Every finding on record at Belltower Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure physician orders were carried out timely for 1 of 3 residents reviewed for urinary tract infection. (Resident B). Finding includes:On 10/27/25, Resident B's medical record was reviewed. Diagnoses included but were not limited to dementia, type 2 diabetes, morbid obesity, chronic obstructive pulmonary disease, rheumatoid arthritis, urinary tract infection, hypertension, history of breast cancer, depression, and chronic kidney disease.Resident B's most recent comprehensive Minimum Data Set (MDS) assessment was a Quarterly assessment dated [DATE]. The Assessment indicated Resident B was able to communicate with others, made herself understood and understood others, had moderate cognitive impairment, and demonstrated no negative behaviors. The resident required substantial assistance for personal hygiene, toileting hygiene, bathing, and partial assistance for transferring, was frequently incontinent of bladder and bowel and was at risk for pressure sores, but did not pressure sores at the time of the evaluation. Resident B also utilized a wheelchair for locomotion.Resident B's Physician Order Report included but was not limited to the following orders,Nephrology appointment on 8/22/25 at 1:30 P.M., facility to transport. Obtain a UA (urinalysis) dip and if positive send to the lab for culture and sensitivity testing, for a urinary tract infection, dated 9/17/25.Obtain a UA with culture and sensitivity testing if indicated, post antibiotic treatment for urinary tract infection, dated 10/6/25. Resident B's Nurse's Progress Notes included but were not limited to,9/23/25 at 8:50 A.M., related to the order to collect urine for testing on 9/17/25, indicated the urine had been obtained, had been sent to the lab, and the facility was waiting for the test results.9/24/25 at 11:03 A.M. the progress note indicated UA results were received and now waiting for the culture results.10/09/25 at 5:28 A.M., relating to the order to collect urine for testing on 10/6/25, indicated a urine specimen was collected, and the lab was called for pick up.10/10/25 at 2:09 P.M., the note indicated the UA results were received, the physician was notified, and the facility was waiting for results from the culture and sensitivity.10/16/25 at 5:29 P.M., indicated the UA test results had been faxed to Resident B's nephrologist on 10/15/25.10/17/25 at 3:56 P.M., Resident B was seen by the nephrologist and orders were received to begin Cipro 500 mg by mouth every day for 14 days for an urinary tract infection.Review of a urinalysis result, dated 9/22/25, indicated a urine sample was collected from the resident on 9/22/25 at 8:00 P.M. and indicated the presence of bacteria. The test had been sent for culture testing.Review of a urinalysis result, dated 10/9/25, indicated a urine sample was collected from the resident on 10/9/25 at 5:00 A.M. and indicated the presence of bacteria and had been sent for culture testing.On 10/29/25 at 3:00 P.M., test results for the culture and sensitivity from orders on 9/17/25 and 10/6/25 were requested from the Director of Nursing, but were not provided.During an interview on 10/29/25 at 1:10 P.M., the Administrator indicated Resident B had not been transported to her Nephrology consult appointment on 8/22/25 because of scheduling confusion. The Administrator indicated the resident should have been transported to the appointment by facility transportation as ordered. The Administrator indicated there was a delay in collecting Resident B's urine for testing on 9/17/25 and on 10/6/25 and that culture and sensitivity results had taken longer than facility policy's expectations.During an interview on 10/29/25 at 3:00 P.M., the Director of Nursing indicated there had been a delay in collecting Resident B's urine for testing that was ordered on 9/17/25 because collecting urine from the resident was difficult. She indicated the urine was not collected until 9/22/25 and had been sent to the lab for testing and was found to be positive for infection on 9/24/25. The Director of Nursing indicated the results were sent on for culture and sensitivity testing as ordered, to determine the appropriate antibiotic for treatment. The Director of Nursing was not certain when the culture results had been received by the facility, but an antibiotic was initiated on 9/26/25 per a physician's order. The Director of Nursing indicated the urine sample should have been collected when ordered and there had been a delay from the time of the order to the collection of the urine. The Director of Nursing indicated when the physician ordered the urinalysis on 10/6/25, the sample was not collected until 10/9/25 and again there had been a delay in collecting the urine for testing. The Director of Nursing indicated the culture and sensitivity result for the urinalysis order on 10/6/25 was not received until 10/17/25 and was positive for infection. The Director of Nursing indicated the facility had not request an order for the culture and an order was not made to collect urine samples through a catheter. The Director of Nursing indicated urine culture results often took six days to obtain and that nursing standards indicated test results should have been obtained in 24 to 48 hours after the urine had been received by the laboratory.During an interview on 10/29/25 at 3:29 P.M., the Nurse Practitioner indicated the facility had not notified her of the delay in obtaining urine samples for the urinalysis ordered on 9/17/25 or 10/6/25 and that the time between the order and the collection time was delayed. The Nurse Practitioner indicated there had been a long delay in receiving the culture and sensitivity results and those results should have been obtained in one to two days after the urinalysis results were received. The Nurse Practitioner indicated when urine samples were difficult to obtain, straight catheterization was an option. She indicated she had not ordered a straight catheterization because she was not aware of the delays in the urine collection.On 10/29/25 at 2:00 P.M., a policy titled, LEADERSHIP POLICIES AND PROCEDURES.TRANSPORTATION POLICY was provided by the Administrator indicating it was the current facility policy. The policy indicated, .The Facility Provides safe and efficient transportation as available. to meet patient and resident needs.Transportation is provided for medical appointments.On 10/29/25 at 2:00 P.M., a policy titled Physician Orders was provided by the Director of Nursing indicating it was the current policy. The policy indicated, .The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines.On 10/29/25 at 3:00 P.M., policies regarding following physician orders for urinalysis testing were requested but not provided.This citation relates to Intake 2650865. 3.1-37(a)(b)

Based on observation, interview and record review, the facility failed to store food in a sanitary manner related to undated and unlabeled foods and drinks for 1 of 1 kitchen areas observed. (Main kitchen) This issue had the potential to affect 82 of 83 residents who consumed food from the kitchen. Finding includes: During an initial tour of the kitchen, on 6/2/2025 at 9:50 A.M. with the Dietary Manager (DM), the following foods were observed in the walk-in cooler undated, unlabeled or expired: -a container of blue liquid, undated and unlabeled. -2 unopened packages of bologna with a use or freeze by date of 5/1/2025. -half a turkey breast, wrapped in saran wrap, undated and unlabeled. On 6/2/2025 at 10:30 A.M., the following foods were observed in the walk-in freezer undated or unlabeled: -2 Ziploc bags containing a pastry-rolled food item, undated and unlabeled. -1 bag of artichoke dip, unlabeled and undated. -multiple pieces of fish wrapped in saran wrap, unlabeled and undated. -a white piece of meat wrapped in saran wrap, unlabeled and undated. -a steak wrapped in saran wrap, unlabeled and undated. During an interview, on 6/2/2025 at 10:50 A.M., the Dietary Manager indicated all food products should have been dated and labeled and expired products thrown away. On 6/3/2025 at 10:45 A.M., the Dietary Manager provided a policy titled, Food Safety in Receiving and Storage dated 6/20/2023 and indicated the policy was the one currently used by the facility. The policy indicated .Food will be received and stored by methods to minimized contamination and bacterial growth .are properly covered, labeled, dated with a use-by date .Mark them clearly to indicate the date by which the food shall be consumed or discarded .The day of preparation or day original container is opened shall be considered day 1 . 3.1-19 (i)(3)

Based on record review and interview, the facility failed to ensure an allegation of abuse resolution was followed regarding care assignments for 1 of 3 residents reviewed for abuse. (Resident C) Finding includes: A record review for Resident C was completed on 5/8/2025 at 8:45 A.M. Diagnoses included, but were not limited to: dementia, psychosis, anxiety disorder and narcolepsy. A Quarterly Minimum Data Set (MDS) assessment, dated 2/20/2025, indicated Resident C had moderate cognitive impairment and required substantial/maximal assistance of one staff member for showers and transfers. A facility reported incident investigation was completed and sent to the Indiana Department of Health on 4/16/2025. The report indicated an insurance case manager had interviewed Resident C and he had reported he felt unsafe and did not like CNA 2 (certified nursing assistant) who cared for him. As a result of the investigation, Resident C was informed CNA 2 would no longer be assigned to care for him. Resident C was satisfied with the resolution. Point of Care documentation (electronic CNA documentation of care provided) indicated CNA 2 had completed care for Resident C on 4/23/2025, 4/28/2025 and 4/29/2025. The care areas included bathing, bed mobility, transfers and toilet use. During an interview, on 5/8/2025 at 9:42 A.M., LPN 3 indicated Resident C preferred that CNA 2 not care for him. During an interview, on 5/8/2025 at 10:24 A.M., Resident C indicated CNA 2 used to scream and yell in his ear. He indicated he got rid of CNA 2, but CNA 2 had continued to provide care for him. During an interview, on 5/8/2025 at 10:41 A.M., CNA 4 indicated CNA 2 worked on the hallway, where Resident C resided, by herself routinely. She indicated she was not aware if there were any residents for whom CNA 2 was not to provide care. A policy was provided on 5/8/2025 at 11:45 A.M., by the Executive Director. The policy titled, Abuse, Neglect, Exploitation, or Mistreatment, indicated, .6. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident .Investigation .G. Measures taken to prevent future incidents This citation relates to Complaint IN00457672 3.1-28(e)

Based on record review and interview, the facility failed to follow a physician's order when administering blood pressure medication for 1 of 6 residents reviewed for quality of care. (Resident E) Finding includes: A record review for Resident E was completed on 5/7/2025 at 11:28 A.M. Diagnoses included, but were not limited to: vascular dementia, cerebral infarction (stroke) hypertension and atrial fibrillation. An admission Minimum Data Set (MDS) assessment, dated 2/7/2025, indicated Resident E had severe cognitive impairment. A Nurse Practitioner Note, dated 4/4/2025, indicated Resident E's hypertension was chronic, stable and staff were to monitor Resident E's blood pressure closely. A Care Plan, initiated on 2/3/2025 and updated on 5/7/2025, indicated Resident E had hypertension and received antihypertensive medication. The goal was to promote vascular perfusion with the blood pressure to be within normal range. The interventions included, but were not limited to: to administer medications as ordered, monitor the medications effectiveness, watch for severe reactions and to report to the physician as needed. A Physician's Order, initiated on 2/2/2025 and discontinued on 4/21/2025, indicated an order for the resident to receive metoprolol tartrate (a beta blocker to decrease blood pressure) 25 milligrams twice daily. A Physician's Order, initiated on 4/21/2025, indicated an order for the resident to receive metoprolol tartrate 25 milligram twice daily with additional orders to hold (the metoprolol tartrate) for a systolic blood pressure less than 100 mmHg and a diastolic blood pressure less than 60 mmHg. Metoprolol tartrate 25 milligrams was given even though the blood pressure readings obtained prior tot he admnistration were below the ordered parameters for administrion on the following days: -4/7/2025 8:38 P.M. 90/53 mmHg (millimeters of mercury) -4/9/2025 9:30 P.M. 88/50 mmHg -4/10/2025 4:49 P.M. 97/60 mmHg -4/11/2025 9:42 P.M. 90/50 mmHg -4/23/2025 4:41 P.M. 93/53 mmHg -4/29/2025 6:54 P.M. 90/58 mmHg -5/6/2025 5:01 P.M. 80/50 mmHg During an interview, on 5/8/2025 at 9:51 A.M., LPN 3 indicated if a systolic blood pressure reading was low, anything under 100-110 mmHg, she would question giving blood pressure medication. She indicated the physicians usually gave parameters on when to hold a blood pressure medication. She indicated if the physician's order indicated to hold the blood pressure medication for a systolic blood pressure under 100 mmHg, she would not give the medication if the resident's blood pressure assessments were below 100 mm/Hg. She indicated if a resident had a systolic blood pressure below 95 mmHg, she would have inform the physician. A policy was provided, on 5/8/2025 at 11:45 A.M., by the Executive Director. The policy titled, Physician Orders, indicated, .The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines .Medication/Treatment 1. The facility should not administer medications or biologicals except upon the order of a physician/prescriber lawfully authorized to prescribe them 3.1-37(a)

Based on observation, interview and record review, the facility failed to store and prepare food in a sanitary manner related to expired leftovers, open and undated food in the walk-in cooler and skillets with missing Teflon for 1 of 1 kitchens reviewed. This had the potential to affect 69 of 69 residents who received their meals from the kitchen. Findings include: During the initial kitchen tour on [DATE] at 9:00 A.M with the Certified Dietary Manager (CDM), the following was observed in the walk-in cooler: -A plastic container with pasta noodles dated, [DATE]. -An opened jar of jalapenos with no opened on or use by dates. -An opened jar of enchilada sauce with no opened on or use by dates. -An opened bag of whipped topping with no opened on or use by dates. -3 cups of mixed berries with no made on or use by dates. -3 cups of yogurt with no made on or use by dates. During the initial kitchen tour with the CDM on [DATE] at 9:20 A.M., three skillets utilized by the facility for preparing meals were found to be scratched and missing some of the Teflon coating. During an interview on [DATE] at 9:25 A.M., the CDM indicated all food that was prepared should have been labeled with a made on date and an expiration date. All jars and containers should be labeled with opened on and expiration dates once opened and left overs should have been disposed of after three days. Skillets with scratches and missing Teflon should not be used and should have been thrown away. The facility does not have a policy related to the condition of the cookware used by the facility. On [DATE] at 10:40 A.M., the CDM provided a policy, dated, [DATE], and titled, Nutrition Policies and Procedures and identified it as the policy currently used by the facility. The policy indicated, .Temperature Control for Safety leftovers are discarded after 3 days unless otherwise indicated .All foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to develop a care plan regarding communication needs for 1 of 1 residents reviewed for Communication and Sensory Needs (Resident 39) and accident hazards for 1 of 1 residents reviewed for Accidents. (Resident 56) Findings include: 1. A record review for Resident 39 was completed on 7/24/2024 at 9:53 A.M. Diagnoses included, but were not limited to, cerebral infarction, neoplasm of the lower jaw bone, and occlusion and stenosis of the right carotid artery. A Quarterly Minimum Data Set (MDS) assessment, dated 7/5/2024, indicated Resident 39 was moderately cognitively impaired, his vision and hearing were adequate, his speech was sometimes understood and he sometimes understood others and he required substantial to maximal assistance from staff for bed mobility needs. The Progress Notes, since he was admitted , indicated Resident 39 was unable to use the call light and staff anticipated his needs. The care plan lacked a problem, goal, or interventions related to the resident's inability to use the call light or the provision of an alternate method to communicate his needs. During an interview on 7/24/2024 at 1:27 P.M., CNA 6 indicated Resident 39 was sometimes able to use the call light. He was able to verbally communicate and called out if he needed anything but if he was angry and yelling, he was hard to understand. She checked on him throughout the shift. During an interview on 7/23/2024 at 11:52 A.M., the resident was not able to answer the surveyor's questions. During an interview on 7/24/2024 at 2:09 P.M., Resident 39 was able to speak. He indicated he was able to push the call button for help but was unable to activate the call button when he attempted to demonstrate his ability to utilize the call light.He indicated he called out for help when he needed it and he was confident if he called out, someone would come. During an interview on 7/25/2024 at 1:53 P.M., Unit Manager 2 indicated the facility had not thought of using a touchpad type of call light. The resident's inability to use the call light should have been on the care plan. During an interview on 7/26/2024 at 2:45 P.M., the Executive Director (ED) indicated the facility did not have a policy that addressed accommodation of needs. 48145 2. During an interview on 7/22/2024 at 10:04 A.M., Resident 56 indicated she cooked all of her own meals in her air fryer in her room and doesn't eat the facility's food. Her brother took her to the store to buy food once a week. During an observation on 7/22/2024 at 10:10 A.M., Resident 56 had an air fryer on a table in her room, plugged in to the electric outlet. There was a spatula hanging from the wall above the air fryer. Resident 56's record review was completed on 7/22/2024 at 10:50 A.M. Her diagnoses included, but were not limited to: type 2 diabetes mellitus and hypertension. A Quarterly Minimum Data Set Assessment (MDS) dated , 6/25/2024, indicated the resident had moderate cognitive impairment. Resident 56's record lacked the documentation she had regarding a Care Plan to address her ability to cook in her room with an air fryer or a Care Plan regarding she had refused to follow the facility's rules about cooking in her room. There were no notes documented in her record referring to education or noncompliance related to using an air fryer in her room. During an interview on 7/24/2024 at 11:10 A.M., CNA 4 indicated she knew Resident 56 cooked in her room and was not aware the resident should not cook in her room. During an interview on 7/24/2024 at 11:30 A.M., CNA 5 indicated staff knew when Resident 56 was cooking because they could smell her food. CNA 5 had never been told Resident 56 should not cook in her room. CNA 5 indicated she did not help Resident 56 cook or clean up after cooking. Duringm an interview with the Unit Manager (UM) 3, completed on 7/24/2024 at 12:11 P.M., she indicated Resident 56 was not allowed to use an air fryer in her room. In the past, Resident 56 had been educated on not cooking in her room, but the resident was not compliant with cooking in her room. There was not a Care Plan regarding using an air fryer or for refusing to follow the facility's policy on cooking in resident rooms. On 7/26/2024 at 2:45 P.M., the Executive Director provided a policy dated, 5/5/2023 and titled, Care Plan Process, Person-Centered Care, and identified it as the policy currently used by the facility. The policy indicated, .The facility will develop and implement a baseline and comprehensive care plan for each resident includes the instructions needed to provide effective and person-centered care of the resident . 11. The person-centered care plan includes: . B. Problem . E. Interventions, discipline specific services and frequency F. Refusal of services and/or treatments 1) Evaluation of resident's decision-making capacity 2) Educational attempts 3) Attempts to find alternative means to address the identified risk/need 3.1-35(a)

Based on interview, observation and record review, the facility failed to keep ensure Resident 56's environment was free of potential hazards for 1 of 1 resident reviewed for environmental hazards. (Resident 56) Finding includes: During an interview on 7/22/2024 at 10:04 A.M., Resident 56 indicated she cooked all of her own meals and does not eat the facility's food. Her brother takes her to the store to buy food once a week. An observation was completed on 7/22/2024 at 10:10 A.M. Resident 56 had an air fryer on a table, plugged in to the electric outlet. There was a spatula hanging on the wall above the air fryer. Resident 56's record review was completed on 7/22/2024 at 10:50 A.M. Her diagnoses included, but were not limited to: type 2 diabetes mellitus and hypertension. A Quarterly Minimum Data Set Assessment (MDS) dated , 6/25/2024, indicated the resident had moderate cognitive impairment. Resident 56's record lacked the documentation she had a Care Plan to address her ability to cook in her room or a Care Plan indicating she had refused to follow the facility's policy regarding cooking in her room. During an interview on 7/24/2024 at 11:10 A.M., CNA 4 indicated she knew Resident 56 cooked in her room and was not aware the resident should not cook in her room. During an interview on 7/24/2024 at 11:30 A.M., CNA 5 indicated staff knew when Resident 56 was cooking because they could smell her food. CNA 5 had never been told Resident 56 should not cook in her room. CNA 5 indicated she did not help Resident 56 cook or clean up after cooking. During an interview with the Unit Manager (UM) 3, completed on 7/24/2024 at 12:11 P.M., she indicated Resident 56 was not allowed to use an air fryer in her room. In the past, Resident 56 had been educated on not cooking in her room but the resident was not compliant with facility's policy on cooking in her room. During an interview on 7/24/2024 at 1:20 P.M., the Corporate Regulation Specialist indicated all electric devices brought into the facility should be tested by the Maintenance Department remove and and add . She was unsure if the air fryer had been inspected. She indicated Resident 56 should not cook in her room. During an interview on 7/29/2024 at 11:10 A.M., the Maintenance Director indicated he had not inspected the air fryer for safety and Resident 56 should not cook in her room. On 7/24/2024 at 2:30 P.M., the Executive Director provided a policy dated, 3/2006 and titled, Maintenance/Housekeeping policies and procedures and identified it as the policy currently used by the facility. The policy indicated, .Written Criteria, which include equipment for life support, infection control, environmental support and equipment support elements are used to identify inclusion in the program .All equipment shall be evaluated for inclusion into the program prior to use 3.1-45(a)

Based on observation, record review and interviews, the facility failed to ensure a care plan meeting was conducted timely and care plans revised timely for 4 of 19 residents reviewed for careplanning. (Resident 15, 39, 58 and179) Finding includes: 1. The record for Resident 15 was reviewed on 8/14/2023 at 12:30 P.M. Resident 15 was admitted to the facility with diagnoses included, but not limited to: nontraumatic subarachnoid hemorrhage, atherlosclerotic heart disease, chronic atrial fibrillation, hyperlipidemia, type 2 diabetes mellitus, mild cognitive impairment of uncertain or unknown etiology, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and insominia. The Quarterly, MDS (minimum data set) assessment, completed on 6/20/2023, indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for bathing needs, had not transferred out of bed, had two stage 3 unhealed pressure ulcers, and an indwelling urinary catheter. During an interview with a representative from Resident 15's Hospice provider, conducted on 8/10/2023 at 11:43 A.M., she indicated Hospice usually attended the care plan meetings with the facility but she could not determine the date of the last coordinated care plan meeting. The care plan documentation from Resident 15's clinicial record indicated the last care plan meeting was conducted in January 2023. During an interview with the Social Service Director, on 8/14/2023 at 11:40 A.M., she indicated the resident was supposed to have had a care plan meeting on 6/30/2023 but she was on vacation and the meeting was not conducted. 38845 2. During an interview, on 8/11/2023 at 11:55 A.M., the Assistant Director of Nurses (ADON) indicated Resident 39 had a non - pressure area to the right buttocks, and a deep tissue injury to the left heel. During an observation, on 8/11/2023 at 11:57 A.M., the following was observed on the left heel: a dark purple area approximately 1 x 1/2. The ADON indicated at times the aides would put a pillow under the legs. The area was measured on Wednesday 8/9/2023, and measured 2.2 cm x 2.5 cm. During an interview, on 8/11/2023 at 11:58 A.M., Resident 39 indicated when I asked them (aides) to put the pillow under my legs they have an attitude and feel like they don't have time. The resident indicated she did not have the area before she fell and fractured her hip. A record review was completed on 8/11/2023 at 2:29 P.M. Resident 39's diagnoses included, but were not limited to: hypertension, fractured hip, anxiety, depression, chronic pain, fibromyalgia and rheumatoid arthritis. A 5-day MDS (Minimum Data Set) assessment, dated 7/19/2023, indicated Resident 39 required extensive assist of 1 staff for bed mobility, transfers, dressing, toilet use and limited assist for eating. A Nurse's Note, dated 7/13/2023 at 6:30 A.M., indicated Resident 39 complained of pain to the left heel this AM.The resident continues to rest in her recliner with lower extremity on hard surface of leg rest. Redness blanchable noted to the left heel. The physician was notified with new orders for skin prep, heel protector and elevating the left lower extremity. Heel protector applied, left lower leg elevated with pillows and resident encouraged to keep it elevated. Resident stated pain relief after treatment started Current Physician Orders included the following: Order date of 7/13/2023 to elevate/float heels while in bed. Order date of 7/17/2023 for a Heel cup to the left heel and to change weekly. Order date of 7/26/2023 to cleanse with normal saline and apply betadine daily to the left heel. A current Care Plan, dated 7/26/2023, indicated the resident has a DTI (deep tissue injury) to her left heel. Interventions included, but were not limited to: Assess and record the condition of the skin surrounding the pressure. Assess the pressure ulcer for location, stage, size length, width, and depth, presence/absence of granulation tissue and epithelization weekly. Conduct a systematic skin inspection weekly. Report any signs of further skin breakdown Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry, and wrinkle free. A Nurse's Note, dated 7/17/2023 at 3:36 P.M., indicated .a skin assessment was completed, noted DTI (deep tissue injury) to the left heel. MD notified and new orders noted for Sure prep (protective barrier) and heel cup, change weekly During an interview, on 8/11/2023 at 3:31 P.M., the Director of Nursing indicated there should have been new interventions put into place when she came back after her surgery and the care plan was not updated and should have been. 44111 3. A record review for Resident 58 was completed on 8/8/2023 at 9:15 A.M. Diagnoses included, but not limited to: type 2 diabetes, hypertension, difficulty walking and muscle weakness. During an interview, on 8/8/2023 at 9:42 A.M., Resident 58 indicated she does not have care plan meetings. The electronic medical record under the care conference section indicated that she had a care plan meeting on 3/16/2023 and 6/20/2022. During an interview, on 8/9/2023 at 10:22 A.M., the Social Service Director indicated she did not have a care conference in June of 2023 or December of 2022, and she should have. They follow the Minimum Data Set Assessment schedule. There was no documentation in the medical record that they met as a team to review her plan of care. 4. A record review for Resident 179 was conducted on 8/10/2023 at 9:30 A.M. Diagnoses included, but were not limited to: unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, quadriplegia, persistent vegetative state, dysphagia following nontraumatic intracranial hemorrhage, gastrostomy status, and contracture of muscle sites-Bilattwrist (bilateral wrist), hip, knee, ankle. A Care Plan, dated 8/28/2018, indicated, [Resident name] has a history of UTI and is at risk for future infections r/t [related to] incontinence. During an interview, on 8/10/2023 at 2:30 P.M., the MDS coordinator indicated she should have revised/resolved the urinary incontinence care plan when he received the foley catheter. On 8/9/2023 at 10:57 A.M., the Social Service Director provided a policy titled, Person Centered Care Plan, dated 10/19/2017, and indicated the policy was the one currently used by the facility. The policy indicated .8. Social Service staff notifies patient/resident and his/her legal representative prior to each care plan meeting and invites them to attend the meeting in order to solicit his/her input. If the patient/resident or their legal representative is unable to attend, the care plan will be reviewed with the patient/resident or their legal representative and their responses will be promptly documented 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety. This deficient practice had the potential to affect the 80 of 82 residents who received food from the kitchen. Findings include: 1.During a tour of the kitchen, conducted on 8/7/2023 at 7:29 A.M. to 7:44 A.M., with the Dietary Manager, the following was observed: - In the dry storage there was an open bag of heath toffee candy pieces and bag of nachos undated. -The freezer had a bag of hash browns and jalapeno poppers not sealed. - The reach in refrigerator had 2 open gallons all items without an open date. During an interview, on 8/7/2023 at 7:43 A.M., the Dietary Manager indicated that all items should have an open date and the 2 items in the freezer should have been sealed properly. 2. During a tour of the nourishment rooms on 8/14/2023 between 10:04 A.M. to 10:13 A.M., with the Dietary Manager, the following was observed: -The long term care room had a container with vegetables/salad in a plastic shopping bag without a name or date, and a bottle of prune juice and 2 pitchers of juice without an open date. - The refrigerator temperatures posted on the appliance was missing entries for 8/12/2023 and 8/13/2023. During an interview, on 8/14/2023 at 10:06 A.M., the Dietary Manager indicated that the food could have been a staff members lunch and the juice should have bend dated. And that his staff oversees checking the refrigerator temperatures twice a day and they did not this past weekend. 3. During an observation, on 8/14/2023 at 10:08 A.M. of the Rehab nourishment room the following was observed: - The refrigerator had an open bottle of prune juice, 2 pitchers of juice and 2 cartons of thicken liquids without open dates. -Temperature monitoring submissions for the following dates: 8/5/2023, 8/6/2023, 8/12/2023 and 8/13/2023. During an interview, on 8/14/2023 at 10:13 A.M., the Dietary Manager indicated the liquids should have been dated when open/made and his staff oversaw monitoring the refrigerator temperatures twice a day and they did not 8/5/2023, 8/6/2023, 8/12/2023 and 8/13/2023. On 8/9/2023 at 1:39 P.M., the Director of Nursing provided a policy titled, Nutrition Policies and Procedures, SUBJECT: Food Safety In Receiving And Storage, revised 6/20/2023, and indicated the policy was the one currently used by the facility. The policy did not address the labeling of an item when it is open. On 8/14/2023 at 2:25 P.M., the Dietary Manager provided a policy titled, Nutrition Policies And Procedures, SUBJECT: Nourishment/Snacks, revised 6/20/2023, and indicated the policy was the one currently used by the facility. The policy indicated .5. Store bulk nourishments in a separate refrigerator from medications. Temperature control is monitored at least twice daily for all nourishment room refrigerators and/or freezers. Anything in the nourishment room that is not properly labeled and dated will be discarded 3.1-21(i)(3)

Based on observation, record review and interviews, the facility failed to ensure the medication regimen was free from unnecessary medication for 2 of 5 residents reviewed for medication use. (Resident 15 regarding monitoring of medications and 51 regarding antibiotic use) Findings include: 1. The record for Resident 15 was reviewed on 8/9/2023 at 9:52 A.M Resident 15 was admitted to the facility with diagnoses included, but not limited to: nontraumatic subarachnoid hemorrhage, atherlosclerotic heart disease, chronic atrial fibrillation, type 2 diabetes mellitus, , hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, morbid obesity, neuromuscular dysfunction of the bladder, dysphasia. The Quarterly MDS (Minimum Data Set) assessment, completed on 6/20/2023 indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for bathing needs, had not transferred out of bed, had two stage 3 unhealed pressure ulcers, and an indwelling urinary catheter The current medications for Resident 15 included Lantus insulin and Tradjenta, medication to treat type 2 diabetes mellitus. There was a Physician's Order indicating a hemoglobin A1C (a laboratory test to determine the effectiveness of the resident's medication and diet in respect to the diabetes disease process) was to have been completed annually but the order had been discontinued and rewritten and there was no Hemoglobin A1C completed in the past 12 months for Resident 15. There was no plan to address the resident's current medication use of Lisinopril and Metoprolol Tartrate, both given to treat hypertension. The last recorded blood pressure for Resident 15 was documented May 28, 2023. The unit manager brought the resident's Hospice binder into the conference room on 8/10/2023 but then realized the most recent note in the binder for Resident 15 was from March 2023. During an interview with the MDS coordinator, on 8/14/2023 at 9:40 A.M. she confirmed there had been no hemoglobin A1C level completed in the past 12 months. 2. The record for Resident 51 was reviewed on 8/8/2023 at 1:51 P.M. Resident 51 was admitted to the facility on with diagnoses included. but not limited to: urinary tract infection, Type 2 diabetes mellitus with diabetic polyneuropathy and moderate, dementia without behavioral disturbance. The Quarterly MDS assessment, dated 7/8/2023, indicated the resident was severely cognitively impaired, required the extensive assistance of two staff for transfers, bed mobility and toileting needs and required the extensive assistance of one staff for w/c locomotion, personal hygiene and dressing needs. The resident's incontinence needs section was not completed on the quarterly review. The current medication regimen for Resident 51 included the antibiotic medication, Macrobid, ordered to start on 8/3/2023 and end on 8/10/2023 to treat a urinary tract infection. A Nursing Progress Note, dated 7/10/2023 at 5:15 A.M., indicated the resident's son had visited the night before and noticed Resident 51's increased confusion and forgetfulness and requested the resident be assessed for a possible urinary tract infection. The note indicated the physician was notified, an order received for a urinalysis with culture and sensitivity if indicated. The sample was collected and the laboratory was notified of the need to pick up the collected sample. The urinalysis was completed and results reported to the facility on [DATE]. The Nurse Practitioner indicated she wanted to wait (to treat) until the culture and sensitivity results were completed. The physician ordered the antibiotic, Levofloxacin, on 7/19/2023 to be given for 8 days to address the resident's urinary tract infection. A Nursing Progress Note, dated 8/3/2023 at 7:17 P.M., indicated the Nurse Practitioner was notified of the resident's urinalysis results and ordered the antibiotic, Macrobid, to be given for 7 days. There was no documentation of a second urinalysis being obtained and no documentation of continued signs and/or symptoms of an urinary tract infection. During an interview with a representative of the laboratory company, on 8/9/2023 at 4:00 P.M., she indicated there was only one urinalysis test ran for Resident 51. The test was received on 7/10/2023 and the culture and sensitivity results were reported to the physician and facility on 7/14/2023. During an interview with the Infectious Preventionist, on 8/14/2023 at 10:19 A M., she indicated the floor nurse thought the fax date on a copy of the urinalysis culture and sensitivity results faxed to the facility, notified the MD and obtained a new antibiotic order in error. The policy and procedure regarding antibiotic orders was requested and not received. An original document regarding the McGreer's system to documenting an infection was presented but the form was completed for the second antibiotic use but utilized the documentation from the 7/10/2023 urinalysis results. 3.1-48(a)(1) 3.1-48(a)(3)

Based on observation, record review and interviews, the facility failed to ensure the comprehensive assessment was accurate and completed for 2 residents reviewed for dental status and bowel and bladder continence . (Resident 1 &51) Findings include: 1. The record for Resident 1, reviewed on 8/10/2023 at 2:54 P.M., indicated the resident was admitted to the facility with diagnosis, including but not limited to: multiple sclerosis, dry mouth and limitation of activities due to disability. The most recent Quarterly Minimum Data Set (MDS) assessment, completed on 6/29/2023, indicated the resident was alert and oriented and there was no indication, under the Oral/Dental Status section of the resident being edentulous (without teeth). Resident 1 was identified as requiring extensive to total staff assistance for activities of daily living, including personal hygiene, transfers and wheelchair locomotion. The significant change MDS assessment, completed 11/2/2022, did not assess the resident as being edentulous. During an interview with Resident 1, on 8/8/2023 at 9:01 A.M., she indicated her dentures were fitting sloppy and she indicated no one was offering to assist her with cleaning her dentures. During an interview with the MDS assessment coordinator, on 8/14/2023 between 8:00 A.M., and 5:00 P.M., she confirmed the MDS assessments were incorrect for Resident 1 regarding her oral status/teeth. 2. The record for Resident 51 was reviewed on 8/9/2023 at 1:51 P.M. Resident 51 was admitted to the facility with diagnosis, including but not limited to: urinary tract infection, type 2 diabetes mellitus with diabetic polyneuropathy, moderate, dementia without behavioral disturbance, lack of coordination, muscle wasting and atrophy multiple sites and muscle weakness. The Quarterly MDS assessment, dated 7/8/2023, indicated the resident was severely cognitively impaired, required the extensive assistance of two staff for transfers, bed mobility and toileting and required the extensive assistance of one staff for w/c locomotion, personal hygiene and dressing needs. The resident's incontinence needs section was not completed on the quarterly review. The Admission MDS assessment, completed on 6/23/2023 for Resident 51, indicated the resident required extensive assistance of two staff for toileting needs and was always continent of her bowels and bladder. There was no bowel or bladder incontinence assessment completed for Resident 51 in the clinical record. The baseline care plan for Resident 51, contained a plan to address the resident's incontinence of bowel and bladder with interventions to assist the resident as needed. During an interview with CNA 13, on 8/10/2023 at 10:04 A.M., she indicated Resident 51 was both continent and incontinent of her bowels and bladder. She indicated the resident was usually aware of her need to void but did not always make it to the bathroom and was often incontinent. During an interview with the MDS coordinator, on 8/14/2023 at 10:04 A.M., she indicated the resident's Admission and Quarterly MDS assessments regarding the bowel and bladder continence section were incorrectly coded and should have reflected Always incontinent not Always Continent. The MDS coordinator confirmed a bowel and bladder incontinence assessment had not been completed. 3.1-31(d)

Based on observation, record review and interviews, the facility failed to ensure nail care was provided for 1 of 6 residents reviewed for Activities of Daily Living (ADL) needs. (Resident 20) Finding includes: A record review was completed for Resident 20 on 8/8/2023 at 3:09 P.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia and dementia without behavioral disturbances. A Quarterly Minimum Data Set assessment, dated 5/15/2023, indicated she was totally dependent for bathing and extensive assist of one with grooming and personal hygiene. A Care Plan, dated 11/15/2023, indicated Resident 20 required assistance with activities of daily living (ADL's) due to cerebral vascular accident with right side hemiplegia. Interventions included: bathing dependent of one staff and dressing extensive assist of one. During an observation, on 8/7/2023 at 11:58 A.M., Resident 20's last 3 fingers on her right-hand curled under, her nails were long and jagged with a brown substance under them and her toe nails were long. During an observation, on 8/9/2023 at 9:34 A.M., Resident 20's last 3 fingers on her right-hand curled under, her nails were long and jagged and both hands had a brown substance under them. During an observation, on 8/11/2023 at 11:00 A.M., Resident 20's last 3 fingers were curled under, her nails were long, jagged and hand brown substance under them. During an interview, on 8/10/2023 at 3:39 P.M., CNA 7 indicated when she gave a shower, she gathered the supplies together then washed the resident's hair and continued down the body, dried the resident off, conducted a skin check, applied lotion, and dressed them. During an interview, on 8/11/2023 at 9:48 A.M., CNA 4 indicated she gathered her linens, informed the resident, she assisted them with washing, hair, nails, shaving, applied lotion then dressing. During an interview, on 8/11/2023 at 9:56 A.M., CNA 8 indicated she gathered linen, informed the resident, and assisted with washing as needed, then dried them off. She charted in the charting system and filled out a shower sheet. On 8/11/2023 at 11:18 A.M., the Regional Nurse indicated they did not have a policy on nail care. 3.1-38(3)(E)

Based on record review and interview, the facility failed to ensure that transfer and discharge paperwork was completed and given to a resident or family members and failed to notify the ombudsman in a timely manner of resident's discharge from the facility for 1 of 1 residents reviewed for notification of discharge. (Resident 76) Finding Includes: A record review was conducted on 8/14/23 at 2:49 P.M., for Resident 76. Diagnoses included, but were not limited to: urinary tract infection, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, malignant neoplasm of uterus, inflammatory disease of uterus. An Admission MDS (Minimum Data Set) assessment, date 5/8/2023, indicated the resident was cognitively intact. A Discharge MDS assessment, dated 7/11/2023, indicated the resident had been discharged with an anticipated return to facility. A Progress Note, dated 7/11/2023 at 4:15 A.M., indicated Resident 76 had a significant change in condition and was sent to the ER (emergency room ). No documentation was available that indicated transfer forms were completed and sent with Resident 76 to the hospital. A Discharge report and email, dated 8/7/2023 at 1:48 P.M., was provided by the Social Services Director on 8/14/2023 at 3:30 P.M., and did not include Resident 76 on the monthly discharge report to the Ombudsman. A Discharge report and email sent to the Ombudsman, dated 8/14/2023 at 3:54 P.M., was provided by the Executive Director which included Resident 76 as being discharged to the hospital. During an interview, on 8/14/2023 at 2:26 P.M., the MDS coordinator indicated that the resident was sent out to the hospital on 7/11/2023. It was unknown if transfer paperwork was sent with Resident 76 as there was nothing in the computer and the resident did not return to the facility. During an interview, on 8/14/2023 at 2:45 P.M., Employee 9 indicated that all transfer and discharge paperwork, including the bed hold paperwork, should be in the computer system, and if not in the computer, it was probably not done as staff has not been consistently completing paperwork. During an interview, on 8/14/2023 at 4:10 P.M., with the Administrator and Director of Nursing indicated there was no copy of transfer paperwork in the chart as paperwork is not duplicated and is sent with a resident when the resident transfers out. The facility would get the packet back when resident returned to the facility. (This resident did not return from the hospital). The Administrator indicated that the Ombudsman was sent a more comprehensive list of discharges for the month of July 2023 which was different from the Social Service Director's list. A current policy was provided by the Regional Nurse, on 8/9/2023 at 11:30 A.M., titled Discharge Notification with a revision date of 10/1/2020. The policy indicated .To specify the limited conditions under which a skilled nursing facility or nursing facility may initiate, transfer or discharge of a resident, the documentation that must be included in the medical record, and who is responsible for making the documentation .the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State long-Term Care Ombudsman and documentation to reflect in the resident's medical record. Document the reasons for transfer or discharge in the resident's medical record .a copy of the transfer/discharge notice must be included in the resident's medical record . Information provided to the receiving provider must include a minimum of the following: contact information of the practitioner responsible for the care of the resident, resident representative information, all special instructions or precautions for ongoing care, comprehensive care plans, diagnoses and allergies, medications and most relevant labs .when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident representative as soon as practicable .Copies of emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis .They facility will keep evidence of monthly notification of Emergent Discharges to the Ombudsman 3.1-12(a)(6)(A)

Based on interview and record review, the facility failed to ensure the Physician Orders for Scope of Treatment (POST) form matched the Physician order for 1 of 82 residents whose Advanced Directives were reviewed (Resident 232). Finding includes: A record review was completed on [DATE] at 1:16 P.M. Resident 232's POST form was signed by the resident on [DATE] indicating to attempt CPR (Cardiopulmonary Resuscitation), and full interventions to meet medical needs. The POST form was signed by the physician on [DATE]. A Physician order, dated [DATE], indicated Resident 232's code status was a DNR (Do Not Resuscitate). A Care Plan, with a start date of [DATE], indicated that Resident 232 had elected a full code status with a goal of directing medical care to make values and treatments known in which stated desires would be honored. Approaches to support Resident 232's code status included, but were not limited to, notifying the physician of resident's desires and any needed physician's order obtained. During an interview, on [DATE] at 2:50 P.M., Employee 12 reviewed Resident 232's chart and indicated that orders stated that Resident 232 was a DNR and that the signed POST form was for a Full Code status. During an interview on, [DATE] at 2:18 P.M., Employee 10 indicated the code status for residents would be found on the face sheet of the residents' chart, and in physician orders. On [DATE] at 2:45 P.M., the DON provided a current policy titled Advanced Directives with no initiation or revision date. The policy indicated .Physician Orders for Life Sustaining Treatment: A form designed to improve patient care by creating a portable medical order form that records patient treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency 3XXX,d+[DATE](I)(7)

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was stored and maintained per professional standards and signage was on the door for 2 of 2 residents reviewed for respiratory care. (Resident 68) Finding includes: A record review was completed for Resident 68 on 8/11/2023 at 9:42 A.M. Diagnoses included. but were not limited to: chronic obstructive pulmonary disease and emphysema. During an observation, on 8/7/2023 at 11:34 A.M., Resident 68 respiratory storage bag was dated 7/28/2023 and oxygen humidifier was very low on water with the same date. During an observation, on 8/8/2023 at 9:35 A.M. the respiratory equipment was still dated 7/28/2023. During an observation, on 8/9/2023 at 9:14 A.M., the respiratory equipment was still dated 7/28/2023. During and observation, on 8/11/2023 at 9:11 A.M. CNA 4 entered the resident's room with a portable oxygen tank, placed the tubing on the machine then wrapped the nasal cannula around the two handles of the wheelchair. During an interview, on 8/11/2023 at 9:19 A.M., CNA 4 indicated she should not have wrapped the tubing around the handles, instead she should have placed it in the bag due to germs. During an observation, on 8/11/2023 at 9:39 A.M., there was no signage on the door that oxygen was in use. During an observation, on 8/12/2023 at 5:15 P.M., there was no signage on the door that oxygen was in use. During an interview, on 8/9/2023 at 9:15 A.M., the Unit Manager 14 indicated that it should have be changed weekly, it was missed. During an interview, on 8/12/2023 at 5:23 P.M., the Unit Manager 15 indicated that a sign should have been on the door that oxygen is in use. A Physician Order, dated 1/5/2023, indicated to change oxygen equipment, tubing/nasal cannula/mask/humidification system weekly. A Physician Order, dated 1/5/2023, indicated to keep oxygen cannula/mask/tubing/and or nebulizer bagged when not in use, every shift. On 8/14/2023 at 2:04 P.M., the Director of Nursing provided a policy titled, Respiratory Policies and Procedures Equipment Change Schedule, dated 4/1/2022, and indicated the policy was the one currently used by the facility. The policy indicated .Nasal Cannula: Change on an as needed basis or per State regulations. Bubbler: change with circuit The policy did not address the storage of oxygen tubing when not in use. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate care of a nephrostomy tube and foley catheter and Physician Orders for treatment for 1 of 1 residents reviewed for urinary and nephrostomy catheter. (Resident 179) Finding includes: A record review for Resident 179 was conducted on 8/10/2023 at 9:30 A.M. Diagnoses included, but not limited to: unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, quadriplegia, persistent vegetative state, dysphagia following nontraumatic intracranial hemorrhage, gastrostomy status, and contracture of muscle sites-Bilattwrist (bilateral wrist), hip, knee, ankle. A Care Plan, dated 7/30/2023, indicated (Resident' first name) requires an indwelling urinary catheter and nephrostomy tube r/t obstructive uropathy. The goal was the following: Resident will have catheter care managed appropriately, as evidenced by: not exhibiting signs of urinary tract infection or urethral trauma. The interventions included: Assess the drainage every shift. Record the amount, type, color, odor. Observe for leakages, Keep catheter system a closed system as much as possible, Nephrostomy and Catheter per MD order, Provide assistance with catheter care, Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine). During an interview, on 8/10/2023 at 9:44 A.M., LPN 3 indicated Resident 179 should have had an order for the foley catheter with size, catheter care, to change monthly, and to irrigate as needed, and she did not see any orders. During an interview, on 8/10/2023 at 9:49 A.M., LPN 3 indicated Resident 179 also did not have a daily dressing change order for his nephrostomy tube. During an observation, on 8/10/2023 at 9:51 A.M., LPN 3 indicated the date on the dressing at the nephrostomy site was dated 8/4 with initials. There was a large clear dressing with visible yellow colored gauze with yellow drainage and a scant amount of blood-tinged drainage. The skin around the ostomy insertion site was noted to be red with blood. A foul odor was noted in the room when she was cleansing the site. During an interview, on 8/10/2023 at 11:04 A.M., LPN 3 indicated Resident 179 was sent out to emergency room (ER) the nephrostomy tube was put in on 6/23/2023 at the hospital they found out he had hydroneprosis and he returned on 6/30/2023 with the nephrostomy tube. A Progress Note, dated 7/22/2023 at 10:00 A.M., indicated he was moaning and facial grimace and a temperature of 100.4, his right nephrostomy tube draining amber urine with visible pus. Physician was notified and was sent to ER. A Progress Note, dated 7/30/2023 at 5:57 P.M., indicated resident returned from the hospital. A Patient Transfer Assessment Form, dated 7/30/2023, indicated he had a urethral catheter. On 8/10/2023 at 10:59 A.M., the MDS Nurse provided a policy titled, Nephrostomy and Cystostomy tube dressing changes, from [NAME] book, dated 2023 and indicated the policy was the one currently used by the facility. The policy indicated .Special considerations: Change the dressings daily and as needed . And a policy titled, Indwelling Urinary Catheter Care and Removal, from [NAME] book, dated 2023 and indicated the policy was the one currently used by the facility. The policy indicated .Provide routine hygiene for meatal care On 8/14/2023 at 9:37 A.M., the Director of Nursing provided a policy titled, Nursing Policies and Procedures SUBJECT: Physician Orders, dated 5/5/2023, and indicated the policy was the once currently used by the facility. The policy indicated .1. The qualified licensed nurse completes an admission medication regiment review from the transfer record form an acute care hospital, home, or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed, 3.1-41

Based on record review, observation and interview, the facility failed to ensure a resident had interventions in place to prevent the development of a DTI (deep tissue injury) skin area for 1 of 4 residents reviewed for pressure ulcers. (Resident 39) Finding includes: During an interview, on 8/11/2023 at 11:55 A.M., the Assistant Director of Nurses (ADON) indicated Resident 39 had a non- pressure area to the right buttocks, and a deep tissue injury to the left heel. During an observation, on 8/11/2023 at 11:57 A.M., the following was observed on the left heel: a dark purple area approximately 1 x 1/2. The ADON indicated at times the aides would put a pillow under the legs. The ADON indicated the area was measured on Wednesday 8/9/2023, and measured 2.2 cm (centimeter) x 2.5 cm. During an interview, on 8/11/2023 at 11:58 A.M., Resident 39 indicated when I asked them (aides) to put the pillow under my legs they have an attitude and feel like they don't have time. The resident indicated she did not have the area before she fell and fractured her hip. A record review was completed on 8/11/2023 at 2:29 P.M. Resident 39's diagnoses included, but were not limited to: hypertension, fractured hip, anxiety, depression, chronic pain, fibromyalgia and rheumatoid arthritis. A 5-day MDS (Minimum Data Set) assessment, dated 7/19/2023, indicated Resident 39 required extensive assist of 1 staff for bed mobility, transfers, dressing, toilet use and limited assist for eating. A Nurses' Note, dated 7/10/2023 at 6:17 P.M., indicated the resident arrived via ground ambulance, transferred to chair by EMS (emergency medical services).Resident returned from [name of hospital] after surgery-fixation left hip IM nailing. Resident is alert and oriented and able to make her needs known, up with walker and 2 assist to pivot to bedside commode. Resident resting with eyes closed in recliner. No signs or symptoms of pain noted at this time A Nurse's Note, dated 7/11/2023 at 5:15 P.M., indicated a follow up skin assessment was completed. Left Hip fracture. Upper surgical area 4 sutures noted, lower left hip 3 sutures noted both surgical areas well approximated. No drainage noted The Note lacked documentation of any assessment of the left heel. An Admission assessment, dated 7/11/2023, indicated a surgical site to the left hip. The Assessment lacked the documentation of a skin assessment being completed on the left heel. A Nurse's Note, dated 7/12/2023 at 5:39 A.M., indicated Resident 39 was in the recliner resting with eyes closed. A Nurse's Note, dated 7/13/2023 at 6:30 A.M., indicated Resident 39 complained of pain to the left heel this AM. The resident continues to rest in her recliner with lower extremity on hard surface of leg rest. Redness blanchable noted to the left heel. The physician was notified with new orders for skin prep, heel protector and elevating the left lower extremity. Heel protector applied, left lower leg elevated with pillows and resident encouraged to keep it elevated. Resident stated pain relief after treatment started. A Nurses's Note, dated 7/15/2023 at 12:36 A.M., indicated BLE ( bilateral lower extremities) elevated and heel protector to left heel in place. Compliant with med's and care and is resting quietly in bed at this time. A Nurse's Note, dated 7/17/2023 at 3:36 P.M., indicated: Skin assessment completed, noted DTI (deep tissue injury) to the left heel, 2 cm (centimeter) x 1 cm. Physician was notified and new orders received for Sure Prep (protective barrier), heel cup (heel protector) and change weekly. A Wound Evaluation and Management Summary, dated 7/19/2023, indicated the resident had an unstageable area to the left heel partial thickness measuring 1.5 x 1.0 cm (centimeters). Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater depth today. Discussed pain and pain management stratigies with the patient, family, and/or care providing staff. Patient not following recommendations to elevate legs. Patient not following repositioning or off loading recommendations. Reviewed off - loading surfaces and discussed care plan. Discussed wound healing trajectory and expectations with patient and/or family The clinical record lacked the documentation to show that Resident 39 was refusing and being non-compliant with the interventions of not off loading her heels. A Nursing Weekly Wound measurement, Date/Time Observed 7/17/2023 at 3:26 P.M. Length - head to toe direction was 2 cm (centimeters). Width - hip to hip direction 1cm Wound healing status: Declining Comments: DTI A Nursing Weekly Wound measurement: Date/Time Observed 7/19/2023 at 7:38 A.M. Length - head to toe direction (centimeters) 1.5 Width - hip to hip direction (centimeters) 1 Comments: unstageable A Nursing Weekly Wound measurement: Date/Time Observed 7/26/2023 at 10:43 A.M. Length - head to toe direction (centimeters) 2 Width - hip to hip direction (centimeters) 2 Wound healing: status Declining Comments: non compliant A current Care Plan, dated 5/19/2023 and revised on 8/8/2023, indicated the resident was at risk for skin breakdown related moisture, and sitting for extended periods of time. Preferred to sleep in a recliner causing additional risk.Interventions included, but were not limited to: .Apply house skin barrier cream as needed. Daily skin inspection by CNA. Weekly skin assessment by nurse. Pressure reducing mattress and labs and diagnostics as ordered. Medications/Supplements as ordered. Notify MD/NP of any new areas. Perform treatment as ordered. Report any decline to wound nurse and wound physician A current Care Plan, dated 7/26/2023, indicated . the resident has a DTI (deep tissue injury) to her left heel. Interventions included, but were not limited to: Assess and record the condition of the skin surrounding the pressure. Assess the pressure ulcer for location, stage, size length, width, and depth, presence/absence of granulation tissue and epithelization weekly Conduct a systematic skin inspection weekly. Report any signs of further skin breakdown Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry, and wrinkle free A current Care Plan, dated 1/28/2018 and revised on 8/8/2023, indicated the resident was at risk for pain/discomfort related to: Fibromyalgia, rheumatoid arthritis, osteoarthritis, history of hip pain, chronic pain, lower back pain. Interventions included, but were not limited to: sleept in recliner for comfort, position for comfort with physical support as necessary. During an interview, on 8/11/2023 at 2:57 P.M., the ADON indicated there were no interventions put into place prior to the resident obtaining the area to the heel. During an interview, on 8/11/2023 at 3:31 P.M., the Director of Nursing indicated there should have been new interventions put into place when she came back after her surgery. On 8/14/2023, a policy for Pressure Ulcer Prevention was requested, but one was not provided prior to the survey exit. This Federal tag relates to complaint IN00411784. 3.1-40

Based on record review and interview, the facility failed to initiate physician signed pharmacy recommendations to decrease a pain medication in a timely manner for 1 of 5 residents reviewed for unnecessary medications. (Resident 39) Finding includes: A record review was completed on 8/11/2023 at 2:29 P.M. Resident 39's diagnoses included, but were not limited to: hypertension, fractured hip, anxiety, depression, chronic pain, fibromyalgia and rheumatoid arthritis. A 5-day MDS (Minimum Data Set) assessment, dated 7/19/2023, indicated Resident 39 required extensive assist of 1 staff for bed mobility, transfers, dressing, toilet use and limited assist for eating. A Pharmacy Consultation Report, dated 1/5/2023, indicated Resident 39 received three or more CNS (central nervous system) medications which can cause an increase risk for fall and fractures. The recommendation was to reevaluate this combination and reduce the dose of Pregabalin (nerve pain medication) to 200 mg (milligrams) BID (twice a day) with the end goal of discontinuation. A Pharmacy Consultation Report, dated 3/6/2023, indicated Resident 39 received three or more CNS medications which can cause an increase risk for fall and fractures. The recommendation was to reevaluate this combination and reduce the dose of Pregabalin to 200 mg BID with the end goal of discontinuation. A Pharmacy Consultation Report, dated 5/7/2023, indicated Resident 39 received three or more CNS medications which can cause an increase risk for fall and fractures. The recommendation was to reevaluate this combination and reduce the dose of Pregabalin to 200 mg BID with the end goal of discontinuation. A Pharmacy Consultation Report, dated 6/7/2023, indicated Resident 39's physician had accepted the pharmacies recommendation to decrease the Pregabalin to 200 mg twice a day on 5/18/2023, but the order has not yet been processed. The recommendation was to please process the accepted pharmacy recommendation and update the medical record accordingly. A Medication Administration Record (MAR), dated May 2023, indicated Resident 39 had received the Pregabalin medication 200 mg three times a day from 5/1/2023 to 5/31/2023. A MAR, dated June 2023, indicated Resident 39 had received the Pregabalin 200 mg three times a day from 6/1/2023 to 6/30/2023. A MAR, dated July 2023, indicated Resident 39 had received the Pregabalin 200 mg three times a day from 7/1/2023 to 7/7/2023. During an interview, on 8/14/2023 at 10:55 A.M., the Director of Nursing indicated the pharmacy recommendation was not followed up timely and should have been. On 8/14/2023 at 4:21 P.M., the Director of Nursing provided the policy titled, Pharmacy Services Policies and Procedures: 1.2 Medication regimen Review, dated 4/1/2022, and indicated the policy was the one currently used by the facility. The policy indicated .6. For non-Urgent recommendations, the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident. Upon receipt of the written Consultant Pharmacist Report of non-urgent recommendations, the DON or facility designee shall provide the report to the attending physician(s) or their designee during the next regularly scheduled visit or within 5 business days, whichever should come first. A. Attending physician or designee should respond to the recommendation within 14 days of the pharmacist's review date, but not later than the Consultant Pharmacist's next monthly MRR (Medical Record Review) 3.1-25(i)

Based on observation, record review and interviews, the facility failed to ensure 1 of 1 residents reviewed for Hospice services, received coordinated care between Hospice and the facility. (Resident 15) Finding includes: Resident 15 was admitted to the facility with diagnoses included, but not limited to: nontraumatic subarachnoid hemorrhage, arteriosclerotic heart disease, chronic atrial fibrillation, hyperlipidemia, type 2 diabetes mellitus, mild cognitive impairment of uncertain or unknown etiology, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, HTN, morbid obesity, neuromuscular dysfunction of the bladder, dysphasia, post COVID 19, depression, constipation, insomnia. On 1/24/2023, major depressive disorder, recurrent, mild was added to his diagnosis list. The Quarterly MDS (minimum data set) assessment, completed on 6/20/2023, indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for bathing needs, had not transferred out of bed during the assessment period, had two stage 3 unhealed pressure ulcers, and an indwelling urinary catheter. During an interview with Resident 15, on 8/8/2023 at 9:50 A.M., he indicated he could not get out of bed because Hospice had taken his Broda chair. He explained he did not feel safe in the high back wheelchair in his room currently, because he just slid out of the chair. He indicated he was working with therapy and when the therapist was ready to work on transfers to the Broda chair, he discovered Hospice had removed the chair from the room. The resident indicated he was looking forward to being able to get out of his bed/room and possibly attend some activities and go outside when his family visited. The current Physician's Orders and Care Plan indicated the resident was receiving Hospice services. A labeled binder at the Nurses' desk, which had the resident's name and Hospice provider on the front, had not been updated since March 2023. During an interview with the Nursing Unit Manager, on 8/10/2023 at 9:30 A.M., the unit manager indicates she did not realize the documentation in the Hospice binder was from February and March 2023 upon review. During an interview with a representative from Resident 15's Hospice provider, on 8/10/2023 at 11:43 A.M it was determined the Hospice provider should have been bringing current clinical notes into the facility every two weeks. She indicated facility's choose whether to have electronic communication or printed documents and this facility was supposed to have been receiving updated , printed notes in the Hospice binder every two weeks. The Hospice representative was unaware the binder had not been updated since March 2023. When queried regarding therapy recommendations and recent services, the representative indicated she was not aware of any approved therapy service for Resident 15. The Hospice provider usually sent their own therapy consultants. The representative did confirm the Broda chair had been removed by Hospice because the resident was not utilizing the chair. She was unaware of any attempts made to request the chair be brought back for the resident's use. When asked if Hospice participated in any care plan meetings with the facility and the resident, they indicated they did but could located or give the most recent care plan meeting they had attended for Resident 15. During an interview with the SSD, on 8/14/2023 at 11:40 A.M., she indicated the resident was supposed to have had a care plan meeting on 6/30/2023 but she was on vacation and the meeting was not completed. Review of facility documentation indicated Resident 15 had a care plan meeting with Hospice participation in January 2023 and had not had a care plan meeting since January. The facility contract with the Hospice provider for Resident 15 indicated the following service to be provided by the Hospice company: .2.3 Information/Documentation provided to Facility on admission and on-going, including: .Most recent POC (plan of care) .Copies of clinical notes after each visit; .2.4 IDT (Interdisciplinary team) Designate a member of each IDT that is responsible for a patient who is a resident of the Facility the designated member is responsible for providing overall coordination of the Hospice care of the patient with the facility reprentative and communicating with Facility representatives and other Hospice to ensure quality of care for the patients/family; 3.1-37

Based on observation, record review and interviews, the facility failed to ensure care plans were developed for 2 of 19 residents reviewed for care planning. (Residents 1 for dental care and Resident 15 Diabetes, Diuretic, anithypertensive and Vitamin D medication use) Findings include: 1. The record for Resident 1, reviewed on 8/10/2023 at 2:54 P.M., indicated the resident was admitted to the facility with diagnoses, included but not limited to: multiple sclerosis, dry mouth and limitation of activities due to disability. The Quarterly Minimum Data Set (MDS) assessment, completed on 6/29/2023, indicated the resident was alert and oriented and there was no indication, under the Oral/Dental Status section of the resident being edentulous (without teeth). The Significant Change MDS assessment, completed 11/2/2022, did not assess the resident as being edentulous. The current health care plans for Resident 1 included a plan to assist the resident with activities of daily living but the plan was not specific to what kinds of oral/dental assistance the resident needed. During an interview with Resident 1, on 8/8/2023 at 9:01 A.M., she indicated her dentures were fitting sloppy and she indicated no one was offering to assist her with cleaning her dentures. The most recent dental exam for Resident 1, completed on 3/11/2020, recommended the resident use adhesive to ensure her dentures were fitting properly During an observation and interview with CNA 14, on 8/11/23 at 9:58 A.M., she thought the resident had dentures but when she was asked if she had assisted the resident with denture care, she changed her mind and said maybe she has her own teeth. When asked to show where the resident's dental care equipment was located, CNA 14 walked into the resident's bathroom and could not locate any dental care equipment. CNA 14 then looked around room and could not locate any dental care supplies. Finally, Resident 1 indicated she thought she had some denture cleansing tablets she had purchased in a three drawer plastic cabinet. CNA 14 opened the top drawer of the cabinet and and there was a box of denture cleansing tablets shoved to the back of the drawer. Resident 1 was interview on 8/8, 8/9, 8/10 and 8/11 after she had received morning care regarding dental care and she indicated she had not been offered and/or assisted with denture care. During an interview with the MDS assessment coordinator, on 8/14/2023 between 8:00 A.M. and 5:00 P.M., she confirmed the MDS assessments were incorrect for Resident 1 regarding her oral status/teeth and she confirmed there was no care plan regarding denture care needs for Resident 1. 2. The record for Resident 15 was completed on 8/8/2023 at 11:45 A.M. Resident 15 was admitted to the facility with diagnoses, included but not limited to: nontraumatic subarachnoid hemorrhage, arteriosclerotic heart disease, chronic atrial fibrillation, type 2 diabetes mellitus, hypertension, and dysfunction of the bladder. The Quarterly MDS (minimum data set) assessment, completed on 6/20/2023 ,indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for bathing needs, had not transferred out of bed, had two stage 3 unhealed pressure ulcers, and an indwelling urinary catheter The current Physician's Orders for medications, included, but were not limited to: a vitamin D supplement, Lantus insulin (a diabetic medication), Lasix (a diuretic medication) , Lisinopril (a medication to treat high blood pressure) Metaprolol Tartrate (a medication to treat high blood pressure, and Trajenta (a diabetic medication). There was no care plan to address the resident's diabetes, vitamin D deficiency, hypertension or diuretic medication use. During an interview with Employee 16, an OT1 on 8/10/2023 at 9:39 A.M., he indicated he had been working with the resident for approximately two weeks in May and when he was ready to work on transfers and chair positioning in the Broda reclining chair, the Hospice staff had removed the chair from the resident's room. He indicated he had requested multiple times for nursing to contact the Hospice staff in regards to the chair, but the chair had not been returned. There was no plan regarding the resident's need for a Broda chair. During an interview with the MDS coordinator, on 8/14/2023 at 9:45 A.M., she confirmed there was no care plan regarding hypertensive, vitamin D and diuretic medication use, no care plan regarding diabetes and no care plan addressing the resident's Broda chair needs. 3.1-35(a) 3.1-35(b)(1)

Based on observation, record review and interviews, the facility failed to ensure preventative pressure ulcer measures were implemented consistently and pressure ulcer treatments were completed as ordered for 2 of 3 residents reviewed for pressure ulcers and/or skin issues (Resident D and F). This deficient practice resulted in the development of an unstageable and Stage 3 new pressure ulcer for Resident F. Findings include: 1. During an observation on 3/22/2023 at 9:51 A.M., Resident F was observed to be lying in bed with on an air mattress. The right foot had a Prevalon boot in place, and the left leg was on a pillow, but the heels were not floated off the mattress. During an observation on 3/22/2023 at 3:19 P.M., the right foot had a Prevalon boot in place, and the left foot was resting on the air mattress. The pillow was on the floor. The record for Resident F was reviewed on 3/22/2023 at 10:47 a.m. Diagnoses included, but were not limited to: Diabetes Mellitus, morbid obesity, and hemiplegia. A Braden Scale for Predicting Pressure Sore Risk on 3/1/2023, indicated Resident was at moderate risk for pressure ulcer development. On 1/13/2022 an unstageable pressure ulcer was identified to Resident F's left lateral ankle. The pressure ulcer measured 2.5 centimeters by 2 centimeters with granulation tissue. A Nurse's Note on 2/1/2023 at 4:08 A.M., indicated the wound physician visited for wound measurements. The left lateral ankle measured 3 centimeters by 2.5 centimeters. A new order was received for Betadine Solution daily. On 2/8/2023 at 1:12 P.M., a Nurse's Note indicated the wound physician visited for wound measurements. A new order was obtained for calcium alginate and wrap with Kerlix daily. On 2/16/2023 at 12:09 P.M., a Nurse's Note indicated measurements per the wound physician to the left lateral ankle were 3 centimeters by 3 centimeters. On 3/1/2023 at 12:53 P.M., a Nurse's Note indicated physician wound measurements to left lateral ankle 3 centimeters by 2.5 centimeters, and a new right heel deep tissue injury measured 0.6 centimeters by 0.5 centimeters. A new order was obtained for skin prep to the right heel and to float the heels in bed. On 3/8/2023 at 2:44 P.M., a Nurse's Note indicated the left lateral ankle measured 2.2 centimeters by 2.2 centimeters by 0.2 centimeters. The right heel deep tissue injury was healed. A Weekly Skin Observation on 3/14/2023 at 8:45 A.M., indicated Resident F did not have any new skin issues noted. This was the latest weekly skin assessment documented. On 3/16/2023 at 2:13 P.M., a Nurse's Note indicated the wound physician was here for measurements. The left lateral ankle had not changed in size. During an observation on 3/23/2023 at 10:56 A.M., with the wound physician, Resident F was observed lying in bed with a Prevalon boot to his left foot and a Prevalon boot was laying in the recliner chair. He did not have his feet floated from the mattress. The wound physician removed a dressing of Kerlix that was wrapped around the the left ankle and foot. The dressing had the date of 3/19 (2023) written on the tape. The wound doctor indicated the pressure ulcer measured 2 centimeters by 2 centimeters. He also indicated Resident F had a new stage 3 pressure ulcer to the left lateral heel, measuring 0.5 centimeters by 0.5 centimeters. During an interview on 3/23/2023 at 11:04 A.M., the wound physician indicated the date on the ankle dressing was 3/19, and the dressing was to be changed daily. During an interview on 3/23/2023 at 11:15 A.M., Resident F indicated it had been a few days since the dressing had been changed. A Wound Evaluation and Management Summary on 3/23/2023, indicated an assessment and evaluation was completed, and a stage 3 pressure wound of the left lateral heel was present for at least one day. The wound size was documented as 0.5 centimeters by 0.5 centimeters by 0.2 centimeters. A treatment of Hydrogel with silver and Kerlix would be completed daily. 11492 2. Resident D was observed on 3/22/2023 at 9:45 A.M., lying in bed on her back. There was a covered foam pressure relieving mattress on her bed and two incontinence pads underneath her. During an interview at this time, Resident D indicated she was getting Silicone cream to her buttocks. The record for Resident D was reviewed on 3/22/2023 at 1:56 P.M. Resident D was recently hospitalized and readmitted to the facility on [DATE]. The hospital records for Resident D indicated she presented to the hospital with a raw red buttocks and red/open excoriation to her back. The hospital discharge orders for Resident D dated 3/2/2023, included orders nystatin cream mixed with house barrier cream to the buttocks every shift. The Medication and Treatment record for Resident D for March 2023 indicated the nystatin cream mixed with house barrier cream to buttocks was only documented as having been completed once a day. During an observation and interview, completed on 3/23/2023 at 11:10 A.M., with the Wound Nurse, wound physician and Director of Nursing, Resident D's skin and wounds were observed. The resident's buttocks and upper posterior thighs had a large area of blanchable purplish skin. There were two bleeding open areas noted on the right buttocks and right ischium. The resident's left hip area was noted to be a bright red. The Director of Nursing indicated the reddened area was warm to the touch. The resident was moaning with pain during the wound observation. There was also an open area, which the Director of Nursing indicated was new, on the left ischium area. The wound physician indicated the whole area was MASD (moisture associated skin damage) with open areas. He indicated the open areas were to be treated with calcium alginate, to stop bleeding and promote skin healing, and covered with a protective dressing. The resident was lying on a covered foam mattress with two quilted incontinence pads and a folded bath blanket underneath her bottom area. During an interview with the Wound nurse, on 3/23/2023 at 11:45 AM., she indicated the wound physician had ordered calcium alginate for the open areas. The wound nurse was unsure what cream/treatment had been applied to the rest of the MASD areas. During an interview with LPN 6, on 3/23/2023 at 1:51 P.M., she indicated the resident was supposed to be receiving nystatin cream mixed with barrier cream to her buttocks areas. She indicated the pharmacy would mix the creams and send the treatment in a white container and the treatment would be kept on the treatment cart. During an observation of the cart with LPN, there was no treatment located for Resident D's buttocks. LPN 6 then looked through the resident's room and could not find any Nystatin cream. During an interview with a pharmacist from the facility's pharmacy, on 3/23/2023 at 2:00 P.M., she indicated the pharmacy had not filled any mixed cream order for Resident D. She indicated a tube of Nystatin cream, 30 grams, had been filled on 3/14/2023 and a new tube was scheduled to be sent out on 3/23/2023. She indicated the facility had house barrier cream to mix with the Nystatin cream. On 3/23/2023 at 2:21 P.M., the Administrator provided a policy titled, Pressure Ulcers. The policy indicated, .Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers unless clinically unavoidable This Federal tag relates to Complaint IN00399975.

Based on interview and record review, the facility failed to monitor a central line for 1 of 1 residents reviewed for central line maintenance, resulting in a hospitalization . (Residents 43) Finding includes: During an interview, on 7/8/2021 at 2:36 P.M., Resident 43 indicated she had been recently hospitalized with [CONDITION(S)] from her PICC line. A clinical record review was conducted on 7/8/2021 at 2:50 P.M. Resident 43's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurses' Note, dated 4/25/2021, indicated Resident was readmitted to the facility with a PICC to her left upper extremity. Resident 43's MAR (Medication Administration Record) and TAR (Treatment Administration Record) showed no indication that her PICC (peripherally inserted central catheter) line had been monitored for signs and symptoms of infection. Resident 43's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurses' Note, dated 5/18/2021 at 11:12 A.M., indicated Resident 43 had been admitted to the hospital with a fever. A Discharge Form from the local hospital, dated 5/24/2021, indicated Resident 43 had been admitted with MSSA([CONDITION(S)] susceptible staphylococcus aureus) to her PICC line and she was septic (widespread inflammation triggered by an immune response to an infection which has spread to the bloodstream). Nurses' Notes lacked documentation the PICC site had been monitored from 5/4/2021 to 5/25/2021. During an interview, on 7/13/2021 at 10:19 A.M., the Unit Manager indicated she was unable to locate any documentation that Resident 43's PICC line had been routinely monitored for signs and symptoms of infection, prior to her hospitalization . A policy was requested related to monitoring a PICC line site, however one was not provided. 3.1-37

Based on interview and record review, the facility failed to obtain a code status on a resident, and in the absence of orders, failed to perform Cardio-pulmonary Resuscitation (CPR) on a resident when he showed signs and symptoms of respiratory and [MEDICAL CONDITION]. This deficiency affected 1 of 3 residents reviewed for death. (Resident J) The Immediate Jeopardy began on [DATE] at 7:15 P.M., when the facility failed to initiate CPR when a resident's vital signs had ceased and the resident's Power of Attorney (POA) had previously elected not to execute any advance directives with the understanding facility staff would respond to medical emergencies with CPR measures and a full code would be instituted. The Director of Nursing (DON) was notified of the Immediate Jeopardy on [DATE] at 4:38 P.M. The Immediate Jeopardy was removed, and the deficient practice was corrected, on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Finding includes: On [DATE] at 12:45 P.M., a review of Incident 101 was conducted. The incident indicated Resident J was found unresponsive, on [DATE] at 7:15 P.M. and expired. The follow up to the incident, stated CPR was not initiated, and the nurses were educated, in regards to residents who had opted out of choosing a code status, would default to a full code status and CPR would be initiated. During an interview, on [DATE] at 1:50 P.M., the DON (Director of Nursing) indicated Resident J did not receive CPR because he had not chosen a code status. On [DATE] at 2:15 P.M., a review of the clinical record for Resident J was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 11, mild cognition deficit. An Advance Directive Acknowledgment, dated [DATE], indicated the resident's Power of Attorney (POA)/daughter had acknowledged by placing her initials on the admission form, that she had elected not to execute any advanced directive, with the understanding the staff would respond to medical emergencies with CPR measures and a full code would be instituted. A care plan, dated [DATE], indicated the resident had elected not to execute any advance directives at this time. Therefore, due to facility policy, he would be a full code. A Progress Note, dated [DATE] at 8:23 P.M., written by LPN 2 indicated .went into residents room at 7:15 pm resident not moving, pale, skin cool, no respirations or heart beat During an interview, on [DATE] at 10:512 A.M., LPN 2 indicated she was not aware of Resident J's code status and his was not on her assignment sheet, as all resident's code status was usually recorded on the assignment sheet. She then reviewed the resident's orders and failed to find a Do Not Resuscitate (DNR) order. LPN 2 indicated it was her mistake and CPR should have been initiated on Resident J. On [DATE] at 4:16 P.M., the DON provided a policy titled Cardiopulmonary Resuscitation, Emergency Code Blue, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .3. The Facility ensure provision of basic life support and CPR, including: A. Staff are directed to initiate CPR when cardiac or respiratory arrest occurs for resident who do not show obvious clinical signs of irreversible death and; 1) Who have requested CPR in their advance directives, or 2) Who have not formulated an advance directive The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: educating all staff on validating a code status prior to responding to a resident without a pulse or respirations, and honoring code status, completing a full audit on all resident's record to ensure appropriate code statuses were ordered and documented, and reviewing any facility deaths for compliance with code status. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to ensure a resident who required extensive assistance was provided supervision to prevent the resident from falling off the bed to the floor resulting in a neck fracture. (Resident C) Finding includes: The clinical record for Resident C was reviewed on 1/18/18 at 11:00 A.M. The [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 10/12/17, indicated Resident C had a BIMS (Brief Interview of Mental Status) score of 11, moderate cognitive impairment, and required extensive assist with bed mobility. A care plan, dated 5/23/17, indicated Resident C was at risk for falls related to impaired mobility, cognition, weakness, use of diuretics, hypertensive and antidepressant drug use. A care plan, dated 9/14/17, indicated Resident C requires assistance with ADLs (activities of daily living) related to impaired mobility and cognition with interventions that included, but were not limited to bed mobility and transfers with assist of one. The Resident Incident/Accident Investigation Worksheet, dated 1/12/18 at 4:15 A.M., indicated Resident C had rolled out of bed with excessive bleeding noted to her head when she was being rolled during bathing, with medical considerations of lack of coordination and muscle weakness. The intervention was for when resident was being washed up, the CNA needs to more aware of surroundings of where the resident is. The Progress Note, dated 1/12/17 at 4:35 A.M., indicated Resident C was found on the floor face down with a large laceration to the head. Resident was transported to the emergency room . The ED (Emergency Department) Note, dated 1/12/18 at 7:37 A.M., indicated Resident C presented to the ED with acute onset of head injury from a fall, she complained of her neck feeling funny, and the resident had been turned and repositioned and was accidentally rolled out of the bed which was what caused the laceration to the middle of her forehead. There was a non displaced fracture that involved the anterior inferior C3 vertebral body and appeared to be a fracture involving the posterior inferior aspect of C3. A Progress Note, dated 1/12/18 at 9:26 A.M., indicated Resident C had returned from hospital with a skin tear to left arm, left hand [MEDICAL CONDITION] et discolored with increasing [MEDICAL CONDITION] overnight, resident resident had fracture of C3 and neck brace was in place. A written statement, dated 1/12/18 at 10:35 A.M., indicated CNA (certified nursing aide) 2 was getting Resident C up for the day, she always got the resident washed up, dressed, and let her lay in the bed. CNA 2 indicated she was washing Resident C up and turned around to get her lotion, resident was on the side of the bed and when CNA turned around she was on the floor. The resident hit the floor directly, nothing was underneath her. CNA indicated Resident C was facing towards her in the bed at the time of the fall. A Record of Inservice, dated 1/12/18 at 10:35 A.M., indicated CNA 2 was educated to ensure proper positioning of resident in bed while performing care and to ensure resident is in a safe position if you need to step away to obtain supplies. During an interview, on 1/18/18 at 2:50 P.M., the DON (Director of Nursing) indicated the CNA should not have turned her back to the resident without first ensuring resident safety. On 1/19/18 at 11:30 A.M., the ADM (Administrator) provided the Fall Management policy, dated 9/18/17, and indicated this was the policy currently being used by the facility. The policy indicated the facility would identify each resident who was at risk for falls and would plan care and implement interventions to manage falls. This Federal tags relates to complaint IN 404. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide foot pedals to a resident's wheelchair that were required due to bilateral lower extremity weakness that resulted in an ankle fracture from foot falling to floor and being caught under wheelchair during transportation in facility. (Resident F) Finding includes: The clinical record for Resident F was reviewed on 11/1/17 at 9:43 A.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 11/1/17, indicated Resident F had a BIMS (Brief Interview Mental Status) score of 12, mild cognitive impairment, required extensive assist with ADLs (activities daily living), and was admitted on [DATE]. The Admission Observation, dated 5/11/17 at 7:32 P.M., indicated Resident F required a mechanical lift transfer. The Focused Observation, dated 5/13/17 at 3:37 A.M., indicated Resident F had weakness to all extremities. The Physical Therapy Plan of Care, dated 5/12/17, indicated treatment [DIAGNOSES REDACTED]. The Resident Progress Note, recorded on 5/16/17 at 1:12 P.M. as late entry, indicated on 5/13/17 Resident F reported to writer that when bringing her back from the dining room the resident's foot dropped due to not being able to hold them up and her feet hit the floor, and Resident F stated her foot went under wheelchair and she thinks they ran it over. The x-ray of the right ankle, dated 5/14/17 at 5:36 P.M., indicated oblique fracture to the distal fibula. The Incident Report, dated 5/16/17, indicated it was brought the DON (Director of Nursing) and ADM (Administrator) attention that an incident occurred on 5/13/17 while Resident F was being pushed in a wheelchair by agency CNA (certified nursing aide) her feet dropped and went behind her or were run over. The Investigation, dated 5/16/17, indicated CNA #6 reported to LPN (Licensed Practical Nurse) she was pushing Resident F toward her room in the hall and Resident F became unable to hold feet up and her feet hit the floor as she was pushing and her feet went backwards. CNA #7 reported that she heard Resident F hollering, Help. Help. My foot. My Foot. CNA #7 indicated she witnessed CNA #6 pulling Resident F backwards in wheelchair and another CNA was carrying her feet and legs. CNA #6 indicated Resident F might have been in wrong wheel chair and while pushing her, her feet went down. On 11/1/17 at 11:41 A.M., the ADM indicated incident and X-ray results of fracture should been reported to her at the time received and state report should have filed at that time. On 11/3/17 at 11:37 A.M., the DON indicated foot pedals should have been on wheelchair, she indicated from her understanding resident was being pushed by CNA in wheelchair when resident's foot fell and CNA did not stop. On 11/3/17 at 11:00 A.M., a policy on incidents and accidents was requested from DON, no policy was provided. On 11/3/17 at 11:53 A.M., the DON (Director of Nursing) provided the Accident/Incident Reporting policy, dated 4/7/14, and indicated the policy was the one currently being used by the facility. The policy indicated the Facility's Leadership would follow the established guidelines for reporting of accidents and incidents. In the event of a state reportable incident, the Facility's Leadership will notify the state regulatory agency according to the applicable law and regulation. All incidents and accidents involving residents are immediately reported to the departmental unit supervisor. In addition, all serious accidents are reported to the ADM and DON. This Federal Tag relates to complaint #IN 665. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to prevent pressure ulcer development for resident who was on bedrest, resulting in a stage 3 pressure area to the right and left buttock, for 1 of 1 residents reviewed for pressure ulcers (Resident #19). Finding includes: A clinical record review was conducted on 11/01/17, at 8:59 AM, for Resident #19 and indicated an admission date of [DATE], with a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) Assessment, dated 10/23/17, indicated a BIMS (Brief Interview for Mental Status) score of 13, cognitively intact. The assessment indicated 2 unhealed pressure ulcers, one stage 2 and one stage 3, that were documented as not being present upon admission/reentry. The care plans did not indicate a current care plan for actual skin impairment, or pressure ulcers. A pressure ulcer prevention care plan was in place, but was not updated to reflect the new skin impairments or wound care orders. The Admission Observation form, dated 10/09/17, indicated the only skin alterations present at that time were 4 surgical incisions. The Wound - Weekly Skin Note form, dated 10/10/17, indicated the presence of an open area to left inner coccyx, that measured 3cm x 4.5cm x 0.5cm; no other description or classification was documented. The Wounds - Weekly Progress Record, dated 10/10/17, indicated a stage 2 pressure area to the left buttock, with the same measurements documented as the coccyx wound. The Focused Observation forms, dated 10/12/17, indicated a partial thickness wound to the coccyx and a stage 2 ptw (partial thickness wound) to the left buttock. The Wound Progress Record form, dated 10/19/17, indicated a stage 2 area to the left buttock, that measured 6.5cm x 3.5cm x eschar. The Re-admission Nutrition Assessment form, dated 10/20/17, indicated pressure areas to the right and left buttocks. The Wounds - Weekly Skin Note form, dated 10/25/17, indicated pressure areas to the right and left buttocks and coccyx; no further measurements or description were documented. The Wounds - Weekly Progress Record, dated 10/29/17, indicated a stage 2 pressure area to the right buttock, measuring 1.5cm x 3cm x 0.1cm; no additional wound documentation noted. The Wounds - Weekly Progress Record, dated 10/29/17, indicated the left buttock wound was now a stage 3 and measured 8cm x 5cm x 2cm. The progress notes, dated 10/10/17, indicated the left buttock wound was noted and the physician notified. Progress notes, dated 10/11/17 & 10/12/17, indicated a stage 2 partial thickness wound to the coccyx, that measured 4.5cm x 3cm x 0.5cm. No further wound documentation notes were available. No documentation of physician notification, with improvement or decline of the wounds, was indicated. The Supplemental Physical Therapy Plan of Care note, dated 10/25/17, indicated the left buttock wound measured 8cm x 5cm x 2cm and the right buttock wound measured 1.5cm x 3cm x 0.1cm. The TAR (Treatment Administration Record), for October, indicated no wound care orders were began prior to 10/13/17. The Physician order [REDACTED]. During an interview, on 11/01/17 at 10:29 AM, the DON (Director of Nursing) indicated there was not a current care plan for Resident #19's pressure areas. Only an at risk care plan was in place that did not address the actual skin impairment. The nutritional care plan in place was not updated to reflect the promed supplement added on 10/31/17 for wound healing. She indicated she would expect a care plan to be in place. Wound care observed, on 11/01/17 at 10:37 AM, with the RPT (Registered Physical Therapist), assisted by the Wound LPN (Licensed Practical Nurse). The RPT was gloved up prior to surveyor entering room and any previous dressing had already been removed. The Wound LPN completed a 5 second hand sanitizer rub, then donned gloves. The RPT picked up and moved the foley bag and set it on the opposite side of bed. Both staff members rolled Resident #19 on her left side. The RPT changed gloves, without washing hands, and used spray cleanser to left buttock wound, then right buttock wound. The RPT dabbed right buttock wound with gauze and tweezers; he removed his gloves and completed a 5 second hand wash. He returned to the bedside, after touching the privacy curtain, and put on new gloves. He dabbed the right buttock wound again, with the same gauze as before, measured the area, applied santyl with a cotton tip swab, and placed [MEDICATION NAME]; no glove change occurred. The RPT dabbed the left buttock wound with same gauze previously used, the wound was measured, and the cotton tip applicator used was placed back on the clean prep table. He removed slough with a scalpel and the same tweezers used for cleaning; gloves were not changed. The wound was packed with gauze and alginate dressing, with the same cotton tip applicator used for measuring, and [MEDICATION NAME] was applied. No duodem was applied to coccyx. Wounds assessments were as follows (per the RPT): Right buttock (stage 3)- 1cm x 1.9cm x 0.1cm; 50% slough, 50% beefy red tissue. Left buttock (stage 3) - 7cm x 4cm x 2cm; 35% slough, 65% beefy red tissue. During an interview, on 11/01/17 at 11:32 AM, the CSD (Clinical Services Director) indicated he did not know why therapy would have been ordered to provide wound care for Resident #19 , only that is was what the physician ordered. He also indicated he would expect glove changes and hand washing between dressing removal, cleaning of the wound, treatment application, and dressing application. During an interview, on 11/02/17 at 9:32 AM, the CSD (Clinical Services Director) indicated the RPT, who had provided wound care, was not aware that a duoderm was supposed to be applied to the coccyx area. During an interview, on 11/02/17 at 1:19 PM, the Wound LPN indicated pressure areas had worsened and that was the reason for asking therapy to take over wound care. A policy was provided by the Interim ED (Executive Director) on 11/02/17 at 9:00 AM, titled Dressing Change Wound Evaluations, dated 06/01/15, and indicated this was the policy currently used by the facility. The policy indicated .1. With each dressing change the clinician should observe and document the following: A. General appearance. B. Drainage. C. Surrounding skin. D. Wound odor .4. In the event of changes (improvement or deterioration), the resident and/or responsible party and the resident's physician are notified A policy was provided by the Interim ED on 11/02/17 at 9:00 AM, titled Wound Evaluations, dated 06/01/15, and indicated this was the policy currently used by the facility. The policy indicated .3. Evaluation results are communicated to the members of the care team through documentation, care plan meetings, and care planning A policy was provided by the Interim ED on 11/02/17 at 9:00 AM, titled Hand Hygiene/Handwashing, dated 09/2011, and indicated this was the policy currently used by the facility. The policy indicated .1. Hand hygiene/hand washing is done: Before: A. Before patient/resident contact .E. Before taking part in a medical or surgical procedure. After : A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids, or wounds .H. AFter removal of medical/surgical or utility gloves 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on record review and interview, the facility failed to provide timely physician notification and intervention after a fall for a resident who had sustained a fall that resulted in hospitalization and surgical repair of a intertrochanteric [MEDICAL CONDITION] proximal femur for one of three residents reviewed for accidents. (Resident B) Finding includes: Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note, dated 12/27/2016 at 2:41 A.M., indicated . resident was in day room in w/c (wheelchair) c (with) seat belt fastened, unbuckled seat belt, stood up and tried to walk, resident fell to floor just as I was getting to resident, resident landed on lt (left) hip as I guided to floor, resident was helped back into w/c. husband notified said he was on way here and to NOT to notify MD (medical doctor) or send to hospital, resident examined found 0 bruising, skin alterations, A progress note, dated 12/ 6 at 6:40A.M., indicated . This nurse went in to assess resident. Her left leg is externally rotated, deformation to the left hip area. Resident complaints of pain with touch. MD notified, new order to send to ER for eval (evaluation) and tx (treat). (name of spouse) called, stated he wants to come in and assess A progress note, dated 12/27/2016 at 6:55 A.M., indicated .(name of spouse) here. I explained to him and showed him my concerns. He wanted to drive her to the ER (emergency room ). I explained the consequences of picking her up and the possibility of causing more injury. He accepted that and I called (name of local ambulance company) for pick up A progress note, dated 12/28/2016 at 12:33 P.M., indicated . Coerrection to progess note of 12/27/2016 @ (at) 2:41 am, fall ocured at 7pm, noted articulated lt hip & knee s (without) objection through full range of motion, resident stated some soreness and mild discomfort. husband arrived adn dstated he wanted to put resident to bed , common practice for husband to put resident to bed s facility assistance. entered residents room @ 8:15 pm on 12/26/2016 to re-asess and to administer prn medications and flush [DEVICE]. At this time resident did not complain of pain or discomfort after medication administration and flushing, discussed c husband the importance of notifing md and DX (diagnosis) follow up testing, husband again refused to notify MD and any costs involved due to fact that he is self pay. Checked on resident multiple times throughout night, each time resident was sleeping comfortable in bed s c/o (complaint of) pain discomfort A Patient/Resident Incident/Accident Investigation Worksheet, dated 12/26/16 at 9 P.M. indicated .Findings and Analysis:Per (name of certified nursing aide) after fall she noted the left leg to be tangled behind/underneath the right leg .(name of nurse) witnessed fall went to grab her as she landed o floor. states she didn't land hard .Sent to ER fracture L hip on return w/c (wheelchair) alarm During an interview, on 6/16/17 at 10:30 A.M., the on call physician indicated he had not been notified of the fall when it occurred, he was notified the next day and gave orders that resident be sent to the emergency room for evaluation. The on call physician indicated he would like to be notified of a fall even if the poa (power of attorney) or guardian refused. During an interview, on 6/19/17 at 12:11 P.M., the residents spouse indicated the nurse who notified him of his spouses fall asked if he could come watch her because they did not have enough staff to watch her, and he was assurred that an assessment for injuries was conducted and none were found at that time. The residents spouse indicated his decision making in regard to care was based on the assessment given to him by the nurse at the time he came to the facility, the nurse had indicated to him the resident would be given tylenol for pain. Resident B's spouse indicated the next day he was notified by the head nurse that Resident B did have a fracture and would need to go to the emergency room and his wife was in alot of pain when he got to the facilty the next morning. On 6/19/17 at 12:25 P.M., the Medication Administration Record [REDACTED]. No documentation noted to indicate Resident B had received any Tylenol from 12/01/17 through 12/28/17. A (name of local hospital) History and Physical, dated 12/27/2016 indicated . History of Present Illness: The patient attempted to get out of the wheelchair without assistance on her own and subsequently fell . This occurred last evening. She reportedly was experiencing pain in her left hip since that time with worsening of the hip pain with any weightbearing. For this reason, she was brought to the emergency room at this facility. X-rays performed demonstrated an acute comminuted intertrochanteric [MEDICAL CONDITION] proximal femur On 6/19/17 at 2:00 P.M., a policy titled Nursing Policies and Procedures with a revision date of 7/1/2016 and provided by the Mobile Director of Nurses on 6/14/17 at 3:05 P.M., was reviewed. The Policy indicated . Procedures: 6. The physician and family are promptly notified and an incident report is completed This Federal Tag is related to Complaint IN 021. 3.1-37(a)