure ulcer to the right heel described as 50% granulation and 50% yellow slough. Tissue type was necrotic/eschar. The wound measured 6.0 x 0.6 cm. The treatment was cleanse with normal saline; apply Santyl, then Hydrogel dressing, foam heel and wrap with Kerlix. On 4/5/16 at 10:42 p.m., the resident was started [MEDICATION NAME](an antibiotic medication) for a wound infection to the right heel. 4/15/16--A Skin Evaluation note indicated the resident had a Stage 4 pressure ulcer to the right heel described as 90% granulation and 100% yellow slough. Tissue type necrotic/eschar. The wound measured 4.3 x 3.6 x 0.6 cm. The treatment was cleanse with normal saline then apply Santyl, then Hydrogel dressing, foam heel and wrap with Kerlix. 4/23/16--A Skin Evaluation note indicated the resident had a Stage 4 pressure ulcer to the right heel described as retention dressing in place since 4/19/16, when the resident had a graft placement to this right heel. The treatment was to leave the dressing intact, wound clinic will remove on Tuesday. Tissue type was necrotic/eschar. No drainage. The wound measured 4.3 x 3.6 x 0.6 cm. 4/29/15--A Skin Evaluation note indicated the resident had a Stage 4 pressure ulcer to the right heel described as skin graft on wound base. Tissue type was necrotic/eschar. The wound measured 4.8 x 4.0 x 0.2 cm. The treatment was not written on note. . On 5/9/16 at 10:27 a.m., RN #11 and the DON was observed changing Resident #31's dressing to his right heel. The resident's right heel had a pressure ulcer the size of a medium egg with beefy red tissue with a white colored tissue extending from the 1-4 o'clock position. A new wound vac dressing was applied to the resident's right heel. RN #11 indicated, at that time she was placing the white colored square foam piece over bone and the black foam over granulation tissue. Resident #31's record lacked documentation indicating his wife was educated regarding the risks versus the benefits of him propelling himself without shoes or slippers to prevent an unstageable pressure ulcer to his right heel, documentation regarding other interventions attempted to prevent pressure to the resident's bilateral heels while sitting in his wheelchair with his feet on the footrests and to prevent further skin breakdown. During an interview on 5/11/16 at 9:04 a.m., the DON indicated the rug burn from 1/2/16, contributed to the right heel wound, but did not cause the wound She indicated Resident #31 was allowed to continue to use his feet to propel himself because he wanted to propel himself around his room. She indicated staff always pushed him outside his room. She indicated there was no padding or other intervention on the footrests while the resident was sitting up in his wheelchair to prevent the resident's heels from resting on the footrests itself while he sat up in his wheelchair for meals or while sitting up in the wheelchair with the foot rests where his heels rested on the footrests. She indicated on 1/8/16, the right heel distal wound originated from a rug burn when the resident used his heels as leverage when he was propelling in his wheelchair. The area presented as a dark purple area of pressure. The resident wore the foam boots to relieve pressure from his right heel while he was in bed. She indicated when he was taken back to his room the staff took his foot pedals off his wheelchair,so he could have his independence to move around in his room, so he could propel himself around his room. She indicated the proximal wound was caused from the pressure from the bed where the resident would turn himself and the heelz up was not effective and he had pressure on his heel. The DON indicated at that time, on 4/8/16, the right heel pressure ulcer was down graded to a Stage IV. 2. On 05/11/2016 at 11:51 a.m., Resident #89's record was completed. [DIAGNOSES REDACTED]. (Resident #89) On 12/28/15 the Skin Evaluation Record indicated: Site description: Buttock. Category: Skin condition. Description: Redness and excoriation to bilateral buttocks . Treatment: Calmo (a skin protectant), turn every 2 hours and monitor. The skin evaluation record lacked measurements of the area. On 12/30/15, an IDT (Interdisciplinary Team) Wound Review indicated, .Resident is followed for the first time in wound rounds and follow up for a new admission. Bilateral buttocks noted with excoriation .Excoriation to buttocks is being treated with [MEDICATION NAME] .Resident's mobility is very compromised .Due to residents' weakened state resident has been in bed 75% of the time The wound review note lacked wound measurements. On 1/8/16, an IDT Wound Review indicated, .Resident is followed for excoriation to bilateral buttocks .Excoriation to buttocks has improved and continue to be treated with [MEDICATION NAME] .Endurance has improved and resident is able to sit up in chair for upto (sic) an hour The wound review note lacked wound measurements for this date. A Progress Note dated 1/14/2016, indicated, .Chief Complaint: Nursing report of shearing. (Interaction of gravity and friction against the surface of the skin) This is a new problem, is acute. Location of the problem is buttock. The problem has occurred for 2 days . (Resident name) reports; the severity of the problem as severe. (Resident name) reports the problem is experienced at rest. Sitting up is an aggravating factor. Nothing is a relieving factor. Resident does not like repositioning Problem list .13 .Pressure ulcer .unspecified stage The Progress Note lacked wound assessment or measurement. A physician order [REDACTED]. The Skin evaluation record dated 1/15/16 indicated, .Site description right buttock. Category: Partial Thickness wound. Type pressure ulcer. Treatment: [MEDICATION NAME] with [MEDICATION NAME]. Description: stage 2, wound base with scattered (sic) yellow slough. Length 1.0 cm, Width 4.8 cm, Depth 0.1 cm .Where occurred HC (Health Center). Where treated HC and cause Pressure. Wound edge healthy. Surrounding skin healthy. Tissue type =slough (Necrotic or avascular in the process of separating from viable tissue. Usually soft, moist, and light in color; may be stringy) , exudate (drainage) amount=0 The IDT Wound Review dated 1/16/16, indicated, .Resident is followed for excoriation to bilateral buttocks .Right buttock is being down-graded to a stage 2 pressure ulcer (A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue; a Stage 2 pressure ulcer is defined as; partial thickness loss of the dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Note; This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation). NP (Nurse Practitioner) was notified of change in clinical condition of right buttock. Heassessed (sic) resident and a new order for [MEDICATION NAME] with Mepilx (sic) dressing was obtained and implemented. Wound base with scattered yellow slough with no drainage or odor A physician order [REDACTED]. Change every other day. An IDT Wound Review dated 1/20/16 indicated, .Resident is followed for excoriation to bilateral buttocks and .stage 2 pressure ulcer to right buttock .Stage 2 pressure ulcer to Right buttock is improving and wound base presents with 80% granulation and 20% yellow slough, no drainage or odor to wound. Surroung (sic) tissue healty (sic) NP assessed area and new order for [MEDICATION NAME] with [MEDICATION NAME] every 4 days and [MEDICATION NAME] boardered (sic) foam to be changed every other day. Frquency (sic) of [MEDICATION NAME] has been changed to help give the tissues regenerate The wound review note lacked wound measurements. A Progress Note dated 1/27/2016 indicated, .History of present Illness .Ulcer of right buttock cheek, continues/on going problem The document Stages of Pressure Ulcers dated 2008, as referenced by the AMDA, (American Medical Director's Association) indicated, .Stages of Pressure Ulcers .Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Note: This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to assess and implement effective preventive interventions to prevent further falls for 1 of 3 residents reviewed for falls (Resident M). These falls for Resident M resulted in lacerations to her bilateral lower extremities, which required sutures to the right lower extremity and a fractured left lower femur. Findings include: The record for Resident M was reviewed on [DATE] at 8:39 a.m. [DIAGNOSES REDACTED]. A Significant Change Comprehensive MDS (Minimum Data Set) assessment dated [DATE], indicated the resident scored an 8 on her BIMS (Brief Interview for Mental Status), which indicated she was moderately cognitively impaired. She was continent of bladder with occasional bowel incontinence. She was not on a toileting plan. She required assistance of one person with transfers, bed mobility, and toileting. A plan of care dated [DATE], indicated the resident had a problem of self care deficit and a potential for falls due to hip fracture, weakness, and immobility with a goal of the resident would have no fall related injuries while in the facility. The interventions included, but were not limited to, therapies as ordered, provide assistance with transfers and toileting, FALL RISK, BLEEDING RISK, continence assessment on admission, put a sign in the resident's room that reminds her not to get up before calling for help, and staff to check on frequently. On [DATE], the following was observed: At 10:06 a.m., the resident was sitting in her room in her w/c (wheelchair) next to her bed and bathroom wall with the room door open and she was partially visible from the hallway. A sign attached to a pole was standing in the far corner of the room out of the direct line of vision of the resident's chair. The sign stated Call and not fall with a cartoon picture of a person falling. At 3:10 p.m., the resident was sitting in her w/c at the nurses desk. Her eyes were closed. Staff members were coming and going all around her, but did not continuously have the resident in their line of sight. At 3:23 p.m., the resident remained sitting in her w/c at the nurses desk. Her eyes were closed, but would open when a call alarm sounded at the desk. She stated they make me jump. No staff were present at the desk or in the hallways adjacent to the desk. During an interview on [DATE] at 11:43 a.m., the Director of Nursing (DON) indicated the resident had a fall on [DATE]. She was getting up out of bed and sat on the floor. The recommendation to prevent further falls was to check on the resident frequently. On [DATE] at 4:47 p.m., Resident M was observed sitting in her wheelchair. She complained her bottom hurt. RN #21 medicated the resident with a pain pill. RN #21 indicated at that time, Resident M did not usually want to lay down during the day, so she was kept her at the nurses desk to prevent her from falling. During an interview on [DATE] at 10:21 a.m., LPN #22 indicated Resident M got anxious and had flashbacks at various times during the day. He indicated she would yell out for her husband who was deceased . During those times, she was taken out to the nurses desk to sit in her wheelchair. During an interview on [DATE] at 11:08 a.m., RN #21 indicated the staff would bring Resident M in her wheelchair to sit at the nurses station, so she did not fall. On [DATE] at 4:00 p.m., the DON provided copies of the facility's Occurrence Reports for Resident M's falls. They indicated the following: On [DATE] at 4:20 p.m., the resident was found on the floor .laying sideways with her head leaning on the wall .She stated ' .she was going to use the commode to toilet, to toilet herself.' Immediate actions taken included, but were not limited to, toileting program and commode toilet placed out of site. Conclusion statement entered by the DON on [DATE] at 9:13 a.m., indicated the resident is confused at times .going to use the commode. Re-education on call light use and staff to check on resident frequently. On [DATE] at 6:05 a.m., the resident was found sitting on the floor in her room. She told staff she was trying to get in her wheelchair. The report indicated the resident was oriented to herself only and she had been toileted at 5:45 a.m. Immediate actions taken were to place in bed, refer to physician, re-direct, keep under continuous supervision, and head to toe body check. Follow up recommendations on [DATE] at 9:31 a.m., indicated the resident was forgetful, forgot to call for help, and staff would continue checking on the resident frequently. On [DATE] at 6:45 p.m., the resident was found in her bathroom sitting in front of the toilet with her legs straddling the toilet between the toilet and toilet riser. She stated she went to get off the toilet and fell . A Nurse's note indicated a copious amount of blood was on the bathroom floor and on both of the resident's legs. She had a large laceration on the right leg, which was bleeding profusely with blood clots coming from the wound. She had a skin tear on the left lower leg. Immediate actions taken included, but were not limited to, application of pressure dressing, placed in wheelchair, kept under continuous supervision, locate closer to nursing station and non-emergency transfer to hospital. She was transported to the hospital at 8:45 p.m. She returned to the facility with sutures and steri-strips to wounds on both lower legs A Nurses note dated, [DATE] at 11:01 p.m., indicated resident continued to try to transfer herself from bed. A Nurses note dated, [DATE] at 6:15 p.m., indicated resident had gone to a follow up doctor's appointment and was admitted to the hospital. A Hospital Consultation report dated [DATE] at 1:23 p.m., indicated the resident was seen for follow up to her left hip surgery done on [DATE]. During the appointment, the resident was found to have another left femur fracture. A Nurses note dated [DATE] at 4:30 p.m., indicated the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. A Nurses note dated [DATE] at 8:18 a.m., indicated the resident was alert to name only. She was educated on the importance of asking for staff assistance and was compliant the majority of the shift. At 9:39 p.m., a nurse's note indicated the resident was attempting to transfer herself. An Occurrence Report dated [DATE] at 6:43 a.m., indicated a recommendation was made to place a sign in Resident M's room to remind her not to get up without calling for help. On [DATE] at 7:35 p.m., the resident was noted getting out of bed when she took a step backwards and landed on her buttocks on the floor by her bed. Immediate actions taken included, but were not limited to, place in wheelchair and take to the nurses station. Follow up recommendations to prevent further falls on [DATE] at 9:20 a.m., documented, were staff would continue to check on resident frequently. During an interview on [DATE] at 4:45 p.m., the DON indicated Resident M was checked on frequently by staff to prevent further falls. She did not indicate how often staff were to check on the resident. Resident M's plan of care, nursing notes, Occurrence Reports, nor Interdisciplinary team notes (IDT) indicated any other interventions. A current policy titled Team Resource For Resident Interventions to Prevent Falls form was provided by the DON on [DATE] at 4:45 p.m., indicated suggested interventions for residents Unable to Transfer Self, Falls with Cognitively Impaired Residents, Fall out of Wheel Chair and Residents with Multiple Falls included, but were not limited to, .contour mattress, body pillows for positioning .bed alarm to alert staff to position changes, toileting schedule, assess for need for pain meds, mat beside bed, offer fluids and snacks between meals .TABs to alert staff to position changes .rocking chair, seat chair alarm .Ask families to make activity basket .trending of falls for the individual-time of day, reason for fall, location fall etc .involve recreation for activity interventions: favorite TV programs, radio shows for high risk times, hydration group activity during risk times This Federal tag relates to Complaint IN 124 and IN 238. 3XXX,[DATE](a)(2)

Based on observation, record review and interview the facility failed to ensure a resident who had an indwelling catheter received the necessary care and services to maintain the integrity of the catheter which resulted in the resident being transferred to the local area hospital where it was determined the resident was septic for 1 of 3 residents reviewed for indwelling catheters. (Resident B). Findings included: The record for Resident B was reviewed on 07-29-15. [DIAGNOSES REDACTED]. The record indicated the resident was admitted with an indwelling Foley catheter. These [DIAGNOSES REDACTED]. A review of the resident's MDS (Minimum Data Set) assessment, dated 05-06-15, indicated the resident was cognitively intact. A review of the Resident's current plan of care indicated, the resident has an Indwelling/Intermittent/Suprapubic catheter use with potential for infection. Interventions to this plan of care included, Maintain closed drainage system, secure catheter to leg to avoid tension on urinary meatus, change catheter and/or drainage bag(s) per facility protocol or as ordered by PCP (Primary Care Physician) to assure patency, monitor for signs of UTI (urinary tract infection) such as change in color or consistency, a foul odor, or blood in urine, suprapubic, flank or abdominal pain, fever, assess for adequate output, color and odor of urine. During an interview on 07-31-15 at 9:00 a.m., while Resident B was observed seated in his wheelchair indicated a nursing staff member indicated it was time to eat. The resident further indicated he told her the bag (in reference to the catheter drainage bag), was full and that she indicated it would be all right. The resident then indicated the nursing staff member pushed him to the dining room anyway. The resident indicated he was aware the bag was full and that it felt heavy and thought it was sliding down his leg. The resident further indicated he was afraid the bag was going to break open while he was in the dining room so he transported himself back to his room room because I had to use the toilet. The bag was all the way down and this (pointing to the catheter) was out. I pushed the button for help. I couldn't do anything. I was lost. I did have pain right afterwards, but not now. During an interview on 07-29-15 at 8:12 a.m., the concerned family member indicated the resident informed the nursing staff his catheter bag was full and the aide made him go to the dining room anyway. She indicated he was afraid it was going to break open so he went back to his room and the catheter came out and blood was everywhere so he called for help. She further indicated when she came in t the facility and when she turned the bed covers down, the sheets were covered in blood. The family member indicated she was aware of what happens with the resident and the catheter and he gets prone to infection, so after it happened and (name of resident) started to complain of lower abdominal pain, I asked the nurse (licensed nurse #16) to request a doctor's order for a ua (urinalysis). (Name of resident) doesn't show typical signs of a urinary tract infection but on that Friday night he had blood in his depends and yellowish something that looked like pus. The family member indicated the request was made four times, before the the Nurse Practitioner ordered it. By that time it was too late. They had to send (name of resident) to the hospital. When he got to the hospital they told me in the emergency room that bag and brief were filled with pus and blood. He has been at risk for kidney failure and previously had a history of [REDACTED]. During an interview on 07-30-15 at 2:30 p.m., licensed nurse #16, indicated the resident's catheter came out while the bulb was inflated and the bag was full and there was blood all over the floor, the toilet and himself. She further indicated the resident had complained about burning pain to his penis and that she alerted (name of Nurse Practitioner) several times about this. The first time another nurse wrote the concern the family member had and for a request for a urinalysis and that request remained in the office for a week without it being addressed. A week later his 'scribe' came to the facility because he ( the Nurse Practitioner) couldn't come here and I told her we still had the same issue with (name of resident) and the blood and some pain he was experiencing. The next week I put the concern in the book again and he still didn't address it. The last time I wrote the order for a urinalysis myself, put it in front of him, and told him to sign it. (Name of Resident B) didn't show any clinical signs or symptoms, but his family member indicated that many times he doesn't. A review of the Clinical record lacked any notation by the Nurse Practitioner related to the concerns the family member had related regarding Resident B. Further review of the clinical record lacked documentation of the catheter coming out from the resident's bladder with the bulb still inflated or the condition of the resident at the time of the incident including blood on the resident, toilet or the amount of urine in the drainage bag. A review of the hospital record on 07-27-15 at 9:00 a.m., indicated the following: ER (emergency room ) Triage note: Not feeling well, recent uti (urinary tract infection) dx. (diagnosis). GU (urinary) Intervention: Secured to leg, immediate output yellow in color, with clots and mucous thread odorous. History of present illness: Pt. (patient) complains of 'feeling tired' bloody drainage from Foley catheter draining blood tinged urine, pt also has thick yellow drainage from the end of his penis. Py (sic) skin is hot and dry and found to have a fever of 101.4 Fahrenheit. ECF (Extended Care Facility) paperwork Foley was anchored on the 5th (July 2015) of the month. History and Physical - Patient not feeling well for the past 2 weeks. Patient complains of burning with urination, suprapubic tenderness and this morning the urinalysis was sent from the nursing home. However, today the patient developed a fever of 101 and shaking chills. In the ER, urinalysis showed positive for UTI and the Foley has been changed in the emergency room . Physical Examination: Temperature 101.4 Fahrenheit. Skin: the patient had bleeding from his penis. The urinalysis showed a large amount of occult blood and [MEDICATION NAME] were negative. Large amount of leukocyte esterase, WBC (white blood cells) greater than 100, and marked amount of bacteria. Further review of the hospital laboratory analysis of the urinalysis indicated the resident's urine was cloudy, with protein of 100 (normal range is negative), with large amounts of blood (normal range is negative) and a large amount of leukocyte esterase (normal range is negative). Hospital Transfer - Principle Diagnosis: [REDACTED]. Additional Diagnoses: [REDACTED]. Patient Transfer Report - Bloody drainage from Foley cath. Pt recently treated for [REDACTED]. also has thick yellow drainage from the end of his penis. Per ECF paperwork Foley was anchored on the 5th of the month. Reason for Hospital Stay: The patient complained of fever, chills for a day. Prior to that, the patient also complained of suprapubic tenderness for a week. On the day of admission the patient was also slightly confused. Hospital Course: 1. SIRS syndrome on admission. The patient had a fever and confusion consistent with SIRS syndrome due to UTI. During the hospital stay with IV (intravenous) antibiotics and IV fluids the patient's fever resolved. 2. Metabolic [MEDICAL CONDITION] due to UTI. 3. UTI The patient has a chronic indwelling Foley and came in with signs of UTI. Patient was started on meropemem (an antibiotic) empirically. Urine culture eventually showed greater that 100,000 E. Coli (Escherichia) and final urinalysis showed more than 3 organisms. This Federal tag relates to Complaint IN 546. 3.1-41(2)

Based on interview and record review, the facility failed to perform a dietary assessment in a timely manner on a resident who had a significant weight loss and failed to implement dietary interventions for a resident who had a significant weight loss for 2 of 3 residents reviewed for nutrition. Resident #39 lost 10.8 pounds or 6% of his body weight in 17 days. (Residents #39 and #14) Findings include: 1. Resident #39's record was reviewed on 4/24/15 at 1:21 p.m. [DIAGNOSES REDACTED]. The resident's weights were as follows during his admission to the facility: 12/18/14--185 (Admission weight) 12/21/14--188 12/29/14--179 1/4/15--174 1/19/14--177 A nutrition progress note dated 12/19/14, indicated "Initial Nutritional assessment completed this date:... Res (resident) unable to answer nutrition questions. Diet RX (prescription) Regular, intake poor, Res refused Bfk (breakfast) this date, wt (weight) 185 lbs (pounds)... estimated needs: 84 gm (grams) prot/day (protein per day)... 2102 cal/day (calories per day)... present intake is not adequate to meet needs. RD (Registered Dietician) will monitor as warranted." A nutrition progress note dated 12/22/14, indicated "...12/21 wt 188 lbs, includes a wt gain of 3 lbs, Res oral intake remains poor with some meal refusals, staff feeding or assisting with meals, unable to determine how Res gained wt, no [MEDICAL CONDITION]. RD will monitor as warranted." A nursing progress note dated 12/22/14 at 7:52 p.m., indicated "...Refused dinner tonight resident offered boost breeze 100% consumes... 3+ [MEDICAL CONDITION] ankle and feet...." A nursing progress note dated 12/27/14 at 9:22 p.m., indicated "...Resident in bed this evening stating his doesn't want to get up in recliner to eat stated he is weak...Lungs congested bilateral cough productive thick clear sputum...appetite remains poor... offered supplement and ice cream 100% consumed...." A nutrition progress note dated 12/29/14, indicated "14 day assessment completed this date: wt 185 lbs... intake poor, will eat ice cream or house supplement instead of solids... RD will monitor as warranted." A nutrition progress note dated 1/9/15, indicated "... wt 1/4 174.2 lbs, indicates a wt loss of 4.4 (2%) in one week, loss of 10.8 lbs (6%) in 17 days, this is a sig (significant) wt loss for Res, wt loss due to less than adequate energy intake, RD spoke to Res at lunch this date, stated usual wt 180 lbs, states he is concerned about his wt loss and would like to gain back to his usual wt... RD asked res if he wold (sic) be able to eat more at meals or a supplement between meal stated he would not be able to eat more at meals... RD will monitor as warranted." A nutrition progress note dated 1/16/15, indicated "30 day assessment was completed... weight was 174.2... RD will monitor as warranted..." There was no documentation in the progress notes or no documentation on the Electronic Medication Administration or Treatment Administration Record, which indicated the resident was receiving ice cream or house supplements consistently as an intervention to prevent weight loss. The resident's laboratory results were as follows: 12/19/15--CMP (Comprehensive Metabolic Panel) Sodium--130 (dietary nutrient) (low) Normal--135-145 meq/L (millieqivalents per liter) Cloride--91 (dietary nutrient) (low) Normal--98-113 meq/L Total Protein--5.9 (low) Normal--6.0-8.2 gm/dL (grams per decaliter) There were no physician orders for weight loss interventions or dietary interventions found in the resident's record, which prevented further weight loss or assisted the resident gain the weight back the weight he lost and reach his usual body weight. During an interview on 4/27/15 at 12:33 p.m., Registered Dietician (RD) #7 indicated she was not the RD when the resident was admitted to the facility. She indicated she started in orientation on 1/5/15. She indicated a contracted RD was the RD in the facility at that time. She indicated dietary interventions should have been put into place to allow the resident to gain the weight back to his usual body weight if that was his desire. She indicated she would have added 500 calories a day depending on the resident's meal intakes to increase his weight to meet his desired goal. She indicated she would have added a dietary supplement three times a day because each shake supplement contained 250 calories. She indicated the RD should always try to promote food before a supplement, but the facility did not have a fortified food program yet, so she would have had to offer the resident a supplement to increase his weight to reach his desired goal. 2. The record for Resident #14 was reviewed on 4/27/15 at 10:32 a.m. [DIAGNOSES REDACTED]. The resident's weights were as follows during her admission to the facility: 10/23/14--205 (Admission weight) 10/27/14--200 10/28/14--196 10/31/14--195 11/1/14--189 (Reweigh) 11/2/14--190 11/3/14--191 11/5/14--190 11/110/14--188 11/11/14--189 A nutrition progress noted dated 11/3/14 at 7:45 a.m., indicated "...RD spoke to Res this AM... states her usual wt 168 lbs two years ago before foot surgery caused decreased activity lelvel (sic), and gained to over 200 lbs... wt 11/2 192.2 lbs, loss 13.8 (7%) in 10 days, wt loss due to drcreased (sic) fluid retention... Res is happy with wt loss and would like to continue to lose wt, education provided on how to restrict sodium... Dietary goals: promote a gradual wt loss... decrease fluid retention. Intervention: reenforce (sic) restricing (sic) high sodium foods, increase activity level as feasible. Rd (sic) will monitor as warranted." During an interview on 4/27/15 at 12:48 p.m., Registered Dietician (RD) #7 indicated she was not the RD at this facility when this resident was admitted . She indicated RD #6 was here during that time, who was a contracted RD. She indicated she had not seen an initial dietary assessment, which RD #6 would have completed for this resident before 11/3/14. She indicated she assessed residents within 3-5 days of their admission. During an interview on 4/27/15 at 3:04 p.m., the Administrator indicated RD #6 was at the facility two days a week on Mondays and Fridays until RD #7 became the full time RD. During an interview on 4/29/15 at 10:21 p.m., the Administrator indicated she had assumed RD #6 was assessing the residents, which was admitted over the weekend on Mondays and assessing the residents on Mondays and Fridays because she was getting reports from her. A current policy titled "Nutritionally At Risk Policy for The Plaza:..." was provided by the Assistant Director of Nursing on 4/28/15 at 5:45 p.m. The policy indicated "Purpose: The purpose the Nutritionally At Risk (NAR) program is to follow and evaluate the nutritional status of those residents who have been determined to be nutritionally at risk... Nutritonally At Risk Definition: Nutritionally At Risk means that a resident has exhibited signs and symptoms of poor or inadequate nutrition. These signs and symptoms may include, but are not limited to: weight loss and/or gain, poor intake at meals/snacks... Criteria for NAR Placement:... The main criteria for being placed on NAR will be focused on weight. Significant changes in weight, whether it be a loss or gain, will be cause for immediate placement in the NAR program. Significant changes in weight are defined as: +/- 5% change in body weight within 30 days +/- 7.5% change in body weight within 90 days +/- 10% change in body weight within 180 days... NAR Process: Once a resident has been identified to be nutritionally at risk, that resident will be placed in the NAR program... The Registered Dietician will be responsible for providing nursing with an updated list of residents who are being followed in NAR weekly. The RD will also provide Social Services, Therapy, and MDS (Minimum Data Set) with a list. These residents will be monitored closely by all disciplines during the week in order to have a complete assessment and find the underlying issues for the weight loss/gain... Interventions to treat weight loss include, but are not limited to: fortified foods, increases in portion sizes, frequent snacks, oral nutrition supplements, nutrition education/counseling, appetite stimulants, or enteral feedings... Care plan problem, goals and approaches will be updated for each resident...." 3.1-46(a)(1)