Every finding on record at Beaumont Rehabilitation and Healthcare Center

Based on observation, interview, and record review, the facility failed to monitor and investigate a reported bruise to a resident's face for 1 of 3 residents reviewed for accidents. (Resident B) Findings include:Review of an anonymous intake, submitted to Indiana Department of Health on 7/16/26, indicated Resident B had experienced a black eye from an unknown source and alleged the facility failed to investigate the cause of the injury. Resident B's clinical record was reviewed on 8/3/26 at 10:02 a.m. Diagnoses included unspecified dementia, severe, with anxiety, major depressive disorder, recurrent, moderate, and generalized anxiety disorder. A 5/14/26 quarterly Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. A 5/11/26 revised care plan indicated the resident was at risk for impaired skin integrity and/or has impaired skin integrity related to dementia, depression, impaired cognition, and bladder incontinence. Interventions included completing a skin inspection every 7 to 10 days and as needed (8/1/25), notifying the nurse of any new areas of skin breakdown noted during bathing or daily care; redness, blisters, bruises, discoloration (8/1/25), and notifying the physician/nurse practitioner/physician's assistant of new areas of impaired skin integrity (8/1/25). A 6/29/26 weekly skin observation indicated her skin was intact and there were no concerns. A 7/6/26 weekly skin observation indicated her skin was intact and there were no concerns. Her weekly skin observations and progress notes lacked documentation related to facial bruising.On 8/3/26 at 11:40 a.m., Resident B was observed seated in the dining room with no facial bruising.During an interview, on 8/3/26 at 11:46 a.m., LPN 17 indicated, on 7/8/26 when she returned to work, she noticed Resident B had a bruise on her left eyelid with yellowish bruising beside her eye. During an interview, on 8/3/26 at 11:55 a.m., CNA 7 indicated, when she returned to work on 7/6/26, Resident B had yellow bruising to her left eyelid and down around the outside of her eye. It had not turned black and blue, and she was unaware of how the bruise had occurred. During an interview, on 8/3/26 at 3:00 p.m., the Chief Nursing Officer indicated there was no documentation related to Resident B's facial bruising. During an interview, on 8/3/26 at 3:34 p.m., QMA 34 indicated she noticed black bruising to Resident B's eyelid on either 7/3/26 or 7/4/26. During an interview, on 8/3/26 at 3:49 p.m., Unit Manager 16 indicated she did not notice any bruising to Resident B's eye. A couple months ago, Resident B's eye was red and she had conjunctivitis (eye infection). Resident B's family member took her to urgent care related to her eye. When Resident B's family member was asked what the doctor had said about her eye, she indicated that the doctor talked about Resident B's progressing dementia. During an interview, on 8/3/26 at 3:56 p.m., the DON indicated she worked a half day on 7/3/26 and did not notice bruising to Resident B's eye. The bruise had not been reported to her. When a facial bruise was noticed, the staff should call her or the Administrator, or she would call the Administrator. Staff should complete a risk management report, a progress note, and a skin assessment, and notify the provider and family.During an interview, on 8/3/26 at 4:11 p.m., Activities Assistant 4 indicated she did not notice bruising to Resident B's face on 7/3/26, but when she returned to work on 7/6/26, Resident B had what appeared to look like black eyeshadow on her left eye. On 7/7/26, her eye looked black, and she reported it to a nurse. During an interview, on 8/3/26 at 4:19 p.m., QMA 25 indicated, on 7/3/26, she noticed blue bruising with a little bit of purple under Resident B's eye. There was nothing documented in Resident B's progress notes, so she contacted the DON. The DON indicated that Unit Manager 16 was aware and was handling it. QMA 25 then notified LPN 6 that Resident B had bruising and that she had notified the DON. A 11/1/23, current facility policy, titled Injuries of Unknown Source, provided by the Administrator on 8/3/26 at 4:29 p.m., indicated the following: .Definition: Injuries of Unknown Source: An injury should be classified as such when ALL of the following criteria are met: The source of the injury was not observed by any person; AND The source of the injury could not be explained by the resident; AND The injury is suspicious because of the extent of the injury or the location of the injury.Procedure: 1. Unexplained injuries, including bruising.and injuries or unknown source will be promptly reported to the nurse upon discovery or observation and will be investigated. 2. Licensed nurse will be responsible to complete an assessment and provide necessary care and treatment as indicated. This includes physician notification and the implementation of any new physician's orders or other facility protocols.4. Relevant information shall be documented in the resident's medical record, including but not limited to: a. Physical assessment findings.c. Notification of physician.e. Notification of resident representative. 410 Indiana Administrative Code (IAC)16.2-3.1-37(a) This citation relates to Intake 3095857.

Based on interview and record review, the facility failed to ensure Resident Personal Funds Accounts were closed within 30 days of resident's discharge and the funds balances were returned at that time for 2 of 3 residents reviewed for management of resident funds (Residents F and J). Findings include:Confidential interviews were conducted during the survey. During a confidential interview, the following concerns were expressed regarding Resident Personal Funds management: A resident's Resident Personal Funds Account was not closed within 30 days of discharge. Both the resident and their new facility contacted the facility and did not receive assistance in receiving the resident's remaining funds within 30 days of the resident's discharge. The funds were returned after approximately 60 days. The resident did not have access to their money for that period of time. During an interview on 6/17/26 at 11:17 a.m., the Corporate Senior Business Office Manager indicated the facility did not have a written policy or procedure regarding the closure of Resident Personal Funds Accounts. The facility instead followed the regulation and closed accounts within 30 days of discharge. The previous Business Office Manager had not closed some resident funds accounts within 30 days of discharge, in error. On 6/17/26 at 11:17 a.m., Resident Person Funds Account were reviewed with the Corporate Senior Business Office Manager, who was operating as the interim Business Office Manger at the facility until the position was filled. Resident F's account information indicated the following: a. The resident was discharged from the facility on 3/24/26.b. Resident F's Social Security Check was received in the facility on 5/4/26 (41 days after the resident's discharge) and was direct deposited into the Residents Personal Funds Account, which had not been closed.c. A check for the amount of the Social Security deposit (79.00) plus one cent (.01) interest was not processed to be mailed until 5/22/26. (18 days after the check was wrongly received). d. The account was recorded as closed on 5/21/26 (59 days after the resident was discharged from the facility). Resident J's account information indicated the following: a. The resident was discharged from the facility on 4/3/36.b. The resident received two Social Security checks in the amount of 1,659.00 each. The first was received on 4/3/26 (the day of discharge). The second was received on 5/1/26 (30 days after discharge).c The resident's account indicated it was closed and a check in the amount of $2,526.98 sent on 5/12/26 (40 days after discharge). During an interview on 6/17/26 at 11:26 a.m., the Corporate Senior Business Office Manger indicated Social Security checks would be rejected and returned to the Social Service Office after an account was closed. She additionally indicated errors occurred under the previous Business Office Manger. A current, undated, facility policy titled, [NAME] Rehabilitation & Healthcare Center Internal Policy & Procedure Maintaining Resident Accounts in RFMS, provided by the Administrator via email on 6/17/26 at 12:45 p.m. indicated he following: Facility process for residents' withdrawing funds from resident trusts fund is as follows: .Check requests, if a resident requests a check be sent to an individual or entity that can request such, the facility has twenty-four hours to process such requests This citation relates to Intake 3020497. 410 IAC (Indiana Administrative Code) 16.2-3.1-6(h)

Based on interview, observation and record review, the facility failed to ensure accurate documentation was reflected in a resident's clinical records for 2 of 2 records reviewed for dialysis. (Resident D and E) Findings include:1.Resident E's clinical record was reviewed on 4/22/26 at 10:18 a.m. Diagnosis included end stage renal disease with dependence on renal dialysis, acquired absence of a kidney, and type 2 diabetes mellitus with diabetic chronic kidney disease.A dialysis pre/post evaluation, dated 1/28/26 at 3:15 p.m., indicated Resident E had a dialysis access location in his left upper extremity.A dialysis pre/post evaluation dated 2/2/26 at 5:52 a.m., indicated Resident E had a dialysis access location in his left arm.A dialysis pre/post evaluation dated 3/25/26 at 5:14 a.m., indicated Resident E had a dialysis access location in his left chest and the access site had a bruit and thrill.During an interview, on 4/23/26 at 9:45 a.m., Resident E indicated his dialysis access site was in his left upper chest During an interview, on 4/23/26 at 4:50 p.m., Resident E indicated he did not have an arteriovenous (AV) fistula dialysis access site in his left arm. LPN 18 was present in his room at this time. LPN 18 confirmed Resident E's only dialysis access site was in his left upper chest and an assessment for a bruit and thrill was not needed due to type of access site he had.2.Resident D's clinical record was reviewed 4/22/26 at 11:00 a.m. Diagnosis included end stage renal disease with dependence on renal dialysis and chronic kidney disease stage 5 (end stage kidney failure that needs dialysis or a kidney transplant).A hospital nephrology note, dated 11/9/25 at 10:44 a.m., indicated Resident D's right AV fistula failed, was nonfunctional, and no thrill was noted. He had a right tunneled dialysis catheter (a long-term vascular access device placed under the skin).A dialysis pre/post evaluation, dated 2/4/26 at 5:42 a.m., indicated Resident D had a dialysis access location in his left upper extremity and the access site had a bruit and thrill.A dialysis pre/post evaluation, dated 2/13/26 at 5:49 a.m., indicated Resident D had a dialysis access location in his right arm and the access site had a bruit and thrill.A dialysis pre/post evaluation, dated 2/18/26 at 4:47 a.m., indicated Resident D had a dialysis access location in his right arm and the access site had a bruit and thrill.A dialysis pre/post evaluation, dated 3/18/26 at 12:50 p.m., indicated Resident D had a dialysis access location in his right arm and the access site had a bruit and thrill.A dialysis pre/post evaluation, dated 3/25/26 at 5:13 a.m., indicated Resident D had a dialysis access location in his right chest and the access site had a bruit and thrill.A dialysis pre/post evaluation, dated 4/6/26 at 12:44 p.m., indicated Resident D had a dialysis access location in his right chest and the access site had a bruit and thrill.A dialysis pre/post evaluation, dated 4/8/26 at 4:58 a.m., indicated Resident D's dialysis access location was in his right chest and the access site had a bruit and thrill.A February 2026 electronic treatment administration record (ETAR) indicated Resident D's AV fistula site was to be checked for a bruit and thrill every shift. The administration record was marked as administered twice a day except on 2/14-night shift and 2/27-day shift. The identified dates lacked documentation and it was blank.A February 2026 electronic medication administration record (EMAR) indicated Resident D's AV access site to his right chest port was to be assessed every shift for a bruit and thrill and if not present to contact the physician and document finding. The administration record was marked as administered twice a day except on 2/27-day shift, which lacked documentation and was blank.A March 2026 ETAR indicated Resident D's arteriovenous (AV) fistula site was to be checked for a bruit and thrill every shift. The administration record was marked as administered twice a day except on 3/7-day shift, 3/13-night shift, and 3/14-night shift in which the record lacked documentation, and it was blank. On 3/23-day shift the documentation indicated the resident was away from the facility.A March 2026 EMAR indicated Resident D's AV access site to his right chest port was to be assessed every shift for a bruit and thrill and if not present to contact the physician and document finding. The administration record was marked as administered twice a day, except on 3/9-night shift and 3/23-day shift, which indicated the resident was away from the facility.An April 2026 ETAR indicated Resident D's arteriovenous (AV) fistula site was to be checked for a bruit and thrill every shift. The administration record was marked as administered twice a day except on 4/10-day shift, 4/11-night shift, 4/13-day shift, 4/15-day shift, and 4/19-day shift. The identified dates lacked documentation and were blank. On 4/14, 4/16, and 4/21-day shift, the record indicated the resident was away from the facility.An April 2026 EMAR indicated Resident D's AV access site to his right chest port was to be assessed every shift for a bruit and thrill and if not present to contact the physician and document finding. The administration record was marked as administered every day except on 4/11-night shift, which lacked documentation and was blank. On 4/14 and 4/16-day shift which indicated the resident was away from the facility.During an interview, on 4/23/26 at 9:43 a.m., Resident D indicated he had a dialysis port in right upper chest. He had a fistula in his right upper arm previously but was no longer used and was deactivated. A dressing to his right upper chest was intact and his right upper arm was scarred.During an interview, on 4/23/26 at 4:48 PM, Resident D confirmed his only dialysis access site was in his right upper chest. The access site to his right arm had not been used for more than six months.During an interview, on 4/23/26 at 4:50 p.m., LPN 18 indicated Resident D's only access site was in his right upper chest and assessment for a bruit and thrill was not needed.During an interview, on 4/24/26 at 11:40 a.m., the DON indicated if a resident's EMAR or ETAR was blank it meant it was either not done or not documented. A check mark on the EMAR and ETAR indicated the task was administered or completed.During an interview, on 4/24/26 at 12:57 p.m., the DON indicated Resident D had an old fistula but was uncertain if it had a bruit and thrill. Resident E did not have an AV fistula access site and recently received vein mapping for an AV fistula placement. Resident D and E used chest ports for their dialysis treatments. She confirmed the EMAR, ETAR, and several nursing assessments indicated Resident D had a fistula with a bruit and thrill.During an observation, on 4/24/26 at 1:50 p.m., the DON indicated Resident D did not have an AV fistula in either upper extremity. The right upper arm was scarred and the fistula had been removed. His only dialysis access point was his right upper chest port. Bruits and thrills could not be assessed in a chest port. She confirmed the nursing assessments, EMAR, and ETAR were documented inaccurately. During an interview, on 4/24/26 at 2:28 p.m., LPN 22 indicated an AV fistula site in an extremity was to be assessed for a bruit and thrill, but not in a chest port. A chest port for dialysis would not have a bruit and thrill. An assessment of a chest port consisted of ensuring the dressing was intact and if there was bleeding. Resident E did not have an AV fistula. LPN 22 confirmed Resident D's dialysis and access site orders on his EMAR and ETAR were written incorrectly and contained errors. Resident D's right chest port should not be assessed for a bruit and thrill, and he did not have an AV fistula.During an interview, on 4/24/26 at 3:00 p.m., the DON indicated when physician orders were entered, they were audited the next business day by the management team. Resident D's dialysis orders had a lot of things wrong within the orders, and she discontinued the orders during the interview. She confirmed nurses had documented AV fistula assessments and neither Resident D nor E had an AV fistula. A current facility policy, undated, titled Documentation in Medical Record provided by the Administrator, on 4/24/26 at 2:42 p.m., indicated the following: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 3. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information should not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.This citation relates to Intake 2970449.410 Indiana Administrative Code (IAC) 16.2-3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the sanitary storage of food for resident use in refrigerators on the nursing units for 2 of 3 nursing unit refrigerators observed. (Intermediate and Arcadia)Findings include:During an observation of the nursing unit's refrigerators, accompanied by the Dietary Manager, on 4/22/26 at 12:53 p.m., the following was observed: 1.On the Intermediate unit, a small refrigerator was located in the nurses' station. The refrigerator contained a packaged deli sandwich, dated 4/14/26, a frozen entree, an unopened bottle of strawberry soda, an unopened strawberry/banana Greek yogurt, four open partial bottles of waters, an open partial bottle of mandarin orange water, and an undated foam container with cabbage, sausage, corn bread, and an unidenti able yellow substance. The freezer section of the refrigerator contained a sticky, soft, ice cream sandwich, two frozen nutritional supplements, and an uncovered Dairy Queen cup that was stuck to the shelf of the freezer. LPN 33 indicated that the refrigerator was for the residents and the staff had a break room for storing their items. They normally stored forti ed pudding and applesauce for the residents in the refrigerator.2. On the Arcadia unit, a refrigerator was located in the dining/kitchen area. The refrigerator contained a staff member's lunch tote. The freezer contained an unopened candy bar, a clear storage bag of our, and a plastic grocery bag with two ice packs. The Memory Care Director indicated the ice packs were used on a resident's breast who had a new diagnosis of breast cancer.During an interview, on 4/23/26 at 4:10 p.m. the Regional Director of Operation indicated that staff should not have stored there personal food in the refrigerators and that there was a breakroom available for staff to store their food. A current facility policy, titled Food Storage, provided by the Administrator on 4/24/26 at 9:48 a.m. indicated the following: .Procedure.12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code. 13. All refrigerator units should be always kept clean and in good working condition. all foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded.410 IAC 16.2-3.1-21(i)(3)

Based on record review and interview, the facility failed to complete physician ordered pre-dialysis assessments for 1 of 2 residents (Resident E) and physician ordered post-dialysis assessments for 2 of 2 residents reviewed for dialysis. (Residents D & E) Findings include:1.Resident E's clinical record was reviewed on 4/22/26 at 10:18 a.m. Diagnosis included end stage renal disease with dependence on renal dialysis, acquired absence of a kidney, and type 2 diabetes mellitus with diabetic chronic kidney disease.Current physician orders included monitor left chest dialysis access site for infection daily, obtain vital signs, blood pressure and pulse, and monitor pre and post dialysis for: altered mental status, lethargy, edema, chest pain, shortness of breath, abdominal pain, nausea, vomiting, unusual itching, bleeding at site, bruises, abnormal muscle cramps, redness, swelling, tenderness, or signs of infection at dialysis site every shift on Mondays, Wednesdays, and Fridays, apixaban 5 milligram tablet (blood thinner) to be administered orally twice a day, and check site of dialysis catheter every shift for drainage and condition of dressing.Review of the clinical record indicated a pre-dialysis assessment was not completed for Resident E on March 6, 24, and 30, 2026.Review of the clinical record indicated a post-dialysis assessment was not completed for Resident E on March 4, 6, 9, 13, 20, 23, 24, 30, and April 3, 8, 10, 22, 2026.Resident E's dialysis binder indicated dialysis had been completed on these dates.2.Resident D's clinical record was reviewed 4/22/26 at 11:00 a.m. Diagnosis included end stage renal disease with dependence on renal dialysis and chronic kidney disease stage 5 (end stage kidney failure that needs dialysis or a kidney transplant).Current physician orders included monitor right chest port for infection daily, apixaban 5 milligram tablet (blood thinner) to be administered orally twice a day, check arteriovenous (AV) access site to right chest port every shift for active thrill and bruit, do not perform blood pressures or venipuncture on access arm, and leave dressing in place (If present) for 12 hours post-treatment, check AV fistula site for bruit and thrill every shift, check site of dialysis catheter every shift for drainage and condition of dressing.Review of the clinical record indicated a post-dialysis assessment was not completed for Resident D on March 4, 6, 13, 20, 23, 25 and April 3, 8, 13, 15, 2026.Resident D's dialysis binder indicated dialysis had been completed on these dates.During an interview, on 4/23/26 at 1:55 p.m., LPN 18 indicated nurses were to perform pre and post dialysis assessments each day a resident had a dialysis treatment. The assessments were to be completed in the resident's electronic health record and there was a communication form in the resident's dialysis binder.During an interview, on 4/23/26 at 2:25 p.m., the DON indicated nurses were to complete a pre-dialysis assessment before the resident left the facility for dialysis and complete a post-dialysis assessment upon the resident's return to the facility. The assessments were to be documented in the resident's electronic health record.During an interview, on 4/24/26 at 2:28 p.m., LPN 22 indicated nurses were to complete pre and post dialysis assessments. The post assessment was important as the nurse was to assess access points for infusion and any dressings that were in place.During an interview, on 4/24/26 at 2:00 p.m., the DON indicated nursing did not complete pre and post Dialysis assessments for Residents D & E.A current facility policy, dated 2/22/21, titled Dialysis provided by the Regional Director of Operations, on 4/23/24 at 2:25 p.m., indicated the following: Policy: To ensure residents receiving hemodialysis are monitored for complications.A current facility policy, undated, titled Hemodialysis Access Care, provided by the Administrator, on 4/24/26 at 12:04 p.m., indicated the following: . Documentation: The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis.This citation relates to Intake 2970449.410 Indiana Administrative Code (IAC) 16.2-3.1-37(a)

Based on record review, observation, and interview, the facility failed to ensure implemented fall interventions were in place to mitigate risk for further falls for 1 of 3 residents reviewed for falls. (Resident E) Finding includes: Resident E's clinical record was reviewed on 4/22/26 at 10:18 a.m. Diagnoses included end stage renal disease, traumatic brain injury, cerebral infarction (stroke), unsteadiness on feet, weakness, and lack of coordination.A 3/31/26 quarterly Minimum Data Set (MDS) assessment indicated Resident E's cognitive status was moderately impaired. He used a wheelchair for mobility. He required substantial to maximal assistance with toileting hygiene, lower body dressing, footwear, personal hygiene, rolling left and right, sitting to standing, and chair or bed to chair transfer.A current fall care plan, revised on 9/15/25, indicated Resident E was at risk for impaired safety, injury, and falls related to a cerebral infarct, traumatic brain injury, weakness, history of falls, mobility, and medications. Interventions included the following: a call for assistance sign placed in room as reminder (12/3/22), non-skid strips on pathway (bedside and in bathroom)(1/26/24), antiroll-back device to wheelchair (3/25/24), brightly colored tape to wheelchair brakes (6/26/25), keep bed in lowest position (6/27/23), lower wheelchair seat to assist with positioning (2/14/23), non-stick strip in place in front of toilet (5/29/24), provide a reacher (2/14/24), educate on proper transfer (6/27/23),call for assistance sign in bathroom (10/2/24), call light within reach, mat to floor at bedside (2/14/24), non-skid footwear (6/27/23), scoop mattress (4/23/25), and toilet riser with handles (1/30/23).A fall risk assessment, dated 1/23/26 at 4:42 p.m., indicated Resident E was at risk for falls.An initial occurrence note, dated 4/4/26 at 8:15 p.m., indicated Resident E sustained a witnessed fall in his room and hit his head. Neurological checks were initiated. The nurse was summoned to the resident's room and found Resident E lying on the floor on his right side. A certified nursing assistant witnessed the fall and reported the resident attempted to stand and fell into a chair on the roommate's side of the room. Resident E indicated he tried to get into bed unassisted. Resident E rated his pain a 5 out of 10 in the right hip. The pain was a new onset. The resident complained of pain with passive range of motion to his right lower extremity and he had sustained two small skin tears to his right elbow.The immediate interventions implemented were to assess Resident E for injuries, obtain vital signs, initiated neurological checks, the medical doctor and resident's daughter was notified, and an order for an x-ray was obtained.A progress note, dated 4/4/26 at 8:38 p.m., indicated after Resident E had sustained a fall in his room. After he was assessed for injuries, he was assisted to a standing position and transferred to his bed. He complained of right thigh pain once in bed with facial grimacing and guarding noted with range of motion activity. Internal rotation was noted. An order for an x-ray was obtained.A fall risk assessment, dated 4/4/26 at 11:43 p.m., indicated Resident E was at risk for falls.An interdisciplinary team progress note, dated 4/6/26 at 8:30 a.m., indicated Resident E sustained a witnessed fall in his room. He was attempting to get into bed. A therapy screen was to be done.During an interview, on 4/23/26 at 9:45 a.m., Resident E was lying in bed. The bed was not in a low position, and the top of the mattress was approximately 34-36 inches from the floor. He indicated he had not fallen recently. A floor mat was on the floor between the right side of the bed and the wall.During an observation, on 4/23/26 at 11:55 a.m., Resident E's room did not have a call for assistance sign posted in the general area of room, non-skid strips were not in place on the floor by Resident E's bed, in the room pathway, or in the bathroom. A reacher accessory tool was not observed in the room. During an observation on 4/23/26 at 12:08 p.m., Resident E sat in a wheelchair at the dining room table. The wheelchair seat appeared to be regular height of a standard wheelchair. The wheelchair did not have anti-tippers in place. The wheelchair brake handles were black and did not have bright tape applied to them.During an interview, on 4/23/26 at 1:55 p.m., LPN 18 indicated care plan interventions were to be followed as indicated. During an interview, on 4/23/26 at 2:25 p.m., the DON indicated fall care plan interventions were updated by either the MDS coordinator, the Assistant Director of Nursing, or herself. The IDT team determined what interventions were to be implemented and the intervention was added to the care plan. The management team ensured implemented care plan interventions were in place. Care Plan interventions were to be followed.During an interview, on 4/23/26 at 2:32 p.m., CNA 38 indicated Resident E was a fall risk. CNA 38 confirmed there was not a call for assistance sign in the general area of Resident E's room. Non-skid strips were not in place in Resident's E room or in his bathroom. Resident E did not fall out of bed, and a low bed was not utilized. CNA 38 had never observed a reacher-type assistive device in the resident's room and had not seen the resident have one. Resident E used to be on another unit, and it was possible he had omitted fall interventions in his old room, but not since he transferred to this unit. She was unsure when he transferred rooms, but it had been quite a while ago.During an interview, on 4/23/26 at 2:36 p.m., LPN 41 confirmed Resident E did not have anti-tippers on his wheelchair, and the wheelchair brake handles did not contain brightly colored tape. She was uncertain if the wheelchair seat was considered lowered or not.During an interview, on 4/24/26 at 11:40 a.m., the DON indicated care plan interventions were to be followed. Resident E last changed rooms in 2024, and previous fall interventions may have been for his previous room and were not transferred with his room change. She observed Resident E's wheelchair on 4/23/26 and his brakes did not have brightly colored tape on them. She was unsure if his wheelchair seat was lowered when she observed the wheelchair but noted the wheelchair did not contain anti-tippers.During an interview, on 4/24/26 at 2:28 p.m., LPN 22 indicated care plan interventions were to be followed. Unit managers followed up with implemented interventions to ensure they were in place. When a resident switched rooms, the interventions would follow the resident to the new room, such as non-skid strips and posted signs.A current facility policy, dated 10/20/25, titled Falls Management and Fall Risk, and provided by the Regional Director of Operations on 4/23/26 at 2:25 p.m., indicated the following: Policy/Procedure: 3. Each resident will have a resident centered fall care plan developed and implemented with updates as needed. 4 The care plan will be reviewed at a minimum of quarterly, post fall, annually, and with significant change in condition.8. The falls related care plan will address both prevention of falls as well as when applicable specific interventions in response to an occurrence of a fall.11. If falling occurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.14.staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.A current facility policy, dated 2/22/25, titled Comprehensive Care Plans, provided by the DON, on 4/24/26 at 1:19 p.m., indicated the following: Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Procedure: 4 .including the right to: e. Receive the services, interventions, and items included in the plan of care .12. The interdiciplinary team reviews and updates the care plan and ensures interventions in place are implemented per plan of care: .This citation relates to Intake 2984573. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(g)(1)410 IAC 16.2-3.1-45(a)

Based on record review and interview, the facility failed to ensure a resident was not administered medication to increase blood pressure when their blood pressure reading was above physician ordered parameters for 1 of 2 residents reviewed for physician orders. (Resident D) Finding includes: Resident E's clinical record was reviewed on 4/22/26 at 11:00 am. Diagnoses included hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and end stage renal (kidney) disease.Current orders included midodrine (increases blood pressure) 10 milligrams, by mouth, two times a day every Monday, Wednesday, and Friday for blood pressure. Hold if systolic (top number) blood pressure is greater than 130 (2/20/26).The clinical record indicated the following:On 2/27/26 the resident's blood pressure was 139/73 millimeters (mm) Hg (mercury). Midodrine was administered.On 3/4/26 the resident's blood pressure was 138/82 mm Hg. Midodrine was administered.On 3/11/26 the resident's blood pressure was 169/93 mm Hg. Midodrine was administered.On 3/25/26 the resident's blood pressure was 132/65 mm Hg. Midodrine was administered.On 4/8/26 the resident's blood pressure was 141/73 mm Hg. Midodrine was administered.On 4/10/26 the resident's blood pressure was 205/100 mm Hg. Midodrine was administered.A current care plan, revised on 3/6/26, indicated Resident D was at risk for medication side effects related to hyperparathyroidism, hypotension (low blood pressure), inflammation, renal failure, chronic obstructive pulmonary disease and anticoagulant use. Interventions included: administer medications as indicated by physician orders (11/20/25).During an interview, on 4/24/26 at 12:57 p.m., the DON reviewed Resident D's midodrine order and administration record. She indicated the order included blood pressure parameters and the electronic administration record indicated midodrine was administered on the identified dates.A current policy, dated 12/1/24, titled Physician Services and Orders, provided by the DON on 4/24/26 at 1:19 p.m., indicated the following: Policy: It is the policy of the facility to ensure that the medical care of each resident is supervised by a physician. The facility will provide care and services related to physician services in accordance with State and Federal regulations. Procedure: 11. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift.410 Indiana Administrative Code (IAC) 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure immediate, individualized fall interventions were developed to mitigate the risk for further falls for 2 of 3 residents reviewed for accidents. (Resident C and E)Findings include: 1.Resident C's clinical record was reviewed on 4/22/26 at 11:03 a.m. Diagnoses included peripheral vascular disease, acquired absence of other right toe(s), other lack of coordination, weakness, unsteadiness on feet, muscle wasting and atrophy, not elsewhere classi ed, unspeci ed site, and cognitive communication de cit. A 1/23/26 quarterly Minimum Data Set (MDS) assessment indicated he was cognitively intact. He used a wheelchair for mobility. He had impairments to his bilateral lower extremities. He required set up assistance for bed mobility. He required supervision or touching assistance with upper body dressing. He required partial to moderate assistance with sitting to lying. He required substantial to maximal assistance with toileting and personal hygiene, lower body dressing, footwear, lying to sitting, sitting to stand, and transfers. He had a care plan revised on 4/16/26 for being at risk for falls related to medication use, lack of coordination, generalized weakness, unsteadiness on feet, muscle wasting & atrophy, and history of falls. His interventions included maintain call light within reach (10/13/25), educate on call light use if needed (10/13/25), maintain needed/frequently used items within reach (10/13/25), educate him to call for assist when feeling weak (11/17/25), fall mat at bedside between bed and door (11/19/25), bed against wall to aid in bed boundaries (2/2/26), bolster cover to his bed (1/28/26), keep wheelchair within resident's reach when in bed (4/8/26). Resident C had the following falls: On 1/27/26 at 8:50 p.m., he was found on his knees between his bed and the wall in his room. He indicated he had a dream that he was shing and went to reach for the line and fell out of bed. The immediate interventions were taking his vital signs and helping him to bed. On 1/31/26 at 2:30 a.m., he rolled out of bed and onto the oor. He complained of pain to his left shoulder and sustained a small abrasion to his left hand. He indicated he was sleeping and rolled out of bed. The immediate interventions were placing him back into bed and he had a mat at bedside. On 2/7/26 6:30 p.m., Resident C's roommate indicated that Resident C fell between the wall and the bed. Resident C was observed on his back on the oor and was noted with an empty wine cooler bottle. He indicated that he didn't know what happened. The immediate intervention was assisting him back to bed by three CNAs, neurological checks and a skin assessment. On 4/7/26 at 4:00 p.m., he was found on his knees, holding himself up using the bedside table and bed. He indicated he was attempting to get into his wheelchair. The immediate intervention was assisting him back into bed and reminded him to use his call light when assistance was needed. On 4/19/26 at 4:15 a.m., he rolled onto the oor from his bed. He indicated that he rolled out of bed and struck his face on the base of his bedside table. He sustained a laceration to the top and bottom of his left eye. The immediate intervention was the laceration was cleansed and covered. During an interview on 4/23/26 at 3:21 p.m., LPN 27 indicated Resident C has had some falls, Resident C thought he could still walk and would get out of bed. Resident C was not complaint with using his call light. The immediate interventions such as obtaining vital signs and picking up the resident from the oor was not an intervention. If LPN 27 was unable to think of an immediate intervention there was a paper with suggested interventions located at the nurses' station. During an interview on 4/23/26 at 5:22 p.m. LPN 47 indicated when a resident fell, immediate interventions included the resident's bed against the wall, neurological checks for unwitnessed falls, low bed, and a floor mat. When she notified the DON, the DON recommended immediate interventions. 2. Resident E's clinical record was reviewed on 4/22/26 at 10:18 a.m. Diagnoses included end stage renal disease, traumatic brain injury, cerebral infarction (stroke), unsteadiness on feet, weakness, and lack of coordination. A 3/31/26 quarterly Minimum Data Set (MDS) assessment indicated Resident E's cogitive status was moderately impaired. He used a wheelchair for mobility. He required substantial to maximal assistance with toileting hygiene, lower body dressing, footwear, personal hygiene, rolling left and right, sitting to standing, and chair or bed to chair transfer. He had a care plan revised on 9/15/25 for being at risk for impaired safety, injury, and falls related to cerebral infarct, traumatic brain injury, weakness, history of falls, mobility, and medications. His interventions included therapy screen (4/7/26), non-skid footwear (6/27/23), remind resident to lock wheelchair prior to transferring (11/18/22), brightly colored tap to be applied to wheelchair brakes (6/26/25), educate on proper transfer (6/27/23), and keep environment clutter free (6/27/23). On 4/4/26 at 8:15 p.m., Resident E sustained a witnessed fall when he stood up unassisted. He stood up and fell into a chair on his roommate's side of the room. The nurse observed Resident E lying on the floor on his right side in the middle of the room. Resident E hit his head during the fall. He sustained two skin tears to his right elbow and complained of right lower extremity pain. Resident E indicated he tried to get into bed unassisted. The immediate interventions were assessed Resident E for injuries, obtained vital signs, initiated neurological checks, the medical doctor and resident's daughter was notified, and an order for an x-ray was obtained. A progress note, dated 4/4/26, indicated Resident E sustained a fall in his room and after he was assessed for injuries, he was assisted to a standing position and transferred to his bed. He complained of right thigh pain once in bed with facial grimacing and guarding noted during range of motion activity. Internal rotation was noted. An interdisciplinary team progress note, dated 4/6/26 at 8:30 a.m., indicated Resident E sustained a witnessed fall in his room. He was attempting to get into bed. A therapy screen was to be done. During an interview, on 4/23/26 at 1:55 p.m., LPN 18 indicated an immediate intervention was to be implemented at the time any resident fell. Nursing assessments, such as checking for injuries, obtaining vital signs, and initiating neurological checks, were not considered immediate interventions. Immediate interventions included looking at footwear and toileting needs. The nursing supervisor assisted in appropriate immediate interventions. During an interview, on 4/23/26 at 2:25 p.m., the DON indicated the nursing staff was to implement an intervention immediately at the time of a resident's fall. The interdisciplinary team (IDT) reviewed the implemented intervention on the next business day and the IDT determined if the implemented intervention was appropriate or if the intervention was to be modified. During an interview, on 4/23/26 at 2:43 p.m., the DON provided a therapy screening form dated 4/6/26, which indicated therapy was not recommended. The DON indicated the therapy screening was the only intervention implemented for Resident E's fall on 4/4/26. During an interview, on 4/24/26 at 2:43 p.m., LPN 22 indicated immediate fall interventions were to be implemented at the time of a residents fall. The IDT reviewed the implemented intervention and determined if the intervention was appropriate or needed changed. A current facility policy, dated 10/20/25, titled Falls Management and Fall Risk, provide by Regional Director of Operations, on 4/23/26 at 2:25 p.m., indicated the following Policy/Procedure: 1. Residents will be assessed for risk for fall on admission, with significant change, annually, and as needed (PRN) post fall.8. The falls related care plan will address both prevention of falls as well as when applicable specific interventions in response to an occurrence of a fall.11. If falling occurs despite initial interventions, staff will implement additional or different interventions. This citation relates to Intake 2984573. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure residents were assisted with bathing per their preference and as scheduled for 5 of 5 residents reviewed for activities of daily living (ADLs). (Residents B, C, D, E, F) Findings include: 1.Resident B's clinical record was reviewed on 3/30/26 at 11:39 a.m. Diagnoses included paraplegia and morbid severe obesity due to excess calories.An admission MDS (Minimal Data Set) Assessment, dated 12/26/25, indicated Resident B preferred bed baths every Tuesday and Friday between 2:00 p.m. to 10:00 p.m.Review of a current care plan for ADLs, revised 3/24/26, indicated the resident preferred a bed bath every Tuesday and Friday from 2:00 p.m. to 10:00 p.m. Review of facility shower sheets and Documentation Survey Reports for January 2026 through March 2026, indicated in January 2026, the resident did not receive scheduled bed baths on the following dates: 1/6, 1/9, 1/13, 1/23, and 1/30. In February 2026, the resident did not receive scheduled bed baths on the following dates: 2/3, 2/6, 2/13, and 2/23. In March 2026, the resident did not receive scheduled bed baths on the following dates: 3/6, 3/17, and 3/20. 2.Resident C's clinical record review was reviewed on 3/30/26 at 1:05 p.m. Diagnoses morbid severe obesity due to access calories and paraplegia. An admission MDS assessment, dated 1/5/26, indicated the resident preferred showers on Tuesdays and Fridays between 6:00 a.m. and 2:00 p.m.Review of a current care plan for ADLs, dated 1/5/26, indicated Resident C preferred showers on Tuesdays and Fridays between 6:00 a.m. and 2:00 p.m.Review of facility shower sheets and Documentation Survey Reports for January 2026 through March 2026, indicated in January 2026 the resident did not receive scheduled showers on the following dates: 1/23, 1/27, and 1/30. In February 2026 the resident did not receive scheduled showers on the following dates: 2/3, 2/5, 2/10, 2/17, and 2/20. In March 2026 the resident did not receive scheduled showers on the following dates: 3/3, 3/6, 3/10, 3/17, and 3/20.3.Resident D's clinical record was reviewed on 3/31/26 at 8:30 a.m. Diagnoses included paraplegia.A quarterly MDS assessment, dated 1/10/26, indicated the resident preferred showers/bed baths on Mondays, Wednesday and Fridays in the evenings. Review of a current care plan for ADLs, dated 11/7/25, indicated Resident D preferred showers/bed baths on Mondays, Wednesdays, and Friday evenings. Review of facility shower sheets and Documentation Survey Reports for January 2026 through March 2026, indicated in January 2026, the resident did not receive scheduled bed baths on the following dates: 1/7, 1/9, 1/12, 1/14, 1/16, 1/21, 1/23, and 1/28. In February 2026, the resident did not receive scheduled showers on the following dates: 2/2, 2/4, 2/11, 2/13, 2/16, 2/18, 2/20, 2/23, 2/25, and 2/27. In March 2026, the resident did not receive scheduled showers on the following dates: 3/2, 3/6, 3/9, 3/16, 3/18, and 3/25.During an interview on 3/31/26 at 12:05 p.m., Resident D indicated recently the lack of bathing had improved. The resident indicated he had gone an extended period of time without receiving a shower or bed bath. 4.Resident E's clinical record was reviewed on 3/31/26 at 11:19 a.m. Diagnoses included acute respiratory failure with hypoxia and obesity. An admission MDS assessment, dated 1/9/26, indicated the resident preferred showers/bed baths on Wednesdays and Saturdays between 2:00 p.m. and 10:00 p.m. Review of a current care plan for ADLs, dated 1/5/26, indicated Resident E preferred showers on Wednesday and Saturdays between 2:00 p.m. and 10:00 p.m. Review of facility shower sheets and Documentation Survey Reports for January 2026 through March 2026, indicated in January 2026 the resident did not receive scheduled showers on the following dates: 1/7, 1/10, 1/14, and 1/31. In February 2026, the resident did not receive scheduled showers on the following dates: 2/11, 2/14, and 2/25. In March 2026, the resident did not receive scheduled showers on the following dates: 3/14, 3/18, 3/25, and 3/28.During an interview on 3/31/26 at 1:00 p.m., Resident E indicated showers were frequently not given as scheduled. The resident indicated she had to go to physician appointments feeling unclean and uncomfortable. She had to apologize for the state she was in during a recent outside appointment. 5.Resident F's clinical record was reviewed on 3/31/26 at 10:05 a.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. A quarterly MDS assessment, dated 2/18/26, indicated the resident preferred showers on Tuesday and Friday evenings. Review of a care plan for ADLs, dated 1/5/26, indicated Resident F preferred showers on Tuesdays and Fridays in the evening. Review of facility shower sheets and Documentation Survey Reports for January 2026 through March 2026, indicated in January 2026, the resident did not receive scheduled showers on the following dates: 1/6, 1/9, 1/13, 1/23, and 1/30. In February 2026, the resident did not receive showers on the following dates: 2/3, 2/6, 2/10, 2/13, and 2/24. In March 2026, the resident did not receive scheduled showers on the following dates: 3/6, 10, and 3/20. During an interview on 3/31/26 at 9:17 a.m., the Administrator indicated the facility had identified a trending concern related to residents not getting showers on 3/18/26. The facility initiated an investigation and determined the concern had validation. The facility had initiated interventions to address the concerns, provided staff re-education and initiated audits to monitor compliance on 3/19/26. During an interview on 3/31/26 at 2:00 p.m., QMA 1 indicated employee absences caused staffing issues. Showers were not always given as scheduled, but it was getting better. During an interview on 3/31/26 at 1:55 p.m., the DON indicated showers were to be documented in the electronic record. Shower sheets were also provided for review and confirmed the Documentation Survey Reports documentation. A current facility policy, dated 12/1/23 and titled Physician Services and Orders was provided by the DON on 3/31/26 at 2:58 p.m. The policy indicated the following: . Procedure .11. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift. This citation relates to Intakes 2965192 and 2807975.410 Indiana Administrative Code (IAC) 3.1-38(a)(3)

A. Based on observation, interview, and record review, the facility failed to prepare, serve, and distribute food under safe sanitary conditions regarding food temperatures at the time of service. This deficient practice had the potential to impact 116 of 116 residents who resided in the facility.B. Based on observation, interview, and record review, the facility failed to ensure sanitation of cookware in the three-compartment sink. This deficient practice had the potential to impact 116 of 116 residents who resided in the facility.Findings include:A. During the initial kitchen tour on 9/15/25 at 10:00 a.m., the three-compartment sink was observed to have food particles in sink 1 (the wash sink), utensils in sink 2 (the rinse sink), and utensils and pans in sink 3 (the sanitizing sink). The Dietary Manager tested the sanitizing sink for the concentration of the sanitizing liquid. The test strip registered zero sanitizing agent. The Dietary Manager indicated the water was too cold and would not activate the sanitizer when it was cold. The water temperature booster had not been working properly. Dietary staff should wait until water was at least at room temperature to begin the sanitation process. All dishware washed in the three-compartment sink would need to be re-washed and re-sanitized.During an observation of the three-compartment sink on 9/17/25 at 12:48 p.m., the wash sink had food particles, utensils were in the rinse sink, and utensils and pans in the sanitizing sink. To the left of the sink, two roasting pans, which were covered with water droplets, were stored upright to dry. The Dietary Manager tested the sanitizing solution in the sanitizing sink/sink 3. The solution registered zero sanitizing agent. The Dietary Manager indicated the water was too cold to register the solution. A current, 4/20, facility policy titled, Cleaning Dishes- Manual Dishwashing, which was provided by the Regional Dietary Director in 9/17/26 at 1:22 p.m., indicated: Sink 3: SanitizeSanitize Dishes:1. Measure the appropriate amount of sanitizing chemical into the appropriate amount of water.Water should be 75 to 100 [degrees] F [Fahrenheit].2. Test the sanitizing solution in the sink using the manufacturer's test strips to assure appropriate levels. A current, 4/21, facility policy titled, Chlorine Solutions, which was provided by the Regional Dietary Director in 9/17/26 at 1:22 p.m., indicated: Manual Washing Using Chemicals to SanitizeAn exposure time of at least 10 seconds of a chlorine solution of 50 mg/L that has a pH of 10.B. During an observation of lunch meal service on 9/15/25 from 11:56 a.m. to 12:10 p.m., [NAME] 13 began serving meal trays without taking temperatures of the food items on the steam table. There were 10 separate food items on the steam table. The cook served 11 meal trays without taking any food temperatures. Following the service of the eleventh meal tray, [NAME] 13 was interviewed and indicated he did not take food temperatures at the point of service on the steam table. He instead had taken food temperatures at the oven/stove prior to the food being put in the steam table and held until service. He did not record the food temperatures on the log. He instead remembered the temperatures of all the items and recorded them when the meal was done. He indicated temperatures should be recorded when taken.Review of facility Daily Food Temperature Sheets for 9/1/25 to 9/15/25 Lunch (15 days and 44 meals), provided by the Regional Dietary Director on 9/15/25 at 3:19 p.m., indicated the following dates and meals which lacked documented food temperatures: 9/4/25 Dinner, 9/8/25 Dinner had only regular textured foods recorded, no pureed foods were documented, 9/8/25 Breakfast and Lunch, 9/12/25 Dinner, and 9/15/25 lunch.During an interview on 9/19/2025 at 10:55 a.m., the Dietary Manager indicated all 116 of the facility's 116 residents received meals prepared in the facility's kitchen.A current, undated, facility policy titled, Food Temperatures, which was provided by the Regional Dietary Director in 9/17/26 at 1:22 p.m., indicated: All hot food must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 [degrees] F.3.1-21(i)(1)3.1-21(i)(3)

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies regarding Enhanced Barrier Precautions (EBP). Finding includes: Review of the Summary Statement of Deficiencies for the facility's last annual recertification and licensure survey, completed on 7/2/24, indicated the facility had deficiencies related to failure to follow infection control guidelines related to EBP.During an interview, on 9/19/25 at 12:41 p.m., the Administration indicated the Quality Assessment and Assurance (QAA) committee met quarterly to review current facility concerns. The QAA committee utilized an online program to assist with streamlining the process, assessing trends, and documentation of these meetings. The current nursing topics were changes in Minimum Data Set (MDS) regulations. The Administrator indicated the facility did not have any current QAPI or Performance Improvement Plans (PIP) in place for isolation procedures such as Enhanced Barrier Precautions (EBP).Repeat concerns regarding infection control were cited during the 9/19/25 survey as follows:Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during a dressing change for 1 of 2 residents reviewed for EBP. (Resident 19)A facility policy, dated 10/1/23, titled, Quality Assurance and Performance Improvement Program Policy, provided by the Administrator following entrance conference on 9/15/25 indicated the following: .C. The Facility shall demonstrate compliance with the federal regulations governing QAPI programs and QAA committees through: a. Evidence of systems and reports demonstrating identification, reporting, investigation, analysis, and prevention of adverse events. B. Data collection and analysis at regular intervals. C. Documentation demonstrating development implantation and evaluation of corrective actions or performance improvement activities.Cross reference F880.3.1-52(b)(2)

Based on record review and interview, the facility failed to provide COVID-19 vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for immunizations. (Resident 44)Findings includes: Resident 44's clinical record was reviewed on 9/17/25 at 1:53 p.m. Diagnoses included essential hypertension, epilepsy, and anxiety disorder. A 1/22/25, physician's order indicated Resident 44 may have all age appropriate and pertinent vaccinations. A 6/13/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident 44 was cognitively intact. Review of the resident's vaccinations included the following: The resident had no historical administration of the Pneumococcal vaccine. A 2/25/25, Vaccine Consent Form, indicated Resident 44 was educated and consented to the appropriate pneumococcal vaccination. The clinical record lacked further documentation of the pneumococcal vaccination. During an interview, on 9/19/25 at 11:50 a.m., LPN 18 indicated she was just recently asked to oversee the vaccination records. She was unable to locate any documentation indicating that Resident 44 received a pneumococcal vaccination. When a resident consented to a vaccination, the facility could request the vaccinations from the pharmacy for administration. The facility had a planned vaccine clinic for this coming October and pneumococcal vaccines would be given. On 9/19/25 at 11:50 a.m., the DON indicated she was unable to provide documentation that Resident 44 had received the appropriate vaccination. A current facility policy, effective 10/31/24, titled, Pneumococcal Vaccination Policy, provided by the Administrator on 9/19/15 at 1:19 p.m. indicated the following: . 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized .#. Prior to offering the pneumococcal immunization, each resident or resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education being documented in the clinical record .5. A consent for shall be signed prior to the administration of the vaccine and filed in the individual's medical record . 3.1-18(b)(2)

Based on record review and interview, the facility failed to provide COVID-19 vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for immunizations. (Resident 44)Findings includes: Resident 44's clinical record was reviewed on 9/17/25 at 1:53 p.m. Diagnoses included essential hypertension, epilepsy, and anxiety disorder. A 1/22/25, physician's order indicated Resident 44 may have all age appropriate and pertinent vaccinations. A 6/13/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident 44 was cognitively intact. Review of the resident's vaccinations included the following: The resident had a historical administration of the COVID-19 vaccination on 1/26/21 and 2/23/21. A 2/25/25, Vaccine Consent Form, indicated Resident 44 was educated and consented to the appropriate COVID-19 vaccination. The clinical record lacked further documentation of the COVID-19 vaccination. During an interview, on 9/19/25 at 11:50 a.m., LPN 18 indicated she was just recently asked to oversee the vaccination records. She indicated she was unable to locate any documentation indicating that Resident 44 received the COVID-19 vaccination. When a resident consents to a vaccination, the facility can request the vaccinations from the pharmacy. On 9/19/25 at 11:50 a.m., the DON indicated she was unable to provide documentation that Resident 44 had received a recent COVID-19 vaccination. A current policy, effective 10/31/24, titled, COVID-19 Vaccination Policy, provided by the Administrator on 9/19/15 at 1:19 p.m. indicated the following: . 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice .13. The facility may administer the vaccine directly or the vaccine may be administrated indirectly through and arrangement with a pharmacy provider or local health department .14. The facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of such .21. The resident's medical record will include documentation of the following: .b. Each dose of the vaccine administered to the resident . 3.1-18(b)(5)

Based on record review and interview, the facility failed to ensure timely completion of a required Level I Preadmission Screening and Resident Review (PASARR) assessment for 1 of 2 residents reviewed for PASARR. (Resident 6) Findings include:Resident 6's clinical record was reviewed on 9/17/25 at 10:20 a.m. Diagnoses included hypokalemia, stage 3 chronic kidney disease, and acute kidney failure. His admission date was 8/6/25. His discharge date was 9/15/25. Review of a Level of Care Screen Outcome, dated 7/31/25, indicated short term approval for intermediate nursing care for the duration of 30 days. The end date was 8/30/25. Review of a Level I PASARR Screen Outcome, dated 7/31/25 indicated the exempted hospital discharge allowed for a 30 day duration without further PASRR evaluation. If more time was required, the nursing facility must submit a new Level 1 screen. This must be completed by or before the 30th day after admission to the nursing facility. During an interview, on 9/18/25 at 3:30 p.m., the Social Service Assistant (SSA) indicated Resident 6's current Level 1 had an end date of 8/31/25. He needed to look for additional documentation and/or screenings for this resident. During an interview, on 9/18/25 at 3:58 p.m., the SSA indicated the facility utilized an online system to prompt for additional screenings that were due or required. This system had stopped updating appropriately in the last few weeks. The corporate office was aware of the program errors and everyone was trying to remain current with screenings. Resident 6 should have had an additional Level 1 when it was discovered his stay would be longer than the approved duration listed in the original Level 1 screening. During an interview, on 9/18/25 at 4:01 p.m., the Social Service Director (SSD) indicated the SSA utilized an online system to streamline and track the screenings required for residents. This system had not been updating appropriately and this issues was forwarded to the management staff. The social services department was doing it's best to keep up to date and current with all screenings. Resident 6 should've had an additional Level 1 since he did not discharge in the 30 day period. An undated current facility policy, titled, PASRR Completion Policy, provided by the Administrator on 9/19/25 at 10:32 a.m., indicated the following: The facility will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed .3. SSD is accountable for monitoring the process of completing the necessary paperwork for the admission. 4. SSD will maintain copies of the LOC and/or PASSRR in the social services resident file.3.1-16(d)(1)(A)3.1-16(d)(1)(B)

A. Based on record review and interview, the facility failed to notify the State Ombudsman of resident transfers to the hospital for 3 of 5 residents reviewed for hospitalization. (Resident 83, Resident 120, and Resident 44) B. Based on record review and interview, the facility failed to provide the transfer/discharge notification and bed hold policy to the resident/representative when the resident was discharged for 2 of 5 residents reviewed for hospitalization. (Resident 18 and Resident 44) Findings include: A1. Resident 83's clinical record was reviewed on 9/18/25 at 12:42 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation and acute and chronic respiratory failure with hypoxia. A 7/18/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 2/16/25, progress note indicated Resident 83 was sent out to the hospital due to shortness of breath. All necessary parties were made aware. A 2/17/25, progress note indicated the resident was admitted to the hospital for pneumonia. A 2/19/25, progress noted indicated the resident returned to the facility from the hospital. Review of the facility Monthly Transfer Report to the Ombudsman for February 2025 lacked Resident 83's discharge to the hospital on 2/16/25. A2. Resident 120's clinical record was reviewed on 9/17/25 at 10:09 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, and fibromyalgia. A 7/25/25, discharge, MDS assessment indicated the resident discharged with a return anticipated. A 7/20/25 social services note indicated the resident was severely cognitively impaired. A 7/25/25 nurse's note. indicated the resident was sent to the emergency room (ER) after rolling out of bed and striking her head. Review of the Monthly Transfer Report to the Ombudsman for July 2025 lacked Resident 120's discharge to the hospital on 7/25/25. A3. Resident 44's clinical record was reviewed on 9/16/25 at 3:59 p.m. Diagnoses included hypertension, epilepsy. and anxiety disorder. A 6/13/25, quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. A 5/25/25, nurse's note indicated the resident was sent to the emergency room due to complaints of difficulty breathing. A 5/25/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 5/29/25, entry MDS assessment indicated the resident returned to the facility. Review of the Monthly Transfer Report to the Ombudsman for May 2025 lacked Resident 44's discharge to the hospital on 5/25/25. During an interview, on 9/18/25 at 1:15 p.m., the Social Services Assistant indicated he kept a monthly log of discharges. He gathered the discharged residents information from the discharge/transfer report. He emailed himself the completed log and then uploaded the log onto the Ombudsman notification website. There was a confirmation number provided when the log was uploaded but he didn't keep the information. He would contact the Ombudsman office to obtain verification of the information he sent. He completed this task at the beginning of every month. During an interview on 9/19/25 at 10:13 a.m., the SSD indicated the Social Services Assistant submitted the monthly transfer/discharge notifications to the State Ombudsman. On 9/19/25 at 10:42 a.m., the Social Services Assistant indicated the Monthly Transfer Report to the Ombudsman for February 2025 included all the residents' transfer/discharge notifications provided to the Ombudsman for February 2025. Resident 83's discharge for 2/16/25 was not included on the log. On 9/19/25 at 10:59 a.m., the Social Services Assistant indicated the facility lacked any further Ombudsman notification information. During a follow-up interview, on 9/19/25 at 11:23 a.m., the Social Services Assistant indicated Resident 44 should have been included on his monthly discharge log for May 2025. A current facility policy, effective 9/11/23, titled, Notice of Transfer or Discharge, provided by the SSD on 9/19/25 at 10:11 a.m., indicated the following: .The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman . B1. Resident 44's clinical record was reviewed on 9/16/25 at 3:59 p.m. Diagnoses included hypertension, epilepsy. and anxiety disorder. A 6/13/25, quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. A 5/25/25, nurse's note indicated the resident was sent to the emergency room due to complaints of difficulty breathing. A 5/25/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 5/29/25, entry MDS assessment indicated the resident returned to the facility. The clinical record lacked documentation that the resident or resident's representative was provided with a copy of the bed hold policy and notice of transfer. B2. Resident 44's clinical record was reviewed on 9/16/25 at 3:59 p.m. Diagnoses included hypertension, epilepsy. and anxiety disorder. A 6/13/25, quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. A 5/25/25, nurse's note indicated the resident was sent to the emergency room due to complaints of difficulty breathing. A 5/25/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 5/29/25, entry MDS assessment indicated the resident returned to the facility. The clinical record lacked documentation that the resident or resident's representative was provided with a copy of the bed hold policy and notice of transfer. During an interview on 9/18/25 at 10:07 a.m., LPN 8 indicated for transfers/discharges the nursing staff were required to print and provide a copy of the bed hold policy and transfer form to the emergency services staff when they arrived to transport the resident to the hospital. The resident's representative was notified of the transfer via telephone. No paperwork was provided to the resident or the resident's representative when they were transferred to the hospital. During an interview, on 9/18/25 at 4:20 p.m., the SSD indicated she was present when Resident 44 was discharged on 5/25/25. She remembered personally providing the Emergency Medical Technician (EMT) with the Bed Hold policy and Notice of Transfer or Discharge. During a follow-up interview, on 9/19/25 at 10:21 a.m., the SSD indicated the facility policy did not tell who the discharge/transfer and bed hold forms should be provided to at the time of discharge. She provided the paperwork to the EMTs and assumed the resident would be given the documents upon arrival to the hospital. On 9/19/25 at 11:00 a.m., the SSD indicated the resident/resident's representative should have been provided with a copy of the bed hold policy and transfer/discharge form when residents were transferred or mailed to them in the event of an emergency. When residents were cognitively impaired, the bed hold policy and transfer discharge form should have been provided to the resident's representative. On 9/19/25 at 11:28 a.m., the SSD indicated the facility was unable to provide any information to indicate the resident representative received copies of the bed hold policy and the notice of transfer/discharge. A current facility policy, effective 9/11/23, titled, Notice of Transfer or Discharge, provided by the SSD on 9/19/25 at 10:11 a.m., indicated the following: It is the policy of the facility to notify the resident and/or their legal guardian or representative before transfer and/or discharge according to state and federal regulations .II. Notice must be made as soon as practicable before transfer or discharge except in such cases when it is unplanned or deemed an emergency .d. An immediate transfer or discharge is required by the resident's urgent medical needs .f. The facility will complete a Notice of Transfer Form and explain to the resident/representative at the time of the transfer and then a copy of the notice shall be mailed to the resident representative on the next business day . A current facility policy, effective 9/11/23, titled, Bed Hold Policy Notice, provided by the SSD on 9/19/25 at 10:11 a.m., indicated the following: .A copy of the facility Bed-Hold Policy will be provided to all residents and/or resident representatives at the time of admission. Additionally, notice will be provided to the resident, and if applicable the resident's representative at the time of the transfer, or in cases of emergency transfer, a verbal notification will be provided within 24 hours and a copy of the Bed-Hold Policy will be mailed to the resident representative the next business day . 3.1-12 (a)(4) 3.1-12(a)(6)(A)(i) 3.1-12 (a)(26)

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during a dressing change for 1 of 2 residents reviewed for EBP. (Resident 19)Finding includes:On 9/15/25 at 10:47 a.m. Resident 19 was seated in a wheelchair watching television while the housekeeper mopped the floor of her room. No EBP signage or personal protective equipment (PPE) cart was observed. Resident 19's record was reviewed on 9/18/25 at 1:38 p.m. Medical diagnoses included major depressive disorder, acquired deformity of left and right lower leg, and polyneuropathy (complex nerve pain). Current physician orders included, surgical site right lower extremity cleanse with normal saline or wound wash, and apply silver alginate. Apply skin protectant film to peri wound then cover with dressing and secure daily. A nurse practitioner's note, dated 9/4/25 at 9:38 a.m., indicated the resident had a wound to her right shin with slough (moist, soft, non-viable tissue) on the surface easily penetrated to the underlying bone with a Q-tip.During a wound observation on 9/19/25 at 8:46 a.m., LPN 15 gathered supplies and entered Resident 19's room after performing hand hygiene with alcohol-based hand rub (ABHR). He did not don a gown prior to entering the room. The LPN donned gloves, created a barrier on the resident's bed for supplies, and removed the previous dressing with gloves hands. During dressing removal, his scrub pants were observed touching the left side of the resident's bed multiple times. He performed hand hygiene, donned new gloves, and applied a new dressing to the area. During the application of the new dressing, LPN 15's scrub pants again touched the left side of the resident's bed. Hand hygiene was performed and the work area was cleaned up. During an observation outside of the resident's room, on 9/19/25 9:01 a.m., an EBP sign was observed across the hall from the resident's room. The sign indicated ENHANCED BARRIER PRECAUTIONS, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing. During an interview, on 9/19/25 at 9:02 a.m., LPN 15 indicated he did not wear a gown during the dressing change because Resident 19 did not require EBP. An order would have been placed in the electronic medical record (EMR) and signage placed outside of the resident's room. During an interview, on 9/19/25 at 9:59 a.m., the DON indicated staff were expected to implement EBP. Residents requiring EBP were placed on Certified Nurse Aide (CNA) assignment sheets and residents with wounds were communicated to staff directly. Resident 19 was not placed on EBP, and staff were not informed she required EBP during care.A Centers for Disease Control (CDC) document dated 11/15/22 from cdc.gov/infection-control/media/pdfs/Webinar-EBPinNH-Nov2022-Slides-508.pdf and reviewed on 9/22/25 at 9:36 a.m. indicated the following: .What are High-Contact Resident Care Activities? .Wound Care Generally defined at the care of any skin opening requiring a dressing.Use EBP when performing high-contact resident care activities and for residents who meet criteria for the use of EBP, includes the use of gown and gloves.3.1-18(b)(2)

Based on record review and interview, the facility failed to implement interventions of two staff for bed mobility for a dependent resident (Resident B) to prevent a fall from bed when the resident rolled from the bed during care and struck their head on a nightstand, resulting in a major head injury and hospitalization in the Intensive Care Unit (ICU). (Resident B) This deficient practice was corrected on 7/29/25, prior to the start of the survey, and was therefore past noncompliance. Findings include:Resident B's clinical record was reviewed on 7/30/2025 at 10:00 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), type 2 diabetes, dementia, stage 2 chronic kidney disease, atherosclerotic heart disease, anxiety, depressive disorder, hydrocephalus (buildup of fluid in brain) and aortocoronary bypass. Resident B admitted to the facility on [DATE] from another skilled facility.Review of the admission observation, dated 7/17/2025, indicated the resident required partial to moderate assistance for rolling left to right.A care plan, dated 7/17/2025, indicated the resident required two-person assistance for bathing and dressing. The resident required a mechanical lift for transfers and a wheelchair for mobility.An admission fall risk assessment, dated 7/17/2025, indicated the resident was alert and oriented to person, place and time. The resident had no falls within the past 30 days. The resident was chair bound and was not able to perform function for gait/balance.A physical therapy evaluation and treatment plan, dated 7/21/2025, indicated the resident was dependent for bed mobility. An occupational therapy evaluation and plan of treatment, dated 7/21/2025, indicated the resident was dependent for bed mobility.A facility self-reported incident, dated 7/26/2025, indicated during care, a CNA assisted Resident B in positioning onto her side. The resident rolled off the bed and her head made contact with the nightstand located next to the bed. The resident appeared to have a change in her level of consciousness. The charge nurse was called, and the resident was sent to the hospital for evaluation and treatment. A small laceration to the back of the head with a scant amount of blood was noted. Upon arrival, the resident was noted to have new onset of atrial fibrillation with RVR (rapid ventricular response) and was placed in observation. A progress note, dated 7/25/2025 at 7:48 p.m., indicated the resident was accidentally rolled out of the bed. She hit her head on the dresser next to the bed. 911 was called and the resident was sent to the hospital. The incident was witnessed by the aide in the room (CNA 3) and the resident was unconscious for a couple of minutes.A progress note, dated 7/26/2025 at 5:21 p.m., indicated when the aide was assisting the resident, the resident got too close to the side of the bed and rolled onto the floor, hitting her head on the dresser. She had a bump on the left front side of her head and a small opening on the back of her head with some bleeding. Pressure was applied to stop the bleeding. She was also placed on her side and was assessed. Neurological assessment was completed and she was alert and oriented to person and time.The facility investigation of the fall included a written statement, dated 7/25/2025, from CNA 3 who indicated that while she provided incontinence care to Resident B, she rolled the resident onto her side and continued with the care. During the process, the resident unexpectantly rolled further and fell from the bed and hit her head. A written statement, dated 7/25/2025, from LPN 1 indicated she heard CNA 3 yell from Resident B's room. When she arrived, the resident was on the floor and was unconscious for a few minutes. The resident was turned to her side and pressure was applied to the back of her head due to bleeding. The resident was able to communicate after a few minutes. Vital signs included temperature 98.3, blood pressure 147/78, heart rate 102 beats per minute and respirations 22 per minute. The resident had an oxygen saturation of 94% and complained of head pain where her head had been struck. 911 was called and the resident was transported to the hospital for evaluation and treatment. A head CT (radiology study), dated 7/25/2025, indicated a small amount of traumatic left frontal subarachnoid hemorrhage (bleeding in space between brain and membrane). No subdural or epidural (other layers of the skull and brain) hematoma. No parenchymal hemorrhage. Ventricles are stable in size. No skull fracture. IMPRESSION: 1. Small amount of traumatic left frontal subarachnoid hemorrhage. No skull fracture.The Emergency Department provider note, dated 7/25/2025, indicated Resident B presented with complaints of a fall at the nursing home, hitting the back of her head on the nightstand. She stated she was not sure why she fell. She was normally non-ambulatory and used a wheelchair. Reported she had a headache. Denied lightheadedness or dizziness. Denied dyspnea (shortness of breath). Denied chest pain. Denied nausea or vomiting. She was without fever, tachycardic (rapid heart rate) with heart rate in the 100s, normotensive (normal blood pressure), with oxygen saturation stable on room air. Head CT demonstrated a small amount of traumatic left frontal subarachnoid hemorrhage with no skull fracture. Neurosurgery was consulted and recommended admission to ICU for close neurological monitoring and repeat head CT in the morning.A Pulmonary admission note, dated 7/26/2025, indicated Resident B was not ambulatory at baseline and mobilized with a wheelchair. She presented to the hospital following a fall where she hit the back of her head to the nightstand. On arrival, she had a small subarachnoid hemorrhage. Unfortunately, this progressed on CT scan this morning with expansion of subarachnoid hemorrhage along with new intracranial hemorrhage as mentioned below. Neurosurgery evaluated and recommended CT angiogram as well as repeat CT head later today. Patient will be initiated on Keppra (seizure medication) for moderate to severe TBI (traumatic brain injury). She was in A-fib with RVR. She had an expanding intracranial hemorrhage and remained at risk for brain herniation (shifting). She had garbled speech. She was also weak on her right side. Repeat CT of the head showed new expansile 2.9 x 3.7 x 3.8 centimeter left frontal intraparenchymal hematoma and enlargement of adjacent left cerebellar hemorrhage. Mild new mass effect (pushing) on the left ventricle (cavity inside brain). No midline shift. Chronic ventriculomegaly with ventriculostomy catheter (shunt) in place. She was also in A-fib on Cardizem (heart medication) and amiodarone (heart medication) infusion.A head CT, dated 7/26/2025, indicated the following: FINDINGS: Left frontal parenchymal hematoma has increased in size measuring 4.0 x 3.8 cm, previously 3.5 x 2.8 cm. No definite change in the adjacent subarachnoid blood. There is likely trace intraventricular hemorrhage layering within the occipital horns on axial 27. Ventricles remain stable in overall size. No midline shift.An inpatient ICU note, dated 7/26/2025 at 7:00 p.m. indicated Resident B's right arm was flaccid (unable to move on own). An ICU consult note, dated 7/29/2025, indicated Resident B remained weak on her right side, but was more awake. She followed simple commands. Her speech remained garbled. During an interview on 7/30/2025 at 3:45 p.m., the facility's Occupational Therapist indicated Resident B was dependent for mobility and transfers upon admission and required 2-person assistance. During an interview on 7/30/2025 at 2:35 p.m., facility CNA 2 indicated Resident B required two-person assistance. CNA 2 provided care for the resident on 7/25/2025. The evening shift CNA had called out and CNA 2 was asked to stay until 8:00 p.m. She indicated she could not stay any later, it was already 6:30 p.m. The facility pulled an aide from another unit and CNA 2 clocked out. CNA 2 indicated the last time she saw Resident B was at approximately 5:45 p.m. and the resident was clean and dry. CNA 2 worked day shift 6:00 a.m. to 6:00 p.m.During an interview on 7/30/2025 at 12:32 p.m., CNA 3 indicated on 7/25/2025 she was pulled to the resident's unit from her usual assignment. She indicated she was not familiar with this unit. The only report she received from the off-going CNA was that everyone had been checked and changed. The nurse on the unit, LPN 1, told her Resident B had been waiting for a long time for incontinent care. CNA 3 gathered supplies and went to assist the resident. There was no pad on her bed and the bed was soiled. Resident B indicated to the CNA that she needed help to roll over. While assisting the resident to roll over, the resident proceeded over the side of the bed, striking her head on the nightstand. The CNA immediately yelled for help. The resident was sent to the hospital for evaluation and treatment due to cognitive changes and a head laceration. CNA 3 indicated she was unaware the resident required two people for assistance. She indicated she did not look at the Kardex (care summary in the health record) or the CNA assignment sheet prior to initiating care.During an interview on 7/30/2025 at 1:20 p.m., CNA 5 indicated the facility utilized assignment sheets and Kardex to communicate the specific needs of the residents. CNA 5 would also talk to the nurse for updates on any changes related to resident care and condition.During an interview on 7/30/2025 at 3:37 p.m., CNA 6 indicated the facility utilized assignment sheets and Kardex to communicate the specific needs of the residents.During an interview on 7/30/2025 at 3:53 p.m., LPN 7 indicated the specific resident needs were usually communicated through verbal reports. However, if a verbal report could not be given, then the facility utilized assignment sheets and Kardex to communicate the specific needs of the residents.During an interview on 7/31/2025 at 3:14 p.m., the DON indicated the use of assignment sheets was new and prior to the assignment sheet, the facility used Kardex which got resident specific information from the care plan. A CNA assignment sheet for 7/25/25 was not available for review. Review of a current undated Certified Nursing Assistant job description was provided by the DON on 8/1/2025 at 12:17 p.m., and indicated the following:Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities for daily living and ensures the health, welfare and safety of al residents. Essential Duties and Responsibilities: .Provide assistance in ambulating, turning, and positioning residents.Review of the current Indiana Nurse Aide Curriculum (Updated 3/21/2014), retrieved from https://www.in.gov/health/ltc/aide-training-and-certification/cna/nurse-aide-training-programs indicated the following: .Lesson #8 Title Activities of Daily Living (Positioning/Turning, Transfers).C. Role of the Nurse Aide. 5. Review care plan a. Know what position is safe for the resident. The deficient practice was corrected on 7/29/25 after the facility implemented a systemic plan that included the education of staff regarding the facility's resident lift and transfer policy, reviewed other residents who required assistance with bed mobility and transfers, and planned for Quality Assurance activities to mitigate risk of reoccurrence of the deficient practice. This citation relates to complaints 2572704 and 2574936.3.1-45(2)

Based on interview and record review, the facility failed to provide current education on influenza vaccines and to obtain current influenza vaccination consents for 4 of 6 residents reviewed for immunizations. (Resident D, E, G, and H) Findings include: 1. Resident D's clinical record was reviewed on 4/2/25 at 11:53 a.m. Diagnoses included type 2 diabetes, hypertension, history of traumatic brain injury, depression, cerebral infarction, obstructive and reflux uropathy, anemia, chronic kidney disease, anxiety, and dementia. A review of the resident's immunization record indicated the influenza vaccination consent form was signed and dated on 10/10/23 and was administered on 10/1/24. Education related to the risk and benefits of the influenza vaccine was dated 8/6/21. The consent for the pneumococcal vaccine was signed and dated 10/10/23. The pneumococcal vaccine was administered on 6/26/23. The consent for the COVID -19 vaccine was signed and dated 10/10/23. The COVID-19 booster was administered on 10/28/24. 2. Resident E's clinical record was reviewed on 4/3/25 at 11:00 a.m. Diagnoses included schizophrenia, anemia, hypothyroidism, osteoporosis, and hyperlipidemia. A review of the resident's immunization record indicated the consent for the RSV (respiratory syncytial virus) vaccination was signed and dated 10/11/23 and was administered on 10/1/24. Education related to the risk and benefits of the influenza vaccine was dated 8/6/21 and was administered on 10/2/24. 3. Resident G's clinical record was reviewed on 4/3/25 at 10:47 a.m. Diagnoses included cerebrovascular attack, coronary artery disease, depression, hypertension, and hyperlipidemia. A review of the immunization record indicated the influenza vaccine was administered on 10/1/24. The clinical record lacked a signed and dated consent form. Education related to the risk and benefits of the influenza vaccine was dated 8/6/21. The pneumococcal vaccination consent form was signed and dated 9/14/23 and was administered on 10/28/24. The COVID-19 vaccination consent form was signed and dated 9/14/23 and was administered on 10/28/24. 4. Resident H's clinical record was reviewed on 4/3/25 at 11:21 a.m. Diagnoses included schizophrenia, depression, dementia, hypertension, and hyperlipidemia. A review of the immunization record indicated the influenza vaccine was administered at a hospital on 9/27/24 and documented on the vaccine consent form. The influenza vaccine was administered in the facility on 10/2/24. The administration record lacked the dose and location of placement. Education related to the risk and benefits of the influenza vaccination was dated 8/6/21. The consent for the COVID-19 vaccine vaccination was dated and signed 10/7/24. The record lacked any documentation that the vaccine was administered or refused. During an interview on 4/2/25 at 1:33 p.m., the Regional Clinical Consultant and the Infection Control Provider (ICP) indicated the facility had not educated residents and/or their families on the risk and benefits of the influenza vaccine using the most current information from the Department of Health and Human Services Center for Disease Control and Prevention. All residents and/or families were given consents for vaccinations every year. The facility did not know why consents for the 2024-2025 influenza season were not provided. A current facility policy, dated 3/8/2017, indicated it was retrieved from the CMS (Centers for Medicare and Medicaid Services) manual titled, Pneumococcal Immunization, provided by the ICP on 4/3/25 at 10:37 a.m. indicated the following: .Before offering the pneumococcal immunization, each resident or the resident's legal representative will be provided education regarding the benefits and potential side effects of the immunization. The resident's medical record includes documentation that indicates, at a minimum, the following: Documentation that the resident and/or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received or did not receive the pneumococcal immunization due to medical contraindication or refusal A current facility policy, dated 5/21/2024, titled Influenza Vaccine Policy, provided by the Regional Clinical Consultant, indicated the following: Procedure: 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during the time period, or refuses to receive the vaccine. 5. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided a copy of CDC's current vaccine information statement relative to the influenza vaccination. 6. The vaccine information statements (VIS) will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine. 7. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed and dated record will be filed in the individual's medical record or the staff's medical file if completed by the facility. 9. The resident's medical record or staff's medical file will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal 3.1-18(a)

Based on record review and interview, the facility failed to ensure shift to shift narcotic reconciliation was completed for 6 of 6 carts reviewed for medication storage of 11 total medication and treatment carts. (Rehab cart, Intermediate back cart, 400 hall cart, 500 hall cart, 200 hall cart and 300 hall cart) Findings include: 1. During a medication storage observation of the 400 hall cart, accompanied by LPN 33, on 6/26/24 at 9:23 a.m., the Controlled Substances Check Form record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In June 2024- 6/1, 6/2, 6/3, 6/4, 6/5, 6/6, 6/7, and 6/8 on all three shifts, 6/10 on evening and night shifts, 6/11 on day and evening shifts, 6/12 from 6:00 p.m.- 10:00 p.m. and night shift, 6/13 on day shift and 2:00 p.m. - 6:00 p.m., and night shift 6/17 on day shift and 2:00 p.m.- 6:00 p.m., 6/18 on evening and night shift, 6/19 on day shift, 6/21 on day shift and night shift, 6/22 on all three shifts, 6/24 on night shift, 6/25 on all three shifts. 2. During a medication storage observation of the 500 hall cart, accompanied by LPN 34, on 6/26/24 at 9:23 a.m., the Controlled Substances Check Form record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In June 2024- 6/2 on day shift, 6:00 p.m. - 10:00 p.m., and night shift, 6/4 from 6:00 p.m. - 10:00 p.m., and night shift 6/5 on evening shift and night shift, 6/6 on night shift, 6/8 on evening and night shift, 6/9 on all three shifts, 6/10 on all three shifts, 6/11 on night shift, 6/12 on all three shifts, 6/13 on all three shifts, 6/14 on day and evening shifts, 6/16 on all three shifts, 6/18 on all three shifts, 6/20 on day and night shifts, 6/23 on all three shifts, 6/24 on all three shifts, 6/25 on all three shifts. 3. During a medication storage observation of the Rehab hall cart, accompanied by LPN 9, on 6/26/24 at 9:47 a.m., the Controlled Substances Check Form record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In June 2024- 6/6 on night shift, 6/19 on day shift and 2:00 p.m. - 6:00 p.m., 6/23 on night shift, 4. During a medication storage observation of the 200 hall cart, accompanied by QMA 20, on 6/26/24 at 10:03 a.m., the Controlled Substances Check Form record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In June 2024- 6/2 on all three shifts, 6/3 on day shifts and 2:00 p.m. - 6:00 p.m., 6/4 from 6:00 p.m. - 10:00 p.m., 6/5 on evening shift, 6/6 on evening and night shifts, 6/8 on day shift and from 2:00 p.m. - 6:00 p.m., 6/9 from 6:00 p.m.- 10:00 p.m. and night shift, 6/10 on all three shifts, 6/12 on evening and night shifts, 6/13 on evening and night shifts, 6/14 from 11:00 p.m. - 6:00 a.m., 6/15 on night shift, 6/18 on night shift, 6/19 on night shift, 6/20 on night shift, 6/24 on evening and night shifts, 6/25 on evening shift. 5. During a medication storage observation of the Intermediate back hall cart, accompanied by LPN 10, on 6/26/24 at 11;10 a.m., the Controlled Substances Check Form record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In June 2024- 6/2 on day shift and 2:00 p.m. - 6:00 p.m., 6/7 on evening shift, 6/9 from 2:00 p.m. - 6:00 p.m., 6/10 on day shift and 2:00 p.m. - 6:00 p.m., 6/12 from 2:00 p.m. - 6:00 p.m., 6/14 on day shift, 6/15 on day shift, 6/17 on night shift, 6/18 from 6:00 p.m. - 10:00 p.m. and night shift, 6/19 from 12:00 a.m. - 6:00 a.m., 6/21 from 6:00 p.m. - 10:00 p.m. and night shift, 6/22 on night shift, 6/23 from 6:00 p.m. - 10:00 p.m., 6/25 on evening and night shift, 6. During a medication storage observation of the 300 hall cart, accompanied by LPN 35, on 6/26/24 at 11:24 a.m., the Controlled Substances Check Form record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In June 2024- 6/1 on day and evening shifts, 6/2 on night shift, 6/4 on evening shift, 6/5 on evening shift, 6/6 from 2:00 p.m. - 6:00 p.m., 6/8 on day shift, 6/13 from 2:00 p.m. - 6:00 p.m., 6/14 on night shift, 6/15 from 12:00 p.m. - 2:00 p.m., 6/20 from 2:00 p.m. - 6:00 p.m., 6/23 on night shift, 6/25 from 2:00 p.m. - 6:00 p.m., During an interview, on 6/26/24 at 10:19 a.m., the Family Tree Unit Manager indicated the expectation was for the nursing staff to sign the Controlled Substances Check Form at the start and end of each shift. She was not sure why this task was not being completed as expected. During an interview, on 6/26/24 at 10:13 a.m., the DON indicated all nurses were to sign the narcotic counts sheets for persons taking over the cart and the person leaving the cart. A lack of signature and incomplete counts was a risk for drug diversion. A current, undated, facility policy titled, Narcotic Nurse to Nurse Reconciliation, provided by the DON on 7/1/24 at 3:45 p.m., indicated the following: . When keys to secured storage area occur between 2 applicable licensed staff there will be a count that is completed to validate the items are accurate Each reconciliation will require: 1. Two signatures (on coming and off going) . 3.1- 25(b)(3)

Based on record review and interview, the facility failed to develop and implement approaches to correct identified deficient practices and audits to measure success of Performance Improvement Plans (PIP) as part of the Quality Assurance and Performance Improvement (QAPI) program. Findings include: During an interview, on 6/26/24 at 10:14 a.m., the DON indicated she had started Performance Improvement Plan (PIP) for an identified concern at the facility, such the failure of nurses to sign in and out to acknowledge reconciliation of the narcotic medication at the change of shift. She indicated the completion date for her PIP was 9/13/24. A current facility PIP guide, provided by the DON on 6/26/24 at 10:14 a.m., indicated the start date as 6/13/24 for nurses not signing in and out on the record of accepting narcotic responsibilities. The plan or tasks to be completed included a review of sign in/sign out sheets, a staff in-service, and Clean Fridays audits were to be initiated. The staff in-service was held on 6/13/24. The facility nursing staff was verbally re-educated on 6/26/24. During an interview, on 7/2/24 at 3:00 p.m., the DON indicated she did not have any audit tools, additional documentation, or evidence to provide to support the implementation of approaches listed on the PIP guidance tool. The Family Tree Unit Manager was doing reviews of the medication cart narcotics binders on Fridays, but the DON had not created the Clean Fridays tool as of yet. She indicated on the review dates listed, she would analyze the audit tools and complete the sections measuring the outcome of the action plan. Review of a current facility policy, titled, Quality Assurance and Performance Improvement, dated 11/23, and provided by the Administrator following the Entrance Conference on 6/24/24, indicated the following: . Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating system identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . Cross reference F755. Cross reference F761. 3.1-52(b)(2)

Based on observation, interview, and record review, the facility failed to effectively monitor and treat pain for a resident with severe cognitive impairment with a healing dislocated and fractured left shoulder for 1 of 1 resident reviewed for pain. (Resident F) This resulted in Resident F having impaired mobility and poor quality of life as evidenced by not leaving his bed per his usual routine. Finding includes: During an observation on 12/27/23 at 12:59 p.m., Resident F was lying in bed with the head of the bed elevated, positioned on his back, unclothed. His eyes were open and he was picking at his incontinent brief with his right hand. His legs were making small movements against the sheets of the bed. During an observation on 12/27/23 at 4:00 p.m., the resident was lying flat in bed, positioned on his back with a hospital gown draped over his right arm. His head was back, his mouth was open, and he was grimacing. He was making small movements with his right arm. During an observation on 12/28/23 at 11:50 a.m., accompanied by QMA 2, Resident F was observed lying flat in bed, positioned on his back with a positioning wedge lying next to his left side. His eyes and mouth were open. The resident lacked verbal response when spoken to, but made eye contact. QMA 2 moved the resident to his right side to place the wedge beneath his left side. The resident began moving his right arm and bilateral legs and grimacing. QMA 2 indicated he had declined in the past week and a half. He previously was walking about the hallways, eating in the dining room, and talking. He indicated it was difficult to dress and turn the resident for incontinent care because of the pain in his left shoulder and arm. He had reported the resident's pain to the nurses. Resident F's clinical record was reviewed on 12/27/23 at 10:07 a.m. Diagnoses included Alzheimer's disease, Parkinson's disease, psychotic disorder with hallucinations, anxiety disorder, and depression. An admission Minimum Data Set (MDS) assessment, dated 9/25/23, indicated the resident had severe cognitive impairment, clear speech, and was usually understood and could understand others. He required limited assistance of one staff member for bed mobility, transfer, toileting and hygiene. He required supervision for walking, dressing and eating, and was steady when moving from a seated position to standing, walking and turning his body. Resident F's comprehensive care plan, revised on 10/2/23, indicated he had chronic conditions with risk for discomfort, complications, or decline. Interventions included assess for verbal and non-verbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, increased anxiety. Medications were to be given per physician order, and staff were to monitor for increased weakness or unsteadiness. A nursing progress note, dated 12/16/23 at 10:50 a.m., indicated the resident had been complaining of pain in his left shoulder and left hip. The physician ordered X-rays of both locations on 12/16/23. An Interdisciplinary Team (IDT) note, dated 12/16/23 at 11:00 a.m., indicated the resident had fallen on 12/13/23 and placed himself on the floor on 12/15/23. He had complained of pain to his left shoulder and left hip on 12/16/23. A nursing progress note, dated 12/16/23 at 5:06 p.m., indicated the X-ray obtained of the resident's left shoulder showed a dislocation and a displaced, comminuted fracture of the humeral head. The resident was sent to the hospital emergency room for treatment. The resident's current physician's orders included acetaminophen (to treat pain) 650 mg (milligram), one tablet every four hours as needed for general discomfort (12/20/23) and perform a pain assessment every shift for pain management (9/21/23). Resident F's electronic Medication Administration Record (eMAR) for December 2023, indicated the following: Acetaminophen was administered on 12/20/23 at 10:34 p.m., 12/21/23 at 7:59 p.m., 12/22/23 at 6:09 a.m., and 12/25/23 at 8:16 a.m. The outcome for each administration was indicated as effective. Review of the December 2023 eMAR pain level assessment orders indicated the following: There was no morning pain assessment completed for 12/5/23, 12/11/23, 12/12/23, 12/17/23, 12/19/23, 12/21/23, 12/26/23 and 12/27/23. There was no evening pain assessment completed for 12/8/23, 12/12/23, 12/13/23, 12/17/23, and 12/25/23. The clinical record indicated pain levels for the resident were documented under the vitals section and included the following: a pain rating of seven on 12/27/23 at 7:00 a.m., a rating of five on 12/26/23 at 7:17 a.m., a rating of seven on 12/21/23 at 10:07 a.m., and a rating of four on 12/15/23, 12/16/23, and 12/17/23. The record lacked indication of interventions being offered for pain relief. During an interview on 12/28/23 at 10:27 a.m., the DON indicated the resident was in pain. They had attempted to weigh him this morning, but he was moaning. She felt his pain may be why he had not gotten out of bed and was recently spitting out his medications. He did have acetaminophen ordered for pain, but the staff had not been providing doses. The documentation of pain ratings should be completed with a numerical value and should be completed each shift. During a phone interview on 12/28/23 at 10:42 a.m., CNA 3 indicated the resident had a drastic change in the last couple weeks. He had previously been walking around and talking. The resident had not been the type to lay around in bed all the time and she felt he was having pain. A current facility policy, revised 11/22, titled, Pain Management Program, provided by the DON on 12/28/23 at 1:35 p.m., indicated the following: .Purpose: To establish a program which can effectively manage pain to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness Definition: .When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the present {SIC} of pain The pain management components: Documentation of pain assessment and monitoring .Assessment of non-verbal residents for signs and symptoms of pain .Standard: 1. Pain assessment protocol will be initiated under any of the following situations: a. Any indication of pain based on the pain assessment performed for each resident at the time of admission and with any condition change and/or incident associated with the potential of pain d. A change in resident condition occurs to require pain control This citation relates to complaint IN00424249. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure proper indwelling urinary catheter care was provided on each shift, to prevent infection in a resident dependent for activities of daily living, for 1 of 3 residents reviewed for urinary tract infections. (Resident C) This deficiency resulted in a hospitalization of Resident C for a urinary tract infection with [CONDITION(S)]. Findings include: During an interview at the time of observation on 3/14/22 at 3:51 p.m., Resident C indicated he was dependent on staff to provide catheter care and other activities of daily living due to his immobility. He indicated he required a continuous urinary catheter and staff typically cleaned his catheter insertion site a couple of times each week. He indicated staff have never cleaned his urinary catheter insertion site every shift. Resident C indicated he had a recent hospitalization that lasted one week for a urinary tract infection and he remained on intravenous antibiotic therapy for treatment. A double lumen Peripherally Inserted Central Catheter (PICC) line was observed in the resident's upper right arm. Resident C indicated he had a suprapubic catheter prior to his hospitalization and it was removed during his hospitalization and a Foley catheter was anchored prior to readmission to the facility on [DATE]. During an observation on 3/14/22 at 4:12 p.m., Resident C's urinary catheter drainage bag was hung on his bed frame and contained 500 milliliters of clear yellow urine. During an observation on 3/17/22 at 12:22 p.m., the resident was observed in bed watching television with the urinary catheter collection bag hung on the resident's bed frame. Clear yellow urine was noted in the urinary collection bag and tubing. During an observation on 3/17/22 at 12:41 p.m., a staff member was at the bedside of Resident C and fed him his meal. Resident C's clinical record was reviewed on 3/18/22 at 3:31 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked an active order for Foley catheter care. An order started on 12/28/21 and discontinued on 2/27/22 was as follows: Suprapubic catheter: 22 French, 10 milliliter balloon to gravity drainage. A quarterly Minimum Data Set, dated dated [DATE], indicated Resident C did not exhibit any rejection of care behaviors and he required total dependence of staff members for transfers, toileting, personal hygiene, and bathing. He required extensive physical assistance of 2 staff members for bed mobility, had an indwelling catheter and always had bowel incontinence. A care plan for activities of daily living, revised on 2/17/21, indicated the resident required assistance with activities of daily living related to [CONDITION(S)]. Interventions included, but were not limited to, dependence on 2 staff members for toileting, bathing and bed mobility. A care plan for antibiotic therapy, initiated 3/7/22, indicated the resident required antibiotic therapy related to infection. Interventions included, but were not limited to, administer antibiotic medication as ordered by the physician. A care plan for incontinence, revised on 3/11/21, indicated the resident was incontinent of bowel, had an indwelling catheter, and at risk for complications due to incontinence, need for assistance, urinary retention and frequent urinary tract infections. Interventions included, but were not limited to the following: observe, document and notify the Medical Doctor as needed for signs and symptoms of urinary tract infections such as fever, dysuria, hematuria or foul smelling urine. A care plan for indwelling catheter, revised 3/14/222, indicated the resident required an indwelling catheter related to [CONDITION(S)] bladder. Interventions included, but were not limited to the following: provide catheter care and empty catheter every shift and as needed and keep Foley catheter anchored to thigh for security and to prevent trauma. Medications included, but were not limited to the following: [MEDICATION(S)] Solution reconstituted 1 gram (antibiotic) daily intravenously for 9 days for [CONDITION(S)] and was dated 3/7/22. Orders included, but were not limited to the following: a. Cleanse suprapubic catheter with soap and water, dry, apply barrier cream and then apply a split gauze two times a day and as needed. This order originated on 12/28/21 and discontinued on 1/27/22. Review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Cleanse suprapubic catheter with normal saline, apply calcium alginate, split gauze and change daily and as needed for wound to suprapubic site. This order originated on 1/27/22 and discontinued on 2/27/22. Review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Foley catheter: 16 French, 10 milliliter balloon to gravity drainage. This order originated on 3/14/22. A Nurse's Note, dated 2/27/22 at 9:19 a.m., indicated the resident was sent to the emergency room for evaluation and treatment due to the resident's request and a change in condition. The resident had an elevated temperature, hematuria noted in indwelling urinary drainage bag, output noted in brief, shaking, and bilateral upper and lower extremity [CONDITION(S)]. A Nurse's Note, dated 2/27/22 at 12:58 p.m., indicated Resident C was admitted to the hospital with a urinary tract infection and [CONDITION(S)]. Review of Resident C's hospitalization Patient Summary Report and Discharge Instructions, indicated Resident C admitted to the hospital on 2/27/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His temperature was initially 103 degrees, pulse was 122, lactic acid 5.2 and a white blood cell count of 25.2 . His suprapubic urinary catheter was removed and a Foley catheter was placed. The urine culture was positive for Escherichia coli. Resident C was discharge back to the skilled nursing facility on 3/6/22 with a PICC line and intravenous antibiotic orders for [CONDITION(S)]. A Nurse's Note, dated 3/6/22 at 4:21 p.m., indicated the resident returned to the facility at this time after an acute hospitalization related to a urinary tract infection with [CONDITION(S)]. A PICC line was noted in the right upper extremity for continued intravenous antibiotic therapy. An anchored Foley catheter was placed at the hospital. Review of a Nurse Practitioner's note, dated 3/8/22 indicated the resident recently returned from the hospital with treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse's Note, dated 3/8/22 at 2:43 p.m., indicated the resident continued with a Foley catheter and intravenous antibiotic therapy. Review of a Nurse's Note, dated 3/13/22 at 5:22 a.m., indicated Resident C continued with a Foley catheter and intravenous antibiotic therapy. Review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the point of care catheter documentation, completed by the Certified Nurse's Aides for the month of March 2022 and provided by Licensed Practical Nurse on 3/21/22 at 4:46 p.m., lacked catheter care documentation for every shift on the following dates: 3/7/22, 3/8/22, 3/10/22, 3/11/22, 3/12/22, 3/14/22, 3/15/22, 3/16/22, 3/17/22, 3/19/22 and 3/20/22. During an interview at the time of observation on 3/21/22 at 1:23 p.m., Resident C indicated no one had performed urinary catheter care on this date and he consented to a urinary catheter care observation. The resident was in his bed slightly turned to his left side. The indwelling catheter drainage bag was not attached to the bed frame or visible during the observation. During an interview on 3/21/22 at 1:32 p.m., Certified Nurse's Aide (CNA) 13 indicated the CNA's documented all of their urinary catheter care in the electronic point of care charting. During an interview and observation on 3/21/22 at 1:42 p.m., Licensed Practical Nurse (LPN) 14 indicated catheter care orders were in the electronic medical record for residents that had urinary catheters. She indicated residents with urinary catheters were expected to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to find an active order for catheter care in Resident C's clinical record and indicated as a result, the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated Resident C had a recent hospitalization for a urinary tract infection with [CONDITION(S)] so she was unsure why his electronic medical record lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the suprapubic urinary catheter care was completed and documented only by the nurses since CNA's were not qualified for suprapubic catheter care. During an observation on 3/21/22 at 1:55 p.m., upon entry to Resident C's room an unknown staff member emptied the resident's urinary catheter drainage bag and then hung it on the frame of the bed once it was emptied. During an interview at the time of observation on 3/21/22 at 1:59 p.m., urinary catheter care was completed for Resident C in his bed by CNA 13 and LPN 14. During the observation, CNA 13 performed hand hygiene, donned gloves, asked the resident for consent to perform urinary catheter care, pulled the resident's linens and unsoiled brief away from the resident's body, then used a disposable personal cleansing cloth and wiped the catheter tubing from the catheter insertion site and moved in a motion away from the body. She immediately repeated the same motion with the same soiled cloth 2 more times with the same disposable personal cleansing cloth. During an interview with CNA 13 at the time of the catheter care observation, she indicated she always used the disposable personal cleansing cloths on the residents' urinary catheter tubing in this manner before she continued the urinary catheter care with soap and water. CNA 13 used a clean cloth with soap and water and cleaned at the insertion site and moved outward from the insertion site then followed with the same motion using a clean rinse cloth and dried in the same motion with a towel. A catheter securement device was not secured to the resident's leg nor applied during the observation. The resident's previously worn unsoiled brief was placed back on the resident prior to leaving the resident's bedside. During the catheter care observation, Resident C held a conversation with LPN 14 who stood at the bedside during catheter care and indicated he had some questions he would like answered by LPN 4 and requested LPN 14 to communicate that information with LPN 4 when the urinary catheter observation was completed. During an interview on 3/21/22 at 2:07 p.m., following catheter care, Resident C indicated, That was the first time catheter care was perform like that since I returned to the facility from my recent hospitalization . He indicated he wanted to speak with LPN 4 about the frequency in which the staff should have provided the urinary catheter care like he received during the observation because staff have not been doing it like that. During an interview at the time of observation on 3/21/22 at 2:15 p.m., LPN 4 indicated indwelling urinary catheter care should have been performed each shift. She indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated Resident C had a recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated urinary catheter care was an important component of infection prevention in residents with an indwelling urinary catheter. LPN 4 indicated the resident had a suprapubic catheter prior to his discharged to the hospital on 2/27/22. He returned to the facility on [DATE] with a Foley catheter from his hospitalization . Upon review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 4 indicated Nurses and Unit Managers were responsible to ensure indwelling catheter care was completed and documented in the residents electronic medical record. During an interview on 3/21/22 at 2:35 p.m., LPN 4 indicated the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/21/22 at 4:00 p.m., LPN 4 indicated Resident C was dependent on staff for activities of daily living. During an interview at the time of observation of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/22/22 at 9:44 a.m., Resident C indicated the difference in catheter care during the observation on 3/21/22 was that they actually cleaned the catheter at the insertion site. He indicated. The staff usually do not touch my penis and scrub the catheter where it goes into my body. Instead, they usually clean around my penis and avoid where it enters my body. He indicated when he spoke with LPN 4 on 3/21/22, she indicated staff were supposed to provide urinary catheter care every shift. He indicated he only received urinary catheter care 1 time on 3/21/22 and he felt it was done due to the requested urinary catheter care observation and as a result of the survey process because no additional catheter care was provided on second shift or night shift. An undated policy, titled Policy for Suprapubic Catheter Care, provided by the Executive Director on 3/22/22 at 11:45 a.m., indicated the following: It is the policy of this facility that all resident with suprapubic catheters will receive catheter care at the site of insertion at least daily to prevent irritation and possible infection. Procedure for Suprapubic Catheter Care .Gently cleanse abdominal insertion site and catheter with warm, soapy water in concentric circles working down the tube away from the insertion site. Rinse in the same manner and dry gently. Remove gloves and wash hands or use alcohol-based hand rub. Apply clean gloves. Apply clean dressing as ordered and secure with tape as needed Document care given and observation about the condition of insertion site A current policy, titled Policy for Foley Catheter Care, provided by LPN 4 on 3/21/22 at 4:46 p.m., indicated the following: It is the policy of this facility that residents will be provided with catheter care twice daily and as needed as soiling occurs. It will include a thorough cleansing of the perineal and catheter-meatal areas using soap and water . Procedure for Foley Catheter Care .The catheter-meatal junction is a significant portal of entry for bacteria in to the urinary tract, potentially causing urinary tract infections. Therefore, it is most important that the perineum, catheter-meatal junction, and tubing be kept clean and free from fecal contamination This Federal tag relates to complaint IN 487 3.4-41(a)(2)

Based on record review and interview, the facility failed to transfer a resident to the hospital for care following resident representative's request and physical decline resulting in resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident B) This deficient practice resulted in Resident B being hospitalized for [CONDITION(S)] (blood poisoning). The facility also failed to provide care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident D) Findings include: 1. During a phone interview on 3/15/22 at 1:19 p.m., the resident's family member indicated the resident was admitted to the facility following a hospitalization after a stroke and COVID-19 infection. He had a catheter and in the past was susceptible to urinary tract infections in the past. The family member was concerned when a change in the resident's condition was noticed upon viewing a video taken. After viewing the video, she requested the resident be sent to the hospital on 1/20/22. The facility refused to send him to the hospital. The facility indicated they would obtain a urine sample to be tested . The family member indicated she knew something was wrong and wanted the resident evaluated in the emergency department, but the staff refused. During a phone interview on 3/17/22 at 10:00 a.m., another family member they indicated his mother was the decision maker and resident representative. He knew that the family member from the previous interview had requested the resident be sent to the emergency room because of his worsening condition at the nursing facility. The family was concerned due to his history of frequent urinary tract infections. The family had been having difficulty getting information about his previous medical tests and X-rays. This family member felt the facility was not addressing the families concerns regarding the resident's decline. He had not requestedthe resident be sent to the emergency room , but was aware the family member from the previous interview and another family member had requested this several times. The staff had continually indicated to family that the resident was comfortable and being cared for without providing details regarding his care. The resident's Admission Packet, dated 1/8/22, indicated the resident's spouse as resident representative The spouse had signed on behalf of the resident on all admission documentation. The clinical record for Resident B was reviewed on 3/15/22 at 1:31 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 1/14/22, indicated the resident had severe cognitive impairment, required extensive assistance of staff for activities of daily living, required supplemental oxygen, had an indwelling catheter, and required a feeding tube for nourishment. A nursing note, dated 1/9/22 at 8:23 a.m., indicated the resident had arrived to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated the resident was allergic to [MEDICATION(S)] and the on call physician service was notified and the facility was awaiting clarification from the provider. A provider message system record was provided by the Administrator on 3/18/22 at 10:58 a.m., and included, but was not limited to, an undated message from the facility staff with the following message timed 1:55 p.m.: On (Resident B), please contact wife. The family is concerned that he does not have an antibiotic for [CONDITION(S)] and pneumonia. I have asked for an antibiotic for him twice but it gets denied. Please call and explain to this family why he is not getting an antibiotic. Thank you. A reply was received at 3:07 p.m., from the nurse practitioner indicating he had talked to the spouse regarding appropriate use of antibiotics. She understands. A nursing note, dated 1/20/22 at 3:54 p.m., entered by LPN 6, indicated the following: This writer received request from staff to call pt's wife, who wants him sent to the hospital. Pt {patient} examined by this writer and found him to be resting comfortably and in no distress. Vitals are stable as noted: B/P {blood pressure} 121/54, T {temperature} 98.2, P [pulse] 82, R [respirations] 18, O2 [oxygen saturation] 95% on room air. Lungs are clear and equal bilaterally there is a wet cough noted. Abd [abdomen] soft and non-tender w/[with] positive bowel sounds in all quadrants Foley catheter patent and draining clear, yellow fluid with scant amount of mucous thread. Pt's rash on his face is much improved and he has been shaved this shift. Wounds are treated per orders and are improving. Reported all the above to DON [Director of Nursing] and MD [Medical Doctor] on call. Received order from MD to keep pt in facility as there is no medical reason to send him out. Reported all the above to pt's wife. Pt's wife stated 'but I just feel like he's going down, and I watched the video my son took of him, he looks awful, and he sounds like he has a death rattle.' This writer attempted to reassure the wife that he was safe and improving and that he does have a cough, but that it was not a death rattle. This writer also reported to the wife the MD's order that the pt had no medical reason to go to the hospital. The wife then accused this writer of lying about pt's symptoms and wanting to keep him to make the facility money. This writer again tried to reassure the wife that he was stable and improving, that this writer was not lying, and that he did not need to go to the hospital. The wife then said 'this is not over!' and hung up the phone. Reported all the above to DON. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record indicated the urine sample was collected on 1/21/22 at 3:45 p.m. A lab result for urinalysis, dated 1/24/22 at 12:02 p.m., indicated a positive result for a urinary tract infection. During an interview on 3/22/22 at 4:35 p.m., LPN 3 indicated the result from 1/24/22 was the only result received from the laboratory and he had no information of a preliminary result being received at the facility. He had checked the lab portal and the electronic health record and was unable to locate a preliminary urinalysis report. A change of condition progress note, dated 1/25/22 at 7:21 p.m., indicated the resident had an altered level of consciousness, shortness of breath, labored breathing, cough, abnormal lung sounds, and decreased urine output. A nursing progress note, dated 1/25/22 at 9:05 p.m., indicated an order was received from the provider to send the resident to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of hospital clinical documentation, dated 1/25/22 at 9:53 p.m., included, but was not limited to: Patient here from extended care facility for urinary tract infection and pneumonia. Family stated patient's condition had been deteriorating and they wanted him to be evaluated at the emergency department. Patient arrived at the emergency department with fever and wet cough. Family just aware of urine results today and he had been started on [MEDICATION(S)] for his pneumonia on 1/20/22. The clinical impression was indicated as [CONDITION(S)] and urinary tract infection. Patient was treated in the emergency room with intravenous (IV) fluids, IV [MEDICATION(S)] (an antibiotic), and IV [MEDICATION(S)] (an antibiotic). The resident was admitted to the hospital for continued inpatient management for urinary tract infection with [CONDITION(S)]. During an interview on 3/18/22 at 10:35 a.m., the Administrator indicated the resident's spouse got very excited and the staff had worked with the resident's children to help mom. The spouse had seen the video the son had taken and she asked for the resident to be sent out emergency room . The physician felt it would be worse for the resident to go out to the hospital due to COVID-19. He indicated the facility had listed the son as the responsible party with the facility and the spouse the emergency contact. An emergency contact can request resident to be sent to the emergency room , but ultimately, given the circumstances with her difficulty with the transition of her husband's condition, the responsible party would be the decision maker. The facility did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A document titled, Resident Rights, revised 2/19/21, provided by the Administrator on 3/17/22 at 12:08 p.m., included, but was not limited to, the following: Residents' Rights .B. Residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Resident's have the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States. 3.1(a)(1) B1. During an observation on 3/14/22 at 11:06 a.m., Resident D was seated in her wheelchair and positioned in the doorway of her room on the 400 unit playing bingo. She was noted with excessive [CONDITION(S)] on her bilateral lower extremities and a dressing noted to her right lower leg. No wraps were in place during the observation. During an observation on 3/15/22 at 9:15 a.m., Resident D sat in her recliner with her bilateral lower extremities wrapped with excessive [CONDITION(S)]. Her legs were not elevated during the observation. During an observation on 3/17/22 at 12:19 p.m., Resident D sat in her recliner in her room with ace wraps on her edematous bilateral lower extremities. Her oxygen was on via nasal canula and her legs were not elevated during the observation. During an observation on 3/18/22 at 2:30 p.m., the resident sat in her wheelchair in her room. Her bilateral lower extremities were wrapped and remained with excessive [CONDITION(S)]. The right ace wraps was wet on the lower leg near the ankle and her legs were not elevated. Resident D's clinical record review was completed on 3/22/22 at 10:47 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Medications included but were not limited to the following: [MEDICATION(S)] (diuretic) 5 milligram by mouth one time a day every 3 days related to [CONDITION(S)] of right lower limb. The order started on 3/17/22 and completed on 3/19/22. There was a discrepancy with the frequency when compared to the provider progress note. Review of a Nurse Practitioner's progress note, dated 3/16/22, indicated the resident had returned from the emergency room with complaints of increased [CONDITION(S)] in her bilateral legs with increased weeping in the right leg. Physical exam indicated 3 + [CONDITION(S)] in the left ankle and foot and 4+ [CONDITION(S)] in the right ankle and foot. The documented plan indicated to add [MEDICATION(S)] for 5 days due to increased [CONDITION(S)] and discomfort and daily weights related to fluid overload. Documentation indicated the plan was communicated with facility staff and placed in the charts on 3/16/22. An active order, dated 3/10/22, indicated monthly weights and vitals were ordered. Review of the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documented weights indicated the last weight was obtained on 3/1/22. A care plan for activities of daily living, revised 6/8/21, indicated indicated the resident required assistance with activities of daily living related to physical limitation, weakness, decreased mobility, [CONDITION(S)], and chronic obstructive pulmonary disease. Interventions included, but were not limited to, resident required assistance of 1 staff member for toileting, transfers, bed mobility, and locomotion in the manual wheelchair for long distances. A care plan for cardiac, initiated 3/16/2022, indicated the resident was at risk for cardiac issues related to hypertension, atherosclerosis and peripheral vascular disease. Interventions included, but were not limited to the following: weights per policy and notify provider of significant losses or gains; observe for [CONDITION(S)], weight gain, and adventitious lungs sounds and report to provider as needed. A care plan for diuretic, initiated 3/16/22, indicated the resident is at risk for adverse effects related to daily diuretic use. Interventions included, but were not limited to, administer diuretic medications as ordered. A Nurse's Note, dated 3/19/22 at 11:29 p.m., indicated the resident received pain medication as a result of reported leg pain. A Nurse's Noted, dated 3/20/22 at 3:44 a.m., indicated the residents legs continued to drain clear fluid and the resident was administered pain medication due to her screaming and yelling about her leg. A Nurse's Note, dated 3/20/22 at 8:39 p.m., indicated the resident complained of leg pain and received pain medication. A Nurse's Note, dated 3/21/22 at 5:44 a.m., indicated the resident complained of pain and burning to her right lower leg. The resident continued with serous drainage from the right leg. During an observation on 3/22/22 at 2:00 p.m., Resident D sat in her wheelchair in the hallway across from the nursing office with continued excessive [CONDITION(S)] noted in her bilateral lower extremities. Her oxygen was on via nasal canula. During an interview on 3/22/22 at 2:13 p.m., Licensed Practical Nurse (LPN 15) indicated all residents with daily weights show up in the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the nurse is required to ensure daily weights are obtained and documented. During an interview on 3/22/22 at 2:18 p.m., LPN 12 indicated she was assigned to the 400 unit on this date and none of the resident on this unit required daily weights. She indicated an order would be in the resident's chart if they required daily weights. During an interview on 3/22/22 at 2:33 p.m., LPN 12 indicated Resident D had significant [CONDITION(S)] noted in her bilateral lower extremities. LPN 12 indicated the electronic clinical record lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated there was a discrepancy in the orders noted on the provider progress noted from 3/16/22 and daily weights had not been obtained according to the providers written order in the progress note. During an interview on 3/22/22 at 2:53 p.m., LPN 4 indicated daily weights were not obtained as ordered by the provider on 3/16/22 and the order was not updated for weights. During an interview on 3/22/22 at 4:15 p.m., LPN 4 indicated there was a discrepancy between the order entered in the the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the discrepancy should have been recognized during the 24 hour report meeting between the unit managers and clarified with the Nurse Practitioner immediately. She was uncertain how this was missed. A current policy, titled Weights, provided by LPN 4 on 3/22/22 at 4:44 p.m., indicated the following: GUIDELINES: Resident should be routinely weighed on the same type of scale . The scale should be tested to ensure it is in calibration as required 2. Resident identified as .risk may be weighed weekly or . per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly weight may be discontinued ., as determined by the . Physician A policy, dated 1/1/14, titled CHANGE IN CONDITION PHYSICIAN NOTIFICATION/PHYSICIAN ORDERS/OVERVIEW GUIDELINES, provided by LPN 4 on 3/22/22 at 4:44 p.m., indicated the following: .All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Medical care problems are communicated to the attending physician in a timely, concise, and thorough manner NURSE RESPONSIBILITIES . The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical intervention NURSING DOCUMENTATION . A. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received. B. All orders taken from the physician or his/her office, the Physician's Assistant or Nurse Practitioner. C. The nurse receiving telephone verbal orders should write it on the 24 Hour Report. D. Acute and subacute problems are to be communicated shift-to-shift by verbal report and highlighting or discussing the problems listed on the 24 Hour Shift Report to facilitate communication and Quality Assessment and Improvement follow-up This Federal tag relates to complaint IN 487. 3.1-37(a)

Based on record review and interview, the facility failed to prevent the development of pressure injuries for a resident identified at risk. This deficient practice led to the resident developing an infection in an unstageable, necrotic wound, leading to septic shock for 1 of 4 residents reviewed for wounds (Resident F). The immediate jeopardy began on [DATE], when Resident F was found to have developed a necrotic pressure injury. The Administrator, DON, Executive Director, and Director of Clinical Services were notified of the immediate jeopardy on [DATE] at 2:18 p.m. The immediate jeopardy was removed on [DATE], but non-compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of Resident F's closed record was completed on [DATE] at 9:08 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had physician orders, current at the time of his discharge for, but not limited to, [MEDICATION(S)] 50 mg (blood pressure) twice daily, [MEDICATION(S)] 75 mg (blood thinner) once daily, [MEDICATION(S)] 2.5 mg (blood pressure), [MEDICATION(S)] 80 mg (blood pressure) once daily, and a regular pureed diet with nectar thickened liquids, weekly weight for four weeks, and a high-calorie supplement three times daily. A [DATE], admission, Minimal Data Set (MDS) assessment indicated Resident F was rarely/never understood. He required extensive assistance for bed mobility and was dependent for transfers. He was incontinent of bowel and bladder. He was at risk for developing pressure injuries and did not receive skin treatments. He had a current, [DATE] care plan problem of potential for impaired skin integrity related to incontinence, decreased mobility, and history of a wound to his gluteal/sacral area. Interventions included, but were not limited to, observe skin integrity, encourage oral intake, monitor incontinence, and therapeutic mattress/air mattress. He had a current, [DATE], revised [DATE] care plan problem of a pressure injury to his sacrum, with interventions initiated on [DATE]. Review of a [DATE] hospital discharge note indicated he had a stage 2 (loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or open/ruptured serum-filled blister) pressure injury to his sacral area. A [DATE] facility admission assessment indicated he was oriented to self only, was dependent for ADLs, and had a 1.1 cm L x 1.0 cm W abrasion to his sacral area. A [DATE] progress note indicated an order was received for weekly laboratory studies to assess hydration status due to poor acceptance of oral food and fluids. A [DATE] nutrition note indicated he required 1977 milliliters (mL) of fluid daily. A high-calorie supplement was recommended due to risk of malnutrition. A [DATE] weekly skin assessment indicated he had no skin issues. The clinical record lacked a weekly skin assessment prior to [DATE]. A [DATE] pressure injury risk assessment indicated he was at high risk for developing pressure injuries. A [DATE] weekly skin assessment indicated he had no skin issues. A [DATE] progress note indicated the Nurse Practitioner had reviewed his lab results and ordered fluids to be encouraged. Review of weights indicated he weighed 174 pounds on ,d+[DATE] and [DATE] and weighed 173 on [DATE]. The clinical record lacked any other weights. Review of meal consumption records indicated the following: On [DATE], he accepted ,d+[DATE]% of breakfast and ,d+[DATE]% of supper; his lunch intake was not recorded. On [DATE], he accepted ,d+[DATE]% of all three meals. On [DATE], he accepted ,d+[DATE]% of breakfast and ,d+[DATE]% of lunch and supper. On [DATE], he accepted ,d+[DATE]% of breakfast and lunch; his supper intake was not recorded. There was no documentation of meal intakes for breakfast or lunch on [DATE]. Review of fluid and supplement intakes for [DATE] indicated the following: On [DATE], he accepted 720 mL of fluid and did not accept any of the high-calorie supplement. On [DATE], he accepted 640 mL of fluid and two servings (120 mL each) of the high-calorie supplement. On [DATE], he accepted 240 mL of fluids, two full servings (120 mL each) and .25 of a serving (30 mL) of the high-calorie supplement. There was no record of physician notification regarding poor oral intakes. An [DATE] at 1:50 p.m. (signed on [DATE] at 1:07 p.m. by the DON) wound assessment note indicated he had a sacral wound present, which appeared to be a Kennedy ulcer (a sacral wound that may develop at the end of life, and has the shape of a butterfly, pear, or horseshoe with irregular borders). The wound measured 8 cm L x 7 cm W x 0.1 cm depth (D) and was 100% covered with necrotic (dark, dead tissue) tissue. An order was received to transfer him to the hospital for evaluation. An [DATE] at 4:06 p.m. change in condition note indicated he had deep, rapid breathing with ,d+[DATE] periods of apnea (no breathing). The physician had been notified at 3:00 p.m. An [DATE] at 4:06 p.m. weekly skin assessment indicated he had a wound to his sacral area, which measured 7 cm L x 8 cm W with no depth indicated; an additional area to his coccyx was 6.2 cm L x 6.3 W with the 1st layer skin gone. His left heel was turning dark and appeared pressured. An [DATE] at 4:21 p.m. change in condition note, signed by RN 30 indicated he was having periods of apnea and an order had been received to send the resident to the hospital. Review of an [DATE] at 2:34 p.m., emergency department report indicated the resident had a 6 cm round wound on his sacral area and DTI (non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) (DTI) to each of his heels. The nursing facility reported to the emergency department staff he had stopped eating or drinking a few days prior to his transfer and had a wound observed four days prior, but it was small. The wound had not been documented or passed along and had tripled in size that morning. The contact at the nursing facility was not sure why he had not been evaluated when he had started to go downhill earlier in the week. He was admitted to the hospital for, but not limited to, septic shock secondary to an infected, unstageable (not able to be staged due to presence of deadened tissue covering wound bed) pressure injury, hypovolemic shock from poor intake, dehydration, and acute [CONDITION(S)]. Review of an [DATE] hospital discharge summary indicated the resident died at the hospital. During an interview, on [DATE] at 9:51 a.m., the DON indicated the resident had not been well when he admitted to the facility and was not in good health due to general debility. On [DATE], he had become less responsive, spiked a fever, and was sent out. A Kennedy ulcer had appeared that morning, and he was a full code, so he was sent out, then died a few days later at the hospital. He had not had any skin issues prior to developing the wound on [DATE]. During an interview, on [DATE] at 11:57 a.m., the DON indicated she had worked the evening prior to the resident's transfer and he had not had a wound present. The resident had sat in the emergency department for a long time before being transferred to the medical floor, which may have attributed to the worsening of the wound. During an interview, on [DATE] at 1:46 p.m., CNA 14 indicated the residents' care plans had current and new interventions for the care of the residents. During an interview, on [DATE] at 1:53 p.m. RN 30, who was present at the time of the resident's discharge, indicated she did not recall the resident, nor any specifics regarding his wound development or change in condition. During an interview, on [DATE] at 2:00 p.m., the hospital Wound Nurse indicated the hospital had not defined the sacral wound as a Kennedy ulcer, due to his having additional pressure injuries. He had DTI to both heels, each measuring 5 cm L x 5 cm W, and a DTI to his right elbow, which measured 0.5 cm L x 2 cm W. His sacral wound was an unstageable, 10 cm L x 12 cm W DTI- it was open and evolving. Review of a current facility policy titled Skin Condition Assessment & Monitoring ., dated [DATE] and provided by the DON on [DATE] at 9:47 a.m., indicated the following: Residents identified will have a weekly skin assessment by a licensed nurse .Each resident will be observed for skin breakdown daily during care Review of an online article titled Bedsores (pressure ulcers), updated in 2021 and retrieved from mayoclinic.org, indicated the following: .Your risk of developing bedsores is higher if you have difficulty moving and can't change position easily while seated or in bed. Risk factors include: Immobility. This might be due to poor health, spinal cord injury and other causes. Incontinence. Skin becomes more vulnerable with extended exposure to urine and stool. Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of warning signs and the need to change position. Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diets to maintain healthy skin and prevent the breakdown of tissues. Medical conditions affecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, can increase the risk of tissue damage such as bedsores .You can help prevent bedsores by frequently repositioning yourself to avoid stress on the skin. Other strategies include taking good care of your skin, maintaining good nutrition and fluid intake The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility began inservicing staff on the facility's policies for skin condition assessment and monitoring, but non-compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the inservicing had not been completed for all staff and monitoring to ensure staff was following the plan was on going. This Federal Tag relates to Complaint IN 068. 3.,d+[DATE](a)(1)

Based on record review and interview, the facility failed to monitor weights and meal and fluid intakes, identify discrepancies, and develop personalized interventions for residents at risk for weight loss and dehydration for 1 of 3 residents reviewed for nutrition (Resident D). This deficient practice resulted in Resident D having had weight loss of 28% and being admitted to the hospital with [REDACTED]. Findings include: Resident D's closed clinical record was reviewed on 3/23/21 at 11:37 a.m. [DIAGNOSES REDACTED]. She admitted to the facility from the hospital on [DATE]. She had physician orders [REDACTED]. for upset stomach. An 11/9/20, admission, Minimum Data Set Assessment (MDS) indicated she was moderately cognitively impaired and required limited assistance with eating. She required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and hygiene. She did not walk and used a wheelchair. She was incontinent of bowel and bladder. She had an 11/5/20 care plan problem of potential alteration of nutrition and/or weight status related to [MEDICAL CONDITION], oral phase dysphagia, [MEDICAL CONDITION], and [MEDICAL CONDITION]; hospital [DIAGNOSES REDACTED]. She needed mechanical altered food or fluids that may alter the likeliness of adequate consumption related to dysphagia, swallow or chewing difficulty, and poor oral/dental condition. Her meal intakes were inadequate to her nutritional needs and were requiring supplementation. She had a potential for weight changes related to [MEDICAL CONDITION], and caloric exchanges of current diet versus usual home consumption. She had a body mass index (BMI) indicative of being overweight and a skin impairment to her coccyx. Interventions included, but were not limited to, monitor nutritionally related labs as needed (11/5/20), monitor skin integrity via supportive documentation (11/5/20), obtain and evaluate weights, notifying the physician, dietitian and family of any significant changes (11/5/20), serve diet as ordered, recording amount of consumption, honor my preferences and offer alternate items if consumption is poor (11/5/20), and serve supplements and snacks as ordered (11/5/20). Review of the Weight and Vitals Summary for Resident D indicated the following: a. 10/29/20 163 pounds b. 11/5/20 refused c. 11/12/20 115 pounds, which was a loss of 29% d. 11/18/20 117 pounds, which was a loss of 28% from 10/29/20. e. 11/24/20 117 pounds Review of a 10/28/20 hospital note indicated she had been admitted for increasing weakness, [MEDICAL CONDITION] related to chronic alcohol use, history of urinary tract infection [MEDICAL CONDITIONS] and weakness. She had increasing confusion, but was able to answer some questions. A hospital face sheet, dated 10/28/20, indicated she weighed 131 pounds. Review of facility progress notes and assessments indicated the following: a. A 10/28/20 admission assessment indicated she weighed 163 pounds and had 3+ [MEDICAL CONDITION] all over. b. A 10/28/20 dietary assessment indicated she was at low risk for dehydration. c. A 10/29/20 Nurse Practitioner order indicated [MEDICATION NAME] (water pill) 40 mg daily for 3 days. Review of the November Medication Administration Record [REDACTED]. d. Review of a 10/30/20 Nutritionally At Risk (NAR) note indicated a poor oral intake and weight of 162 pounds. She received a regular diet with chopped meats and thin liquids. e. On 10/31/20 and 11/1/20, the [MEDICAL CONDITION] remained. f. On 11/2/20, the [MEDICAL CONDITION] was not present. g. On 11/3/20, the [MEDICAL CONDITION] was not present. h. On 11/5/20, she refused to be weighed and refused breakfast; she stated she used to weigh more and watched what she ate. Review of an 11/5/20 NAR meeting indicated an intervention of being educated on intakes and weights; she had refused 35% of her meals. Review of an 11/5/20 nutritional risk assessment indicated her most recent weight was 163 on 10/29/20, indicative of being overweight. Her minimum estimated daily caloric needs at this weight were 1850-2200 calories and 2225 mL of fluid. Review of November 2020 fluid intakes (through 11/23/20) for Resident D indicated daily intakes of 200 mL to 900 mL on 10 days, 901 mL to 1500 mL on 11 days, and 1501 mL to 1760 mL on two days. There were no interventions added to the resident's plan of care to address her poor oral fluid intake. On 11/12/20, her weight was 115 pounds, and the clinical record system indicated it was a 29% weight loss since 10/29/20. On 11/13/20, the Nurse Practitioner spoke with the resident's family about the resident's continued decline and the expectations of decline related to alcohol-induced dementia. Review of an 11/14/20 NAR note indicated she refused 26-50% of meals and had refused being weighed. She was educated on intakes and weights. The NAR note did not address the 11/12/20 weight loss, nor her poor fluid intake. An 11/14/20 change in condition note indicated she weighed 134 pounds on 11/13/20. The 11/14/20 weight of 134 pounds reflected a 17% weight gain in two days. An 11/14/20 post fall assessment indicated she did not recall the current season, location, room, or staff in the past seven days. Her estimated fluid intake in the prior 24 hours had been 480 mL and her intakes for the previous three meals was 25-50%. There were no interventions added to address the poor intake of food and fluids in the previous 24 hours. Review of November 2020 medication administration records (MAR) indicated she refused the high-calorie supplement twice and accepted a half dose twice. A 11/24/20 facility transfer sheet indicated she was being transferred to the emergency department per family request due to a decline. She weighed 117 pounds (a 13% loss from the 11/13/20 recorded weight). An 11/24/20 note indicated she had been admitted to the hospital with [REDACTED]. Review of an 11/24/20 hospital note indicated she was admitted with [MEDICAL CONDITION] secondary to UTI, [DIAGNOSES REDACTED] (low potassium), [MEDICAL CONDITION] (high sodium) due to dehydration, and acute metabolic [MEDICAL CONDITION]. She was ill-appearing and cachetic (muscle wasting) but non toxic, with a clinical impression of stupor, dehydration with [MEDICAL CONDITION], [DIAGNOSES REDACTED], and acute [MEDICATION NAME] without hematuria. Lab work from the hospital report indicated the following: a. Sodium 152 milliequivalents per liter (mEq/L) (normal between 135 and 145 mEq/L) b. Potassium 2.0 millimoles per liter (mmol/L) (normal between 3.6 to 5.2 mmol/L) c. Urinalisys was positive for [MEDICATION NAME] and [MEDICATION NAME] (normal is negative), and was 3+ bacteria. During an interview, on 3/24/21 at 9:50 a.m., the Administrator indicated the resident's initial weight at the facility would have been documented in error. When compared to the hospital weight of 131, it appeared the wheelchair weight had not been subtracted before being documented, which probably accounted for 30 pounds. This would have placed the resident's weight in the 133 pound range. She was admitted with a lot of [MEDICAL CONDITION], and some weight loss could be attributed to water loss after use of the [MEDICATION NAME] ordered on [DATE]. During an interview, on 3/24/21 at 10:47 a.m., the DON indicated the weights reviewed by the NAR team were obtained from the weight reports list in the clinical record; they would not have reviewed the progress notes. She didn't know why there would be weights documented in the progress notes, as they would have been in weights section of the record. She then indicated if there were weights documented in the progress notes, they would have been reviewed. The facility had attributed the weight loss to the diuretic use. Review of a current, undated, facility policy titled NUTRITIONALLY AT RISK (NAR) COMMITTEE, provided by the Administrator on 3/24/21 at 8:49 a.m., indicated the following: .The facility has a 'Nutritionally at Risk' (NAR) Committee for the purpose of monitoring and intervening in the care of patients as it relates to weight loss and weight gains. Additionally, those issues of hydration and other related clinical issues are to be reviewed by the NAR committee .The committee will identify, prevent, and reduce the risk factors associated with nutritional disorders .Criteria for NAR monitoring: .All readmissions and new admissions for 4 weeks or until weight has stabilized This Federal Tag relates to Complaint IN 560. 3.1-46(a)(1)

Based on, interview and record review, the facility failed to provide services to prevent the development of a pressure ulcer for 1 of 4 residents reviewed for pressure ulcers. This deficient practice resulted in a delay in receiving the physician prescribed treatment while in facility and negative-pressure wound therapy upon discharge (Resident B). Findings include: The closed clinical record for Resident B was reviewed on 3/28/19 at 10:12 a.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/4/19, indicated the resident was cognitively intact. The assessment indicated he did not have any unhealed or current pressure ulcers. He required one-person physical assistance with transfers, dressing and hygiene. The discharge MDS assessment, dated 3/15/19, indicated the resident had one stage 3 pressure ulcer that developed in the facility. A health care plan, dated 10/3/18 and revised 2/5/19, indicated the resident was at risk to develop a pressure ulcer related to [MEDICAL CONDITION] and urinary incontinence. Interventions included, but were not limited to, ointments and treatments per physician order. A Braden (pressure ulcer assessment tool) scale, dated 2/18/19, indicated the resident was at moderate risk for developing pressure ulcers. A progress note, dated 3/6/19 at 9:37 a.m., indicated the resident had an area to the right intergluteal cleft that measured 3.0 cm x 1.0 cm x <0.1 cm. The area appeared to be related to maceration, but now had an area of necrosis and was unstageable. There was no indication in the notes the wound had been identified through skin checks or bathing prior to the wound becoming unstagable. A skin and wound note, dated 3/7/19 at 8:36 a.m., indicated the wound measured 3.0 cm x 1.0 cm x <0.1 cm. The wound had a small amount of drainage and tenderness upon palpation. A new order for Duoderm ([MEDICATION NAME] dressing) to be applied to the right intergluteal cleft and changed every three days was received. A body assessment/observation, dated 3/7/19, indicated the left buttocks and sacrum were intact. A note indicated the resident was being followed by wound care and treatment was being applied. The Treatment Administration Record (TAR) indicated to apply DuoDerm to the right intergluteal cleft and change every three days. The dressing was completed on 3/7/19 and 3/10/19. The TAR indicated to see progress notes for the 3/13/19 treatment. An Alert Charting note, dated 3/11/19, indicated the resident's wound to the right gluteal had gotten worse and the skin around the wound was black. The wound nurse was notified and they were awaiting on physician orders. A progress note, dated 3/13/19, indicated the treatment was done as the wound physician was in the facility. An initial wound evaluation and management summary, dated 3/13/19, indicated the resident had a stage 3 pressure wound to the coccyx for at least 1 days duration. The physician indicated to apply Santyl (enzymatic [MEDICATION NAME] ointment) once daily for 30 days to the necrotic area and alginate calcium once daily for 30 days. A skin and wound note, dated 3/14/19 at 2:52 p.m., indicated the resident was seen by the wound physician because the wound had worsened. The resident had a facility acquired stage 3 pressure area that measured 6.0 cm x 2.0 cm x 0.3 cm. The wound bed was composed of 60% granulation tissue and 40% necrotic tissue. There was a moderate amount of drainage. A new order to cleanse with normal saline, apply nickel thick Santyl to the necrotic area and calcium alginate (promotes healing) applied to the remaining area. The wound was to be covered with bordered foam and changed daily for 30 days. The Treatment Administration Record (TAR) indicated an order for [REDACTED]. The dressing was to be changed daily. The TAR indicated the treatment for [REDACTED]. During an interview on 3/29/19 at 11:13 a.m., RN 2 stated the physician came in one 3/13/19. She indicated it did not sound right the treatment for [REDACTED]. She was also unsure how the initial order for Santyl and alginate calcium did not reflect the order on the TAR or physician orders. Review of a facility policy, revised (MONTH) (YEAR), titled,Pressure Ulcers/Skin Breakdown-Clinical Protocol was provided by the Administrator on 3/29/10 at 12:43 p.m. The policy indicated the following: .Treatment/Management 1. The physician will order pertinent wound treatments, including .and application of topical agents. This Federal tag relates to Complaint IN 405. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure appropriate interventions were in place to prevent elopement and falls for 2 of 5 residents reviewed for accidents. This deficit practice resulted in Resident C falling from bed, receiving a subdural hematoma which lead to death. (Residents C and B) Findings include: The clinical record for Resident C was reviewed on 10/11/2016 at 9:00 a.m. The [DIAGNOSES REDACTED]. The most current Significant Change Minimum Data Set (MDS) assessment, dated 9/26/2016, was reviewed on 10/11/2016 at 9:00 a.m. Resident C received the following Activities of Daily Living (ADL) assistance; bed mobility - extensive assist with 1 person physical assist, transfers - extensive assist with 2 person physical assist, dressing - total assist with 1 person physical assist, eating - extensive assist with 1 person physical assist and toilet use and personal hygiene - extensive assist with 1 person physical assist. Resident C had impaired to range of motion in both the upper and lower extremities on 2 sides. The Resident had a BIMS (Brief Interview for Mental Status Score) of 0 out of 15, indicating severe cognitive impairment. Review of the clinical record indicated Resident C fell on the following dates: 8/5/2016 with injury (broken clavicle), 8/17/2016 with injury (bruising to face and laceration to nose) and 9/21/2016 with injury (inoperable subdural hematoma). Review of the hospital emergency department progress notes dated 9/21-22/ 2016, indicated Resident C had been evaluated in the emergency room and found to have a subdural hematoma. Review of a nursing note, dated 9/21/2016 at 9:35 p.m., indicated res was found on the floor beside her bed, lying in blood, res was on her right side in a fetal position, the blood appeared to be coming from her head on the right side, res was non verbal to staff stimuli, but alert to her surroundings, res was last seen by nurse at 8pm, at that time res was given her 8pm hydro (analgesic medication), along with her other HS (hours of sleep) meds, res was lying in bed on her right side facing the window with feet hanging off the side, res was clean and dry, res did not appear to be restless, this writer helped res put her legs in the bed and elevated her head slightly, bedside table was near and call light was within reach. res was last toileted by CNA (Certified Nursing Assistant) at 7:30pm without incident, staff notified 911, once here they rolled res over onto her back, and then i (sic) noticed res had a laceration and a hematoma to the right side of her head, res became aggressive with paramedics as they were transferring her from the floor to the cot. res was then transported to the (name of hospital) ER, notified DON, notified (name of daughter), and PCP notified (name of hospital) and gave report to (name) RN. (sic) Review of a nursing note, dated 9/21/2016, indicated nurse was alerted by CNA that res had fallen out of bed, once i (sic) entered the room res was lying on the floor on her right side in fetal position, there was blood coming from her head, this writer unsure where from. res would not respond to verbal communication or physical stimuli, res was conscious, but non verbal, res would not allow staff to do any vitals or look into her eyes. Review of the current care plans indicated the following: Name of Resident C) has had an actual fall and remains at risk for additional falls related to poor balance, unaware of safety needs, cognitive impairment, weakness, incontinence, anxiety, impulsiveness with attempting to get up unassisted. This care plan was dated 7/5/2016. The goal indicated for the resident to resume usual activities without further incident through the review dated. This goal was dated 7/5/2016. Interventions included, but were not limited to: Anticipate and meet (Resident's name) needs. Dated 6/16/2016. The resident needs a safe environment with: a working and reachable call light, the bed in low position at night, personal items within reach. Dated 6/16/2016. (Name of Resident C) is to use Optima chair. Dated 9/22/2016. Bed in low position. Dated 9/6/2016. The care plan lacked any other interventions for the prevention of falls from the bed. Review of current care plans indicated the following: The resident has had an actual fall (with no injury) Poor Balance. This care plan was dated 7/5/2016. The goal for this care plan indicated the resident would resume usual activities without further incident through the review date. This goal was dated 7/5/2016. Interventions added after the fall with injury on 8/5/2016 included the following: Attempt to keep in a common area while up. Dated 9/6/2016. Ensure resident has proper cushions in w/c (wheelchair) per OT (Occupational Therapy) recommendation while up in wheelchair. Dated 8/9/2016. Scoop mattress to bed. Dated 9/6/2016. On 9/7/2016 the Resident was placed in a broda chair. On 9/1/2016 Occupational Therapy discharged the Resident and placed her in an Optima Chair. No other interventions were initiated to prevent falls from the bed. Review of a nursing note, dated 9/5/2016 at 1:47 p.m., indicated Res. has wet-sounding cough. Speech therapy alerted. Res. eats small amounts and spits out food and throws drinks. Res. threw drink at breakfast and soaked CNA. Res. reached across table and threw another drink at lunch. Res. was pulled up in geri-chair several times this shift. Res. flops legs over side and slides herself back down. Lifted with (person's name), and this nurse, and several CNAs throughout shift. Res. threw pillow and blankets off several times, even though nurses' station was very cool. Review of a nursing note, dated 9/6/2016 at 12:13 p.m., indicated Res alert. Tolerating medications well with no s/s (signs or symptoms) of adverse reaction. Res. was up in geri-chair for breakfast. Res. frequently flops legs over side of geri-chair and slides down in chair. Res lifted up in chair several times this shift. Res. occasionally leans forward in chair. Res. was fed this morning. Res. frequently throw sunglasses and blankets on floor and will throw drinking glasses full of fluids if allowed to do so. During an interview on10/11/2016 at 3:14 p.m., CNA #6 indicated I checked on her around 7:30 p.m. and all that day she kept flopping her legs over the side of the bed. I did bed checks around 9:30 p.m. to 9:35 p.m. and the door was open and I saw her lying on the floor with blood all around her. CNA #6 indicated the Resident often tried to get out of bed unassisted. We don't have side rails anymore so I just kept putting her back in bed. I did put a pillow up against her. Another CNA said it was just a matter of time before she fell out of the bed. She was even doing it in her chair. During an interview on 10/12/2016 at 10:22 a.m., LPN #1 indicated Last time I worked was 9/19/2016 before her fall. I feed her twice a day on average. I didn't see her in bed very much, she was usually up. She did have agitation. She would constantly throw her legs over the side of the geri chair. We would lift her back up in the chair and reposition her. During an interview on 10/12/2016 at 9:05 a.m., CNA #4 indicated, Yes I have taken care of her before. She tried to get out of her bed more than her chair, but yes, she would try. She would normally roll herself. She was known to hang her legs over the side of the bed or chair. Not difficult to reposition. But she would not stay in that position for long. I heard she rolled out of the bed the last time. We were told to keep her comfortable. We had to check on her a lot more frequently. We checked on her frequently like every hour and sometimes more than that. During an interview on 10/12/2016 at 3:45 p.m., the Director of Nursing indicated the facility had no further information to provide. 2. The clinical record for Resident B was reviewed on 10/11/2016 at 9:54 a.m. The [DIAGNOSES REDACTED]. The most current Quarterly Minimum Data Set (MDS) assessment, dated 9/10/2016, was reviewed on 10/11/2016 at 9:54 a.m. Resident B received the following Activities of Daily Living (ADL) assistance; bed mobility and ambulation - minimal assist with physical assist of 1 person; transfers and dressing - extensive assist with physical assist of 1 person; toilet use and personal hygiene - extensive assist with physical assist of 1 person. The Resident had impaired range of motion in both the upper and lower extremities on 2 sides. The Resident had a BIMS (Brief Interview for Mental Status Score) of 3 out of 15, indicating severe cognitive impairment. Review of the clinical record indicated the record lacked any elopement risk assessment and any care plan for elopement. Review of the nursing note, dated 10/1/2016 at 4:15 p.m., indicated Res (resident) outside building, walking on access road to parking lot, approached res and asked what she was doing res stated, 'Well, I decided to run away but I didn't think it through very well because I forgot my shoes and my walker,' res was assisted back into building, upon checking her ankle her wanderguad was no longer in place. Applied new/active wanderguard to (R) (right) ankle. Assisted res to room and given snack, is not exit-seeking at this time. (sic) Review of the facility investigation indicated Resident B was seen walking down the 500 hall in the back of the building on 10/1/16. The hall had a security door at the end of the hallway. During an interview on 10/11/2016 at 1:41 p.m., LPN # 9 indicated she was on duty at the time of the Resident's elopement. LPN #9 indicated this was her first time working in the facility. She also indicated several alarms were going off and she had to ask staff what the alarms meant. LPN #9 indicated she was not aware Resident B had eloped until she was brought back into the facility. During an interview on 10/11/2016 at 3:00 p.m., LPN #7 indicated she had been out of the facility on break when she noticed someone walking with difficulty. I was outside on my break in my car. I saw someone having a problem getting her foot up on the curb. She was wearing a sweat suit and socks, but had no walker and no shoes. She normally isn't active until about 8:00 p.m. LPN #7 indicated she approached the person and discovered it was Resident B. LPN # 7 then redirected the Resident and returned her to the facility. During an interview on 10/12/2016 at 9:05 a.m., CNA #4 (Certified Nursing Assistant) indicated the secured door alarms will trigger if visitors hold the door open too long. When we hear the door alarms we are supposed to immediately check them and check the surrounding areas. We are to report it to the management. During an interview on 10/12/2016 at 3:34 p.m., the Administrator indicated the alarm system was in working order at the time of the elopement. The alarms did sound, but the staff had a delayed response. During an interview on 10/12/2016 at 9:34 a.m., CNA #3 indicated if the door alarms sound, staff do a head count to see if any resident exited the facility, then report any missing residents to the nurse. During an interview on 10/12/2016 at 3:34 p.m., the Director of Nursing indicated Resident B never had a wanderguard until the elopement. The nurse documented her (Resident B) wanderguard was missing but she never had a wanderguard. This Federal tag relates to Complaint IN 327. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure appropriate interventions were in place to prevent falls for 1 of 3 residents reviewed for accidents. This deficit practice resulted in the fracture of the left distal clavicle in 1 resident. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/6/2016 at 12:55 p.m. The [DIAGNOSES REDACTED]. The most current Quarterly Minimum Data Set (MDS) assessment, dated 7/11/2016, was reviewed on 9/6/2016 at 12:55 p.m. Resident B received the following Activities of Daily Living (ADL) assistance; extensive assist with 1 person physical assist for dressing bathing and hygiene and extensive assist with 1 person physical assist for toileting. Resident B had impaired range of motion in both the upper and lower extremities on 2 sides. Resident B had been assessed as having severe cognitive impairment. Review of the clinical record indicated Resident B fell on the following dates: 7/5/2016 with no injury, 8/1/2016 with no injury and 8/17/2016 with injury (bruising to face and laceration to nose). Review of the hospital discharge notes indicated Resident B had been seen in the emergency roiagnom on [DATE] for a fall with injury (fractured clavicle). Review of the nursing notes, dated 8/1/2016 through 8/17/2016, indicated Resident B was found on the floor lying on the left side on 8/1/2016 at 8:50 p.m. The note indicated Resident B was assessed, family and MD were notified. The nursing note lacked any documentation of immediate fall prevention interventions. The nursing notes lacked any documentation of the fall on 8/5/216. Review of a nursing note dated 8/5/2016 at 2:44 p.m., indicated the NP had been contacted at 10:10 a.m. regarding a bump on the left side of Resident B's head. Orders for an immediate CT of the head was ordered. The note further indicated Resident B was holding the left arm, grimacing (sic) and verbalizing pain. The NP was again notified and Resident B was sent to the emergency room for evaluation and treatment. The nursing note lacked any documentation in regards to how Resident B fell or any interventions put in place after the fall. Review of Resident B's current care plans indicated the following: Resident is High risk for falls r/t Unaware of safety needs, cognitive impairment, weakness, incontinence: . This care plan was dated 6/16/2016. The goal indicated for Resident B would not sustain serious injury through the review date. This goal was dated 6/17/2016. Interventions included: Anticipate and meet opals (sic) needs. Dated 6/16/2016. The resident needs a safe environment with: a working and reachable call light, the bed in low position at night, personal items within reach. Dated 6/16/2016. Maintenance to check safety and function of w/c (wheelchair). Dated 8/17/2016. Resident to use optima Chair (sic). Dated 8/22/2016. The care plan lacked any other interventions addressing the root cause of the falls or even addressing the unwitnessed fall of 8/5/16. Review of Resident B's current care plans indicated the following: The resident has had an actual fall (with no injury) Poor Balance. This care plan was dated 7/5/2016. The goal for this care plan indicated Resident B would resume usual activities without further incident through the review date. This goal was dated 7/5/2016. No interventions or root cause analysis were documented after the fall on 8/5/2016. Interventions added after the fall with injury on 8/9/2016 included the following: Attempt to keep in a common area while up. Dated 9/6/2016. Ensure resident has proper cushions in w/c per OT recommendation while up in wheelchair. Dated 8/9/2016. Scoop mattress to bed. Dated 9/6/2016. Review of the CNA kardex on 9/6/2016 at 2:00 p.m. indicated the Special Instructions lacked any information related to how Resident B transferred or use of any devices such as a gait belt. During an interview on 9/6/2016 at 1:49 p.m., CNA #1 indicated the CNA's used the information in the task sheets (computer documentation) to know how to provide care for the residents. We look it up on the kiosk. I always ask if I have a new patient or did someone leave at the beginning of my shift. CNA #1 indicated the information in the kiosk would indicate if the resident required any assistive devices and the number of staff for assist with transfers. During an interview on 9/6/2016 at 2:24 p.m., CNA #4 indicated all the information regarding resident care was in the kiosk. During an interview on 9/7/2016 at 10:46 a.m., RN #3 indicated the resident care information in the kiosk should have been updated routinely. The information is not complete. There should be information on how the resident transfers, any assistive devices needed like lifts. It should tell how many staff are needed for toileting, transfers and the such. During an interview on 9/7/2016 at 12:23 p.m., CNA #9 indicated resident care information was on the kiosk. I always read the kardex (kiosk) before I start. I can also go to my nurse and ask if I have questions. During an interview on 9/7/2016 at 1:11 p.m., the Assistant Director of Nursing indicated the kardex information for the CNA's in the kiosk was not complete. The ADON acknowledged the information in the kiosk should reflect the current MDS information but did not. It is a problem I have identified and am currently working on improving. We should have had better interventions in place and followed them. Then perhaps (name of Resident B) might not have fallen the second time. The ADON provided an inservice given to all nursing staff to address the lack of appropriate interventions for fall prevention and documentation. The inservice included the following: .What is you (sic) new intervention? You need to have an IMMEDIATE intervention for EVERY fall and document it in the nurses note along with notification of MD and family. Look at HOW and WHY they fell . (no shoes, wet floor, self-transfer, etc.) During an interview on 9/7/2016 at 1:20 p.m., the Administrator indicated the incident reports lacked any interventions put in place after a fall. That is something we will address. This Federal tag relates to Complaint IN 407. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a system was in place to monitor nutritional interventions ordered to prevent further weight loss for 1 of 2 residents (Resident #D) reviewed who had lost weight and failed to ensure a resident was given replacement nutrition for food uneaten during [MEDICAL TREATMENT] treatments for 1 of 1 [MEDICAL TREATMENT] resident (Resident #B reviewed for nutritional services in a sample of 6. Findings include: 1. The clinical record for Resident #D was reviewed on 12/3/14 at 1:40 p.m. [DIAGNOSES REDACTED]. The clinical record indicated the resident received hospice services. A significant change Minimum Data Set (MDS) assessment, dated 9/30/14, indicated Resident #D was severely cognitively impaired and required the assistance of the staff for all activities of daily living. A health care plan problem, revised on 7/29/14, indicated Resident #D was at nutritional risk due to diabetes mellitus, dysphagia, depression, and diuretic use. One of the approaches for this problem was for the staff to encourage and assist as needed to consume all foods and/or supplements and fluids offered at and between meals. Weight records for Resident #D indicated the resident weighed 124.2 pounds on 9/5/14 and 113.2 pounds on 11/18/14. The weight record indicated this was a 7.5% weight loss during that time period. A dietary telephone order, dated 11/21/14, indicated the Registered Dietician (RD) had evaluated the resident and made the following recommendations: Pro Mod (a protein supplement) 30 cc (cubic centimeters) three times daily, frozen nutritional treat 2 times daily with lunch and dinner, and cottage cheese with lunch related to weight loss and wounds. The clinical record indicated these orders were obtained on 11/24/14. The clinical record lacked any documentation of the extra cottage cheese and/or frozen nutritional treats having been given as ordered by the physician related to the resident's weight loss. The DON was interviewed 12/4/14 at 3:20 p.m. Additional information was requested related to the lack of documentation of the weight loss interventions noted for Resident D. She indicated interventions given by the nursing staff between meals or during medication passes were recorded on supplement consumption records and/or medication records. She indicated weight loss interventions given with meals were not monitored and she had no information to provide to document they had been provided as ordered and/or accepted. 2. The clinical record for Resident #B was reviewed on 12/3/14 at 12:30 p.m. [DIAGNOSES REDACTED]. The clinical record indicated the resident had been admitted to the hospital from the [MEDICAL TREATMENT] center on 12/1/14 due to bleeding from the [MEDICAL TREATMENT] graft site. A quarterly MDS assessment, dated 9/26/14, indicated Resident #B required extensive assistance of one staff member for eating. A health care plan problem, revised on 12/1/14, indicated Resident #B was at nutritional risk due to [DIAGNOSES REDACTED]. A health care plan problem, dated 7/5/14, indicated the resident needed to be up for meals, was "unable to feed herself in order to prevent malnutrition and prevent choking hazard, staff to feed res at meals in intermediate dining room". Weight records for Resident #B indicated the resident weighed 167.4 pounds on 6/21/14 and 156 pounds on 10/2/14. The weight record indicated this was a 7.5% weight loss during that time period. The weight record indicated the resident weighed 148.6 pounds on 11/26/14. The weight record indicated this was a 10% weight loss since the 6/21/14 weight was recorded. This indicated the resident had lost 18.8 pounds from 6/21/14 through 11/26/14. The clinical record indicated the resident went out to the [MEDICAL TREATMENT] center 3 times a week for [MEDICAL TREATMENT] treatments. A dietary timeline record, provided by the Registered Dietician (RD) on 12/4/14 at 2 p.m., included, but was not limited to, the following: "...8/1/14 - Weight review/[MEDICAL TREATMENT] review Determined at this review resident was not receiving sack lunch at [MEDICAL TREATMENT]. Spoke with Renal Dietician due to reports of not eating sack lunch. [MEDICAL TREATMENT] to assist with set up of meals... ...11/21/14 - Weight review/[MEDICAL TREATMENT] review Called Renal Dietitian due to reports of resident not receiving sack lunch again. Resident was placed on alert charting for sack lunch...." A RD nutritional note, dated 11/21/14 at 2:15 p.m., included, but was not limited to, the following: "...Resident goes to [MEDICAL TREATMENT] M, W, F (Monday, Wednesday, and Friday). Resident is on CHO (carbohydrate) controlled/high protein renal diet with variable po (oral) intake 25-100%. Resident receives sack lunch on [MEDICAL TREATMENT] days.... Resident does not always consume sack lunch d/t (due to) vision problems at [MEDICAL TREATMENT]. Resident is on alert charting for sack lunch. Should resident return from [MEDICAL TREATMENT] without consuming sack lunch, writer is to be notified so nutrition can be provided and [MEDICAL TREATMENT] notified...." A RD nutritional note, dated 11/24/14 at 10:50 a.m., included, but was not limited to the following: "Spoke with dietician at [MEDICAL TREATMENT] regarding resident's behavior and eating habits while at [MEDICAL TREATMENT]. Resident tends to return to facility with sack lunch not consumed.... Resident has vision problems and [MEDICAL TREATMENT] center sets her up for lunch once [MEDICAL TREATMENT] begins. Dietician stated resident tends to sleep and cry through [MEDICAL TREATMENT]. If resident is asleep they let her sleep. If resident is awake they set up the sack lunch for resident. Resident does not respond well to set up. Resident will tend to leave food in front of her untouched...." The November 2014 food consumption record for Resident #B lacked any information related to the amount of the sack lunch consumed by the resident during the noon meal on her [MEDICAL TREATMENT] days. The record contained the letters "OF" where the percentage of meal eaten should be recorded. The code key indicated this meant the resident was "unavailable" for the meal. RN #1 (the Unit Manager for Resident #B's unit) was interviewed on 12/4/14 at 9:45 a.m. She indicated the resident had severe vision impairment. The resident required assistance with eating. The [MEDICAL TREATMENT] center would assist with setting up the meal at times, but would not assist the resident with eating d/t the nature of their work with blood products. She indicated this had been a long term problem and she had attempted to change the resident's [MEDICAL TREATMENT] times, but had been unable to do so. RN # 1 also indicated the sack lunch was frequently returned to the facility uneaten or partially eaten. Staff were supposed to offer replacement to the resident if needed. There was no system in place to record the amount of food eaten a [MEDICAL TREATMENT] or any food replaced for the amounts uneaten when the sack lunch was returned. She thought the resident's daughter had been going to the [MEDICAL TREATMENT] center to assist her with her meal, but the daughter had moved and she had no idea if she was still assisting the resident or not. The problem of the sack lunch returning unopened had been much worse over the last 7-10 days. The RD was interviewed on 12/4/14 at 11:05 a.m. She had talked with the dietician at the [MEDICAL TREATMENT] center on several occasions. She was unaware of the resident's daughter ever going to [MEDICAL TREATMENT] to feed the resident. The [MEDICAL TREATMENT] center would set up the sack lunch if the resident was awake, but would not feed her. She further indicated she had been notified that the sack lunch was coming back uneaten and had put the resident on alert charting about 10 days ago so the meal could be replaced if uneaten. She had been notified only one time during that time period that the resident had returned with the sack lunch uneaten. This federal tag relates to Complaint IN 549 and IN 017. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure treatments to pressure wounds were maintained and/or completed as ordered to promote healing of the wounds and prevent contamination from fecal matter resulting in a worsening of the pressure ulcers and increased potential for infection for 1 of 3 residents reviewed for pressure ulcer treatment in a sample of 6. (Resident #D) Findings include: During an observation with LPN #4 on 12/8/14 at 8:45 a.m., Resident #D was resting in bed. The dressing on her left heel was checked by LPN #4. The dressing was dated 12/6/14 and contained the initials of (LPN #10). The dressing change was completed by LPN #3 and LPN #4. The old dressing, dated 12/6/14, was removed, the wound cleansed, and the new treatment and dressing applied as ordered. LPN #3 dated and initialed the new dressing on the left heel. The area on the left heel was measured during the completion of the treatment. LPN #3 indicated the wound measured 3 cm by 3 cm. This indicated a worsening of the wound since it was measured on 12/4/14. The wound to the resident's right lower buttock was also observed on 12/8/14 at 9:10 a.m. LPN #3 and LPN #4 removed the resident's incontinent brief so the wound could be observed. No dressing was in place on the resident's wound on the right lower buttock. The wound was open to the brief and a smear of fecal matter was noted in the brief and in contact with the open wound. The brief was checked and no loose dressing was present in the brief. The wound on the resident's right lower buttock was measured during the observation above. The wound measured 5.5 cm by 3 cm. The center of the wound was gray and was indicated by LPN #3 to be "slough". The wound was cleansed and the treatment completed as ordered on [DATE]. The new dressing was dated 12/8/14 and LPN #3 initialed the dressing. A smaller excoriated area was noted above the larger wound. It measured 2.5 by 2 cm. Both areas were covered by the dressing. LPN #3 and LPN #4 were interviewed on 12/8/14 at 9:30 a.m. They indicated no CNA had notified them that the dressing was not in place on the wound when peri care was last given. They indicated they were unaware the wound was undressed until the observation made at this time. The clinical record for Resident #D was reviewed on 12/3/14 at 1:40 p.m. [DIAGNOSES REDACTED]. The clinical record indicated the resident received hospice services. A significant change Minimum Data Set (MDS) assessment, dated 9/30/14, indicated Resident #D was severely cognitively impaired and required the assistance of the staff for all activities of daily living. A health care plan problem, dated 11/14/14, indicated Resident #D had a unstageable ulcer to the right buttock related to diabetes, impaired mobility, incontinence, and friction. One of the approaches for this problem was for the staff to administer treatment per the physician's orders [REDACTED]. A skin risk assessment, dated 11/13/14, indicated Resident #D had a score of 13. This indicated the resident was at moderate risk for development of pressure ulcers. A Nurse Practitioner (NP) note, dated 12/4/14, indicated Resident #D had a pressure ulcer on her left heel. The note indicated the area measured 2.0 centimeters (cm) by 2.0 cm. The note indicated the area was "unstageable". The treatment order for this area, dated 12/4/14, indicated the staff were to apply a [MEDICATION NAME] dressing (a medicated dressing) to the left heel daily and cover with [MEDICATION NAME] (a dressing to help protect the wound and keep the [MEDICATION NAME] dressing in place). The NP note also indicated the resident had an open area on her right hip. The note indicated the area measured 4.0 cm by 4.0 cm. A treatment order, dated 12/4/14, indicated the previous treatment was being discontinued and new order was written for Normagel (a spongy gel dressing) to the hip wound daily covered by a [MEDICATION NAME] dressing. The December, 2014 Treatment Administration Record (TAR) for Resident #D indicated the treatment on the left heel was initiated on 12/4/14 as ordered by the physician. The TAR indicated the treatment was completed by (initials of LPN #10) on 12/6/14 which is consistent with the date and initials on the dressing observed on 12/8/14. The December, 2014 TAR also indicated the dressing was changed on 12/7/14 by (initials of RN #11). This date and initials are not consistent with the date and initials observed on the dressing on 12/8/14. This indicated the treatment was not completed as charted on 12/7/14. Review of the current facility policy, dated 1/2013, titled "Skin Practice Guide", provided by the DON on 12/8/14 at 10:45 a.m., included, but was not limited to, the following: "...Wound Management Treatments Dressing selection is based upon wound type tissue type need to contain exudate need to protect wound bed need to minimize pain treatment goals protection of peri-wound area ... Dressing changes are performed using non-sterile, clean techniques unless otherwise ordered by the attending physician.... ...documentation --completion of treatments are documented on the Treatment Administration Record immediately after being performed. dressings are dated and initialed...." This federal tag relates to Complaint IN 549 and IN 017. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure 4 of 4 residents reviewed were supervised when traveling off facility grounds in their wheelchairs on busy city streets. (Residents A, B, C, and D). This had the potential to affect an additional 9 residents who were identified by the facility as being independent and allowed to travel off the facility grounds in their wheelchairs after signing out on LOA (leave of absence). The facility further failed to ensure 4 of 4 residents reviewed were assessed for safe smoking and were smoking in a safe area. (Residents A, B, C, and D). This had the potential to affect an additional 9 residents who were identified by the facility as being independent smokers. This resulted in an immediate jeopardy. The immediate jeopardy began on 6/14/12, when 8 residents were observed off the facility grounds, traveling on a busy street in their wheelchairs, with traffic slowing or swerving to avoid hitting them. The DoN (Director of Nursing) was notified of the immediate jeopardy on 6/14/12 at 12:50 P.M. The immediate jeopardy was removed on 6/15/12 but noncompliance remained at the lowered scope and severity level of pattern no actual harm with potential for more than minimal harm that is not immediate jeopardy Findings include: Observations of the two facility parking areas and the street connecting them on 6/14/12 included the following: 9:30 A.M.: Resident B was observed at the edge of the front parking lot by the street smoking independently. When Resident B finished smoking, he propelled himself through the parking lot to the front entrance of the facility. A car entering the parking lot had to swerve to miss hitting him. There were no facility staff present. 10:05 A.M.: Resident A and Resident D were observed traveling down a public street from the front parking lot to the back parking lot in their wheelchairs. They stopped for a minute in the middle of the street, then went on to the back parking lot and began smoking at the edge of the parking lot, partially in the street. During this observation, several cars had to slow down as they passed the residents in the street. 10:50 A.M.: Residents A, B, and D were observed traveling in their wheelchairs down the same public street, and Resident B was in the middle of the street. A backhoe (construction equipment) had to slow and then swerve to miss hitting these residents. 11:20 A.M.: There was a large, covered, enclosed, outdoor smoking area observed on the facility grounds with receptacles for cigarette butts and ashes, and benches outside the main hall near one of the facility dining rooms. 12:10 A.M.: Resident B and Resident C were observed in the front parking lot smoking. Two cars had to slow and swerve to miss these residents as they traveled across the parking lot. Both residents had oxygen equipment on their wheelchairs. Resident C had his oxygen nasal cannula tubing lying on his lap. The oxygen was turned off. Resident B had his nasal cannula tubing in place in his nostrils, but said it was turned off so he "would not blow up." Both residents said they don't smoke with their oxygen running. 12:35 P.M.: Resident D was observed traveling down the same public street in her wheelchair. There were no staff present for any of the above observations. This street was a side street (Monticello), but there were several business locations along the street and at the end of the street. There was a moderate amount of traffic on this street from 9:30 A.M. through 12:35 P.M., including cars, trucks, a bus, and construction equipment. There was one street light at the front parking lot, and one street light 100 feet past the back parking lot. There was a small overhead light at the side entrance door near the front parking lot, but no other lighting along Monticello street. Tall trees obscured both street lights making this street very dark at night. There were no sidewalks, no bike lanes, and no shoulders or berms along the street in front of the facility and the side street. None of the wheelchairs for these residents had lights, reflectors, or flags. At 12:10 P.M., there were more than 200 cigarette butts observed along the edges of the front parking lot; most of them in dry, brown grass and dry, brown leaves surrounding the parking lot. a. Review of the clinical record for Resident A on 6/14/12 at 11:45 A.M., indicated the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had signed out LOA (leave of absence) 7 times in May, and 3 times in June. There was no documentation the resident had signed back in to the facility for 7 of those LOA absences. A quarterly MDS (Minimum Data Set) assessment, dated 6/11/12, indicated this resident had a BIMS (Brief Inventory of Mental Status) score of 15. This score indicated the resident was alert and oriented. There was no assessment of the resident being able to smoke safely without supervision, and no care plan for smoking independently or traveling off grounds in a wheelchair independently. b. Review of the clinical record for Resident B on 6/14/12 at 12:50 P.M., indicated the resident was admitted to the facility on [DATE]. The resident had signed out LOA 14 times in June. On June 10, he signed out at 6:00 A.M. None of the other sign out entries were marked A.M. or P.M., so it was not possible to determine what time of day or night he was LOA. There was no documentation the resident had signed back in to the facility for 8 of those LOA absences. A quarterly MDS (Minimum Data Set) assessment, dated 6/4/12, indicated this resident was alert and oriented. There was no care plan for smoking independently or traveling off grounds in a wheelchair independently for this resident. A patient education record form, dated 6/8/12, indicated: "safe smoking education re (sic) O2 (oxygen) tank and usage on LOA." There was no documentation the resident was assessed for safe smoking or traveling in a wheelchair off grounds. c. Review of the clinical record for Resident C on 6/14/12 at 1:00 P.M., indicated the resident was admitted to the facility on [DATE]. The resident had signed out LOA 3 times in May and none in June. There was no documentation the resident had signed back in to the facility for any of those LOA absences. A quarterly MDS (Minimum Data Set) assessment, dated 6/5/12, indicated this resident had a BIMS score of 9, and was not always alert and oriented. There was no care plan for smoking independently prior to 6/14/12, and no care plan for traveling off grounds in a wheelchair independently for this resident. There was no documentation the resident was assessed for safe smoking or traveling in a wheelchair off grounds. Resident C had diagnoses' including but not limited to: Alzheimer's dementia, seizure disorder, falls, and debility. d. Review of the clinical record for Resident D on 6/14/12 at 1:10 P.M., indicated the resident had signed out LOA 28 times in June. There was no documentation the resident had signed back in to the facility for 5 of those LOA absences. There was no documentation of A.M. or P.M., so it was not possible to determine what time of day or night the resident was LOA. A quarterly MDS (Minimum Data Set) assessment, dated 5/17/12, indicated this resident was alert and oriented with a BIMS score of 15. There was no documentation the resident was assessed for safe smoking or traveling in a wheelchair off grounds. There was no care plan for smoking independently or traveling off grounds in a wheelchair independently for this resident. This resident was admitted to the facility on [DATE]. Review of the current policy and procedure for "Leave of Absence Patient," dated 3/2010, and provided by the DoN on 6/14/12 at 11:40 A.M. included, but was not limited to the following: "...Procedure: Patient, if own responsible party, signs out of the center on the leave of absence form including the current date, time, and anticipated time of patient return...Upon return to the center, the patient or individual that accompanied the patient to the center signs the patient back into the center on the leave of absence form including the date and time of return." An interview with Residents B and C on 6/14/12 at 12:10 P.M., indicated both residents were upset they had to leave the facility to smoke. They both said the facility changed their smoking policy in January 2012 and residents are no longer allowed to smoke on facility grounds. Resident C said staff members smoke in their cars in the parking lot, then tell the resident' they can not smoke there. An interview with Resident D on 6/14/12 at 12:35 P.M., indicated she was upset the facility had no smoking area for them. She said residents who can smoke independently should have their own safe place to smoke. An interview with the DoN on 6/14/12 at 11:40 A.M., indicated residents in the facility that are independent can sign out LOA and travel on the public streets to the Village Pantry or a nearby tobacco shop in their wheelchairs. The DoN provided a list of 13 residents in the facility who were authorized to do this on a regular basis 24 hours per day, 7 days per week. The two streets residents had to travel to the Village Pantry were main thoroughfares, and heavily traveled by cars, trucks, buses, and other vehicles. The DoN confirmed both businesses were approximately one half mile from the facility. The DoN indicated the facility had been concerned about the safety of residents traveling this route and had contacted their legal services department regarding this issue. She said the legal department informed them if the residents signed themselves out LOA, the facility could not prevent the residents from leaving the facility grounds on their own. The DoN indicated there were 9 residents in the facility who needed supervision to smoke, and they were the only residents who were permitted to smoke in the covered, enclosed smoking area on grounds, after the facility became "smoke free" on January 1, 2012. The DoN had no additional documentation Residents A, B, C, and D were assessed for their ability to leave the facility unsupervised, or to smoke unsupervised. The DoN indicated residents in the facility who were independent did not have assessments or care plans for smoking or traveling off grounds because the facility believed it was not necessary. The immediate jeopardy that began on 6/14/12 was removed on 6/15/12 when the facility completed assessments and care plans, and implemented a new policy and procedure for smoking and LOA, but the noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the plan of correction had not been fully monitored on a regular ongoing basis. This federal tag is related to Complaints IN 723 and IN 781. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure [MEDICAL CONDITION] suctioning every 4 hours as ordered by the physician to maintain an airway, which resulted in respiratory distress, unresponsiveness, and [MEDICAL CONDITION] requiring resuscitation and hospitalization for 1 (Resident A) of 4 residents among the sample of 5, reviewed for [MEDICAL CONDITION] care. Findings include: The facility's ,[DATE], Respiratory: Suctioning-Nasal, Oropharyngeal and Tracheostormy Policy was provided by the Director of Nursing [DATE]. The purpose was to remove secretions from the pharynx, trachea and bronchi, to maintain a patent airway, decrease the potential for infection, and stimulate the cough reflex. Family member #1 of Resident (A) was interviewed by telephone at 1:45 p.m., [DATE]. Family member #1 indicated on [DATE], following the respiratory distress and [MEDICAL CONDITION],the emergency room (ER) physician had said a lack of oxygen over several minutes had led to a [MEDICAL CONDITION] ([MEDICAL CONDITION], or stroke) causing brain damage. Family member #1 indicated the ER physician had explained a new [MEDICAL CONDITION] (trach) required suctioning more than ,[DATE] times a day, and if not done, would result in aspiration. Family member #1 indicated the ER physician had also said [MEDICAL CONDITION] clogged with thick secretions, with no place to go, and had shut off the air way of Resident (A). The record of Resident (A) was reviewed at 3:15 P.M., [DATE], and indicated a [DATE], admission with [DIAGNOSES REDACTED]. The initial [DATE], physician orders [REDACTED]. The orders were changed on [DATE], to suction and lavage of [MEDICAL CONDITION] 4 hours and as needed. The ,[DATE]-[DATE], treatment administration record (TARS) indicated the suctioning and lavage were completed every 4 hours through 6:00 A.M., [DATE]. Documentation did not indicate the [DATE], 10:00 A.M., suctioning of [MEDICAL CONDITION] done. A [DATE], 12:35 P.M., nursing note, documented by Licensed Practical Nurse (LPN #1) indicated Resident (A) was being changed by staff and began having a, "panic attack." Documentation [MEDICAL CONDITION] was performed. .LPN #1 documented she was unable to suction the trach. Documentation indicated the nurse practitioner (NP #1) was called to the room and lavaged the resident. Resident (A) became unresponsive, compressions were started, and 911 was called. Resident (A) was transported to the hospital by the emergency medical service (EMS). At 1:40 P.M., [DATE], a visit was made to the hospital. The Registered Nurse (RN) Medical Unit Manager (#1) indicated Resident (A) had been transferred to her unit from intensive care following a [MEDICAL CONDITION]. RN Unit Manager (#1) indicated family member #1 had requested Resident (A) not return to the facility due to concerns with [MEDICAL CONDITION]. The review of the [DATE], hospital record included the EMS 12:30 P.M.,record with documentation the nursing staff had initiated cardio [MEDICAL CONDITION] resuscitation (CPR) prior to their arrival. The EMS noted a radial pulse. An electro cardiogram (ECG) monitor was placed and indicated a sinus [MEDICAL CONDITION](rapid rate). The EMS documented when in Medic 2 during transport, the crew suctioned [MEDICAL CONDITION] an occlusion was removed. The [DATE], ER report indicated respiratory and [MEDICAL CONDITION] on arrival with oxygen saturation levels in the 50s. Documentation indicated when [MEDICAL CONDITION] was attempted, Resident (A) again had [MEDICAL CONDITION] and CPR was given. Documentation indicated after [MEDICAL CONDITION] changed to a #7 endo-tube, Resident (A) immediately had good breath sounds and the oxygen saturation increased to 96%. The ER physician documented the trachea had a large mucous plug distally. The physician also documented [MEDICAL CONDITION] had been defective when Resident (A) had been seen in theER on [DATE], and was not inflatable. The primary [DIAGNOSES REDACTED]. LPN #1 was interviewed by telephone at 3:55 P.M., [DATE]. LPN #1 indicated Resident (A) had gestured she did not [MEDICAL CONDITION] at 10:00 A.M., [DATE]. LPN #1 indicated Resident (A) was not congested and there was no respiratory trouble at the time. LPN #1 indicated she had honored the preference of Resident (A) and had omitted the suctioning. The DoN was interviewed at 4:30 P.M., [DATE]. The DoN indicated honoring a resident's choice for refusal of suctioning would be permissible if there were no secretions or respiratory problems. The DoN indicated protocol would be to re-approach the resident within an hour after the refusal, assess, and re-attempt to suction the trach. This federal tag relates to Complaint IN 572. 3XXX,[DATE](a)(5)