Every finding on record at Brickyard Healthcare - Fountainview Care Center

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for diets were provided with their preferred diet (Resident B).Finding includes:On 2/17/26 from 12:30 P.M. to 1:10 P.M., Resident B was observed in the common area being fed by Certified Nursing Assistant (CNA) 4. The meal ticket on the resident's tray indicated she was on a full liquid diet. CNA was feeding the resident a meal of beef broth, yogurt, magic cup supplement, mighty shake supplement, chocolate pudding, and juice. Resident B was taking the liquid diet via a spoon and straw without difficulty.During an observation on 2/18/26 at 8:30 A.M., Resident B was in the 200 Hall common area dining room and was being fed breakfast by CNA 5. The meal consisted of cream of wheat cereal, yogurt, broth, and juice. CNA 5 indicated he often assisted the resident with meals and she normally did very well and did not seem to have any eating concerns such as choking, spitting up, or coughing.On 2/17/26 at 12:40 P.M., Resident B's Power of Attorney (POA) was present for the lunch meal and indicated the resident could eat soft foods and wanted the resident's diet changed from a liquid diet to a mechanical soft diet. The POA indicated the resident had been on soft foods before a recent hospitalization due to dehydration and malnutrition. Resident B's POA indicated the diet was changed to a liquid diet while the resident was in the hospital. The POA indicated the resident's family had been asking for a diet change but were told by the facility that they would not change the diet order. Resident B's POA indicated the family frequently fed the resident soft foods such as mashed potatoes and cottage cheese and the resident had no swallowing difficulty. Resident B's POA indicated in a recent care plan meeting, the family was told they would have to sign a waiver of responsibility for feeding the resident foods other than what was allowed on a liquid diet and provided by the facility.During an interview, on 2/17/26 at 10:25 A.M. the Therapy Department Manager indicated Resident C had gone out to the hospital twice recently and each time, upon return, had been evaluated by Speech Therapy. The Therapy Department Manager indicated Resident B could not follow commands so she did not meet the criteria for a diet change. There was no indication that the resident's swallowing capabilities had been evaluated thoroughly when she had returned from her most recent hospital stay.During an interview, on 2/17/26 at 3:45 P.M., the Director of Nursing indicated the facility had to follow physician orders so Resident B was on a full liquid diet as ordered. The Director of Nursing indicated the resident had been evaluated by physical therapy and since the resident could not follow commands, physical therapy a swallow study could not be performed for the resident. It was unclear why the physical therapy department was making decisions regarding swallow study testing. In addition, the Director of Nursing indicated the facility had had multiple meetings with Resident B's family regarding their desire for Resident B to be on soft diet and indicated the family had refused to sign a waiver that would have allowed the family to feed the resident what they wanted to feed her. Finally, the Director of Nursing indicated that Speech Therapy was scheduled to perform a swallow study test the following day, on 2/18/26, per the family's request.During an observation of a swallow study test on 2/18/26 at 10:45 A.M., the Speech Therapist indicated the resident had been on a soft mechanical diet before her most recent hospitalization for dehydration. The Speech Therapist indicated the resident was placed on a liquid diet in the hospital because of poor intakes and the hospital had been trying to get increased calories into the resident. The Speech Therapist indicated the liquid diet was not due to a swallowing concern but rather the resident's nutritional status. The Speech Therapist completed the swallow study test and immediately initiated a pureed diet for the resident.Resident B's clinical record was reviewed on 2/17/26 at 3:31 P.M. Resident B was admitted to the facility with diagnoses that included but were not limited to Alzheimer's Disease, hypertension, emphysema, chronic obstructive pulmonary disease (COPD), Right eye blindness, polyneuropathy, hearing loss, dementia, acute kidney failure, and signs and symptoms concerning food and fluid intake.Review of the Resident's face sheet indicated her daughter was her Power of Attorney.A Nutrition assessment dated [DATE], indicated the facility was to encourage food and fluid intakes for the resident.A Hospital Inpatient Nutrition Services consult note dated 2/6/26 at 10:08 A.M., indicated the resident was admitted to the ER on [DATE] for hypernatremia and that the Registered Dietician intervention was needed for an evaluation. The note indicated the resident was on a full liquid diet to promote nutritional intake and that Resident B had been improving her oral intakes and had had a good oral nutrition supplement intake.A Care Plan meeting note dated 2/13/2026 at 2:35 P.M., indicated Resident B's family had requested a meeting and the family had discussed their concerns about the resident's current diet and orders that had followed the resident from the hospital. The family indicated that they were able to feed their mother cottage cheese, pudding, and yogurt in the hospital. They indicated that she was able to eat these types of food items with no problems. The Administrator informed the family that she could have the facility legal team complete a waiver for family going against medical advice. Physician Orders included but were not limited to a full liquid diet dated 2/8/2026, and discontinued on 2/18/2026, followed by a regular diet of pureed texture initiated on 2/18/2026 at 11:25 A.M.On 2/23/26 at 11:11 A.M., Director of Nursing 2 provided the policy titled, Resident Rights, dated 2025 and indicated it was the current facility policy. The policy indicated the resident had the right to self-determination and the resident representative had the right to exercise the resident's right to the extent those rights were delegated to the resident representative. The policy indicated the resident had the right of self-determination and the facility must promote and facilitate resident self-determination. This Citation relates to Intakes 2737137 and 2738679.1.3-20(a)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 dependent residents reviewed for hydration was provided adequate fluids to maintain hydration.(Resident B).Finding includes:During an observation on 2/17/26 at 9:40 A.M., Resident B was observed in the 200 Hall common area seated in a reclining wheelchair in front of a television. There were no fluids available for the resident.During an observation on 2/17/26 at 9:43 A.M, no water had been passed to the resident in her room.On 2/17/26 at 10:04 A.M., Resident B was observed in the 200 Hall common area with no fluids available to her.On 2/17/25 at 11:26 A.M., Resident B remained in common area with no fluids available to her.During a dining observation on 2/17/26 from 12:30 P.M. to 1:10 P.M. Certified Nursing Assistant (CNA) 4 fed Resident B her lunch tray, which consisted of a liquid diet of broth, yogurt, magic cup, a mighty shake, chocolate pudding, and juice. The resident's family came and took over feeding the resident during the meal time. CNA 4 indicated she had not given the resident any fluids between breakfast and lunch.On 2/18/26 at 9:00 A.M., Resident B was observed in the 200 Hall common area in her reclining wheelchair chair by the television and there were no fluids beside her. At 9:05 A.M., no fluids had been passed in the resident's room. During an observation on 2/18/25 at 11:20 A.M., Resident B remained in the 200 Hall common area and there were no fluids available to her.During an interview on 2/17/26 at 9:28 A.M., Resident B's family member indicated the facility had not pushed fluids for the resident, which had resulted in a recent hospitalization for dehydration and elevated sodium levels. The family member indicated that he or one of his siblings had came to the facility daily to feed their mother because the staff did not feed her enough and the facility had not offered her enough fluids. The family member indicated earlier in the month, they were unable to come to the facility due to their illnesses to feed their mother and she had became dehydrated. The facility felt it was due to the lack of staff offering her adequate fluids. The family member indicated the facility continued to not offer fluids after the resident had returned to the facility.During an interview with Certified Nursing Assistant (CNA) 4, she indicated she had not given the resident fluids between breakfast and lunch.Resident B's clinical record was reviewed on 2/17/26 at 3:31 P.M. Resident B was admitted to the facility with diagnoses that included but were not limited to Alzheimer's Disease, hypertension, emphysema, chronic obstructive pulmonary disease (COPD), Right eye blindness, polyneuropathy, hearing loss, dementia, acute kidney failure, and signs and symptoms concerning food and fluid intake.A Nutrition assessment dated [DATE], indicated the facility was to encourage food and fluid intake.An Emergency Department note from a local hospital dated 2/3/26 at 3:12 P.M., indicated the resident had been admitted to the hospital and was very dehydrated with a dry oral cavity, significant abnormal lab results including an elevated sodium level of 170 and a low potassium level of 3.0. The note indicated the resident was admitted to the hospital from [DATE] to 2/5/26 where treatment included, but was not limited to, receiving intravenous (IV) fluids for dehydration.Resident B's Care Plans included but were not limited to the following:The Resident has dehydration or potential for fluid deficit related to diuretic use, dated 12/10/25. The Care Plan indicated the resident would be free of symptoms of dehydration.A policy titled, Hydration, dated 2025, was provided by Director of Nursing 2 on 2/17/26 at 3:24 P.M. The policy indicated that the facility would offer each resident sufficient fluid, including water and consistent with the residents' needs and preferences to maintain proper hydration and health. Sufficient meaning the amount of fluid needed to prevent dehydration and maintain health.This Citation relates to Intake 2737137 and Intake 27388679. 1.3-46(b)

Based on observation, interview, and record review, the facility failed to ensure a physician order for CAT scan was completed for 1 of 3 residents reviewed (Resident U).Findings include:On 12/30/25 at 2:30 P.M., Resident U was interviewed in her room. She was observed with faded bruising around her right eye. The faded bruising extended from below her right eyebrow to below her right eye. A dark red/purple quarter size bruise was observed on top of her right cheekbone. When asked, Resident U indicated she had been hit on her forehead by a part of the mechanical lift used to transfer her. When asked, Resident U indicated she was told she was to have a CAT scan done but she hadn't had one done.On 12/30/25 at 1:43 P.M., Resident U's record was reviewed. Diagnoses included falls with fractured right femur.A care plan indicated Resident U was on antiplatelet therapy related to a fracture. She was prescribed Aspirin 81 milligrams by mouth 2 times per day.A nurse note, dated 12/8/25 at 2:17 p.m., indicated Resident U was being transferred with a Hoyer lift when the lift tipped and the resident hit her forehead on the weight mechanism. A large hematoma appeared immediately on her forehead. The resident was given pain medication and ice pack to relieve swelling to the area.A physician order, dated 12/13/25, was to obtain a CAT scan of Resident U's head and face due to direct trauma with a large frontal hematoma and periorbital (around eyes) ecchymosis.Review of records didn't show results for a CAT scan dated on or after 12/13/25.On 12/30/25 at 3:20 P.M., the Regional Nurse Consulted (RNC) was interviewed. She indicated she was unable to find a CAT scan report, ordered on 12/13/25. The RNC indicated she would follow up to see if the scan had been completed as ordered.On 12/31/25 at 11:20 A.M., the RNC indicated the CAT scan ordered on 12/13/25 had not been completed as ordered but should have been done.A current policy, titled Provision of Physician Ordered Services, provided by the Assistant Director of Nursing on 12/31/25 at 4:00 P.M., stated: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.Facility will maintain a schedule of diagnostic tests in accordance with the physician's orders.Nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity.This Citation relates to Intake 2691743.3.1-37

Based on interview and record review, the facility failed to notify the Long Term Care (LTC) Ombudsman in a timely manner of resident discharges for 3 of 5 residents reviewed for discharges. (Residents 32, 75 and 76) Findings include: 1. On 4/17/2025 Resident 75 was discharged to home after completing therapy and meeting goals. On 5/23/2025 at 1:42 P.M. a list of LTC Ombudsman discharge notifications for February, March and April 2025 were requested from the ED. During an interview on 5/27/2025 at 9:11 A.M. the ED indicated she received an email from the LTC Ombudsman with the discharges for February and March 2025 but not April. The email indicated the LTC Ombudsman had not received any documentation of discharges for April 2025. The ED indicated April 2025 discharges should have been sent on May 1, 2025 but had not been sent. 2. During an interview on 5/19/2025 at 10:35 A.M., Resident 32 indicated he had been sent to the hospital in March. Resident 32's record review was completed on 5/23/2025 at 1:25 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, emphysema, major depressive disorder and generalized anxiety disorder. A Nursing Note dated, 3/8/2025 at 2:32 P.M., indicated Resident 32 had been admitted to the hospital for pneumonia. A review of the March 2025 Ombudsmen notification list was completed on 5/27/2025 at 9:45 A.M. Resident 32's name was not on the list. During an interview with Executive Director (ED) on 5/27/2025 at 8:45 A.M., the ED indicated Resident 32's name was not on the Ombudsmen notification list for March 2025. 3. Resident 76's record review was completed on 5/23/2025 at 12:57 P.M. Diagnoses included, but were not limited to: dementia, dysphagia, fracture of right femur, cellulitius and rhabdomyolysis. A Change in Condition note, dated, 2/21/2025 at 2:41 A.M., indicated Resident 76 had been sent to the hospital. Resident 76 was discharged from the facility on 2/22/2025 and was not readmitted . A review of the February 2025 Ombudsmen notification list was completed on 5/27/2025 at 9:46 A.M. Resident 76's name was not on the list. During an interview with Executive Director (ED) on 5/27/2025 at 8:46 A.M., the ED indicated Resident 76's name was not on the Ombudsmen notification list for February 2025. On 5/27/2025 at 9:00 A.M., the ED provided an undated policy title, Transfer and Discharge and identified it as the policy currently used by the facility. The policy indicated, . 5. The facility will maintain evidence that the notice was sent to the Ombudsman 3.1-12 (a)(6)(iv)

Based on observation, record review and interview, the facility failed to provide a safe and sanitary environment for 7 of 19 rooms reviewed for the environment. ( room [ROOM NUMBER], 112, 114, 115, 117, 118 and 119) Findings include: On [DATE], beginning at 10:30 A.M., the following was observed on the 100 Unit: - Room105 had multiple gouges in the wall near the baseboard behind the bed of the resident nearest to the window. - room [ROOM NUMBER] had 4 to 5 gouges on the north wall, basketball sized. The window blinds had 3 horizontal slats that were broken and partially missing. - room [ROOM NUMBER] had a broken closet door. - room [ROOM NUMBER] had a broken closet door. - room [ROOM NUMBER] had a broken closet door and the window blinds were non-functional. - room [ROOM NUMBER] had a broken closet door. - room [ROOM NUMBER] had a broken closet door. During an interview, on [DATE] at 2:28 P.M., the Area Maintenance Director indicated 24 rooms a month were toured to identify problems. The Area Maintenance Director indicated the facility utilized a TELS (technilogial system to streamline building maintence) system to submit work orders and all staff should have been submitting requests (regarding the broken and damaged items above). The Area Maintenance Director indicated the damaged and disrepaired items needed to be repaired and remedied. On [DATE] at 10:08 A.M., the Director of Nursing (DON) provided a policy titled, Facility Maintenance Guidelines and Procedure, undated and indicated the policy was the one currently used by the facility. The policy indicated .provide a clean, comfortable environment .Maintenance will attempt to repair items as soon as possible . 3.1-19 (e)

Based on observation, record review and interview, the facility failed to follow a Physician's order related to providing nutritional supplements for 1 of 1 resident who was reviewed for nutrition. (Resident 53) Finding includes: During meal observations, Resident 53 did not have a health shake on his lunch meal tray on the following dates: -5/20/2025 -5/21/2025 -5/22/2025 Resident 53's record review was completed 5/22/2025 at 2:15 P.M. Diagnoses included, but were not limited to: dysphagia, rhabdomyolysis, protein-calorie malnutrition, starvation and sacral pressure ulcer. A current Physician's order, dated, 2/28/2025, indicated Resident 53 was to receive a health shake at lunch and dinner. However, a review of the May 2025 Medication Administration Record (MAR) indicated Resident 53 was documented as having received his lunch health shake on 5/20, 5/21 and 5/22/2025 even though there was no health shake served to Resident 53. During an interview on 5/23/2025 at 1:30 P.M., LPN 4 indicated Resident 53 had drank all of his lunch health shake on 5/23/2025. LPN 4 indicated the kitchen was responsible for providing the health shake and the nurse was responsible for documenting the intake. During an interview on 5/23/2025 at 1:37 P.M., Dietary Aide (DA) 5 indicated Resident 53's meal tickets showed a standing order for him to receive a health shake on his lunch tray. DA 5 indicated it was the kitchen's responsibility to provide the health shake, but if the health shake was missing, the nurse should should have contacted the kitchen. On 4/23/2025 at 2:24 P.M., the Director of Nursing (DON) provided an undated policy titled, Nutritional and Dietary Supplements and identified it as the policy currently used by the facility. The policy indicated, . 2. The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs 3.1-46 (a)(2)

Based on interview and record review, the facility failed to ensure a Skilled Nursing Facility-Advanced Beneficiary Notice Form (SNF-ABN) was provided timely following the end of Medicare skilled services for 2 of 3 residents who were discharged from Medicare services. (Resident 64 & 178) Finding includes: 1. During a review of Resident 64's SNF-ABN form, on 5/22/2025 at 2:05 P.M., the SNF-ABN document indicated Resident 64's Medicare coverage had ended on 4/1/2025. An undated Notice of Medicare Non-Coverage (NOMNC) form had been provided to Resident 64 and she had signed the document, but there was no date indicating when the resident had been informed. During an interview on 5/22/2025 at 1:34 P.M., the Business Office Manager (BOM) indicated she was unaware Resident 64 needed to have been given the SNF-ABN and NOMNC documents to sign and Resident 64 had not been given the SNF-ABN or NOMNC documents 48 hours before her had therapy ended. 2. During a review of SNF-ABN form, on 5/22/2025 at 2:07 P.M., the SNF-ABN document indicated Resident 178's Medicare coverage had ended on 1/28/2025. An undated NOMNC form had been provided to Resident 178 and he had signed the document, but there was not a date to indicate when the resident had been informed. During an interview on 5/22/2025 at 1:35 P.M., the Business Office Manager indicated she was unaware Resident 178 needed to have been given the SNF-ABN and NOMNC documents to sign and Resident 178 had not been given the SNF-ABN or NOMNC document 48 hours before his therapy ended. On 5/22/2025 at 2:54 P.M., the Director of Nursing provided an undated policy title, Advance Beneficiary Notices, and identified it as the policy currently used by the facility. The policy indicated, .7. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay . 3.1-4(f)(2)

Based on record review and interview, the facility failed to ensure an individualized plan of care was created for a resident with an Activity of Daily Living (ADL) self-care performance deficit for 1 of 21 residents reviewed for care plans. (Resident 65) Finding includes: The clinical record of Resident 65 was reviewed on 5/20/2025 at 2:50 P.M. The residents' diagnoses included but were not limited to: local infection of skin and subcutaneous tissue, falls, anxiety, depression, hypertension, bipolar disorder, sepsis and dysphagia. An admission Minimum Data Set (MDS) assessment, dated 4/9/2025, indicated the resident was severely cognitively impaired and required substantial assistance with upper and lower body dressing, putting on footwear, personal hygiene, toileting, showering and bathing. A current Care Plan, initiated 4/23/2025, indicated Resident 65 had an ADL self-care performance deficit and required assistance by one staff but failed to document the type and frequency of bathing preferred by the resident. During an interview, on 5/22/2025 at 2:08 P.M., the Director of Nursing (DON) indicated resident care plans were completed with an interdisciplinary approach. Social Services completed their portion of the care plan and other disciplines completed their care plans. The DON indicated an aide would have known Resident 65 was an assist of one for bathing or showering but the resident preference on the type or frequency of bathing and the care plan should have been included in the care plan. On 5/22/2025 at 2:30 P.M., the DON provided a policy titled, Comprehensive Care Plans, dated 2025 and indicated the policy was the one currently used by the facility. The policy indicated .develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing, and .ALL services that are identified in the resident's comprehensive assessment . 3.1-35(a)

Based on interview, observation and record review, the facility failed to update a care plan with interventions put into place after a fall for 1 of 1 resident reviewed for falls. (Resident 2) Finding includes: A record review was completed on 5/22/2025 at 11:24 A.M. for Resident 2. Diagnoses included, but were not limited to: acute and chronic respiratory failure with hypoxia and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 4/29/2025, indicated Resident 2's cognition was severely impaired, was dependent for toileting, bed mobility and transfer needs and had had no falls since admission. On 5/22/2025 at 1:52 P.M. a current Care Plan, initiated on 1/8/2025, indicated Resident 2 was at risk for falls. Interventions included: call light within reach and anticipate and meet the resident's needs. A Nursing Progress Noted indicated on 4/14/2025 at 8:20 A.M., Resident 2 fell out of bed and sustained an injury to her head. The post-fall evaluation, completed on 4/14/2025, indicated a fall mat was placed by the bed, the resident was placed in a low bed and the interventions would be placed on the Care Plan. However, the Care Plan was not updated to reflect the interventions until 5/20/2025 when the fall mat was added. The low bed was not added to the Care Plan. During an interview on 5/22/2025 at 2:29 P.M., the DON indicated the care plan should have been updated at the time of the fall with the new interventions. On 5/22/2025 at 2:29 P.M. a current policy, dated August 2024 and titled, Care Plan Revisions Upon Status Change was provided by the DON. The policy indicated, .The care plan will be updated with the new or modified intervention 3.1-35(e)

Based on interview, observation and record review, the facility failed to notify the Physician of a resident's new pain for 1 of 1 residents reviewed for pain. (Resident 49) Finding includes: During an interview on 5/19/2025 at 9:30 A.M., Resident 49 indicated his Foley catheter (indwelling urinary catheter) was causing him pain and he rated the pain as a 7 out of 10, with 0 being no pain and 10 being the worst pain. He pulled his brief down and exposed his catheter. The leg strap of the catheter was stuck to the tip of Resident 49's penis with a dime size amount of blood noted on the catheter strap. During an observation and interview,on 5/19/2025 at 9:34 A.M., the Unit Manager (UM) put on gloves and assessed Resident 49's Foley catheter. Resident 49 again reported his pain as a 7 out of 10. The UM put the leg strap onto the resident's leg and repositioned the Foley catheter tubing. The UM indicated Resident 49 had scheduled pain medications ordered, but did not have any pain medication ordered for breakthrough pain. The UM indicated she had requested an as needed (PRN) pain medication to be added to Resident 49's orders, but the Hospice provider had not yet ordered a PRN medication. During an interview on 5/19/2025 at 11:05 A.M., Resident 49 indicated his Foley catheter was still hurting and rated his pain as an 8 out 10. Resident 49 indicated he had not received any pain medication since his morning medication pass. Resident 49's record review was completed on 5/21/2025 at 9:26 A.M. Diagnoses included, but were not limited to: neurogenic bladder, schizophrenia, anxiety disorder, dysphagia, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment indicated Resident 49 had moderate cognitive impairment and was able to understand others and make himself understood. A current Physician's order indicated Resident 49 received Hospice services. Resident 49's record lacked the documentation that the Physician had been contacted on 5/19/2025 regarding the new pain Resident 49 was having related to his Foley catheter. A review of Resident 49's Hospice binder was completed on 5/21/2025 at 9:40 A.M. Resident 49 had been seen by the Hospice Nurse (HN) on 5/20/2025, but the HN had not addressed the penile pain caused by the indwelling catheter. During an observation of catheter care on 5/21/2025 at 10:00 A.M., Resident 49 indicated his Foley catheter was still causing him pain. CNA 3 indicated the nurse was aware of the resident's pain and continued with the Foley catheter care without asking Resident 49 if she could continue the catheter care. During an interview with the Clinical Educator (CE) on 5/21/2025 at 10:05 A.M., the CE indicated Resident 49's pain had been reported to a nurse, but not the nurse that was taking care of Resident 49. She indicated Resident 49's pain had not been assessed and the Foley catheter care should not have been continued until he had been assessed by his nurse. During an interview with the UM on 5/21/2025 at 11:03 A.M., the UM indicated Resident 49 had not complained of Foley catheter pain in the past and she had called Hospice after Resident 49's catheter care had been completed on, 5/21/2025, to report his pain and requested a nurse visit for that day. The UM indicated Resident 49's pain had not been assessed on 5/21/2025, after the resident had reported his pain to the nursing staff. The UM indicated she had called Hospice on 5/19/2025 but had forgotten to add a note to the record. The UM indicated she had added a late entry note for 5/19/2025 on 5/22/2025. The note indicated Hospice had been notified of the new pain. The UM was unable to provide the name of Hospice employee she had spoken with at the Hospice provider's office on 5/19/2025. The UM indicated the Hospice provider had not given any new orders and had not been to the facility to see Resident 49 since the new pain (pain with the Foley catheter) had started and was reported to them on 5/19/2025. The UM indicated she had had conversations with the Hospice nurses about adding a PRN pain medication in the past, but no PRN pain medication order had been provided by Hospice. During an interview with a Business Office Associate (BOA) of the Hospice company on 5/21/2025 at 12:50 P.M., the BOA indicated she had reviewed the notes and call logs related to Resident 49 and could not find an entry or a call logged from the facility on 5/19/2025. The BOA indicated Resident 49 had been seen by the Hospice Nurse on 5/22/2025 in the facility. During an interview with a Hospice Nurse (HN), on 5/21/2025 at 2:00 P.M., she indicated Resident 49 had been seen by Hospice on 5/20/2024 and the facility had not reported any new or worsening pain related to Resident 49's Foley catheter or requested any PRN pain medication. The HN indicated Resident 49 had not complained of pain with the Foley catheter in the past to her. The HN reported the new pain to the Hospice Physician and obtained an order for a PRN pain medication for Resident 49. During an interview with the Hospice Director of Operations (HDO) on 5/21/2025 at 2:04 P.M., the HDO indicated she had reviewed the call logs to the Hospice office and there was no logged calls from the facility on 5/19/2025 nor did she locate any notes that the facility had called about Resident 49's complaint of penile pain due to his catheter prior to 5/21/2025. A HN had visited Resident 49 on 5/20/2025 and staff had not reported any pain related to the Foley catheter to the HN. The HDO indicated Hospice had not received any requests from staff to include a PRN pain medication. The HDO indicated the facility should have reported the new pain on 5/19/2025 and before they provided catheter care on 5/21/2025 so Resident 49 did not have any unnecessary pain. On 5/21/2025 at 1:03 P.M., the DON provided an undated policy titled, Pain Management, and identified it as the policy currently used by the facility. The policy indicated, .The facility must ensure that pain management is provided to residents who require such services . Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: . b. Evaluate the resident for pain and the cause upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain.) .2 . j. Facility staff will notify the practitioner, if the resident's pain is not controlled by the treatment regimen 3.1-5 (a)(2)

Based on interview, observation and record review, the facility failed to notify the address a resident's pain timely and effectively for 1 of 1 residents reviewed for pain. (Resident 49) Finding includes: During an interview on 5/19/2025 at 9:30 A.M., Resident 49 indicated his Foley catheter (indwelling urinary catheter) was causing him pain and he rated the pain as a 7 out of 10, with 0 being no pain and 10 being the worst pain. He pulled his brief down and exposed his catheter. The leg strap of the catheter was stuck to the tip of Resident 49's penis with a dime size amount of blood noted on the catheter strap. During an observation and interview,on 5/19/2025 at 9:34 A.M., the Unit Manager (UM) put on gloves and assessed Resident 49's Foley catheter. Resident 49 again reported his pain as a 7 out of 10. The UM put the leg strap onto the resident's leg and repositioned the Foley catheter tubing. The UM indicated Resident 49 had scheduled pain medications ordered, but did not have any pain medication ordered for breakthrough pain. The UM indicated she had requested an as needed (PRN) pain medication to be added to Resident 49's orders, but the Hospice provider had not yet ordered a PRN medication. During an interview on 5/19/2025 at 11:05 A.M., Resident 49 indicated his Foley catheter was still hurting and rated his pain as an 8 out 10. Resident 49 indicated he had not received any pain medication since his morning medication pass. Resident 49's record review was completed on 5/21/2025 at 9:26 A.M. Diagnoses included, but were not limited to: neurogenic bladder, schizophrenia, anxiety disorder, dysphagia, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment indicated Resident 49 had moderate cognitive impairment and was able to understand others and make himself understood. A current Physician's order indicated Resident 49 received Hospice services. Resident 49's record lacked the documentation that the Physician had been contacted on 5/19/2025 regarding the new pain Resident 49 was having related to his Foley catheter. A review of Resident 49's Hospice binder was completed on 5/21/2025 at 9:40 A.M. Resident 49 had been seen by the Hospice Nurse (HN) on 5/20/2025, but the HN had not addressed the penile pain caused by the indwelling catheter. During an observation of catheter care on 5/21/2025 at 10:00 A.M., Resident 49 indicated his Foley catheter was still causing him pain. CNA 3 indicated the nurse was aware of the resident's pain and continued with the Foley catheter care without asking Resident 49 if she could continue the catheter care. During an interview with the Clinical Educator (CE) on 5/21/2025 at 10:05 A.M., the CE indicated Resident 49's pain had been reported to a nurse, but not the nurse that was taking care of Resident 49. She indicated Resident 49's pain had not been assessed and the Foley catheter care should not have been continued until he had been assessed by his nurse. During an interview with the UM on 5/21/2025 at 11:03 A.M., the UM indicated Resident 49 had not complained of Foley catheter pain in the past and she had called Hospice after Resident 49's catheter care had been completed on, 5/21/2025, to report his pain and requested a nurse visit for that day. The UM indicated Resident 49's pain had not been assessed on 5/21/2025, after the resident had reported his pain to the nursing staff. The UM indicated she had called Hospice on 5/19/2025 but had forgotten to add a note to the record. The UM indicated she had added a late entry note for 5/19/2025 on 5/22/2025. The note indicated Hospice had been notified of the new pain. The UM was unable to provide the name of Hospice employee she had spoken with at the Hospice provider's office on 5/19/2025. The UM indicated the Hospice provider had not given any new orders and had not been to the facility to see Resident 49 since the new pain (pain with the Foley catheter) had started and was reported to them on 5/19/2025. The UM indicated she had had conversations with the Hospice nurses about adding a PRN pain medication in the past, but no PRN pain medication order had been provided by Hospice. During an interview with a Business Office Associate (BOA) of the Hospice company on 5/21/2025 at 12:50 P.M., the BOA indicated she had reviewed the notes and call logs related to Resident 49 and could not find an entry or a call logged from the facility on 5/19/2025. The BOA indicated Resident 49 had been seen by the Hospice Nurse on 5/22/2025 in the facility. During an interview with a Hospice Nurse (HN), on 5/21/2025 at 2:00 P.M., she indicated Resident 49 had been seen by Hospice on 5/20/2024 and the facility had not reported any new or worsening pain related to Resident 49's Foley catheter or requested any PRN pain medication. The HN indicated Resident 49 had not complained of pain with the Foley catheter in the past to her. The HN reported the new pain to the Hospice Physician and obtained an order for a PRN pain medication for Resident 49. During an interview with the Hospice Director of Operations (HDO) on 5/21/2025 at 2:04 P.M., the HDO indicated she had reviewed the call logs to the Hospice office and there was no logged calls from the facility on 5/19/2025 nor did she locate any notes that the facility had called about Resident 49's complaint of penile pain due to his catheter prior to 5/21/2025. A HN had visited Resident 49 on 5/20/2025 and staff had not reported any pain related to the Foley catheter to the HN. The HDO indicated Hospice had not received any requests from staff to include a PRN pain medication. The HDO indicated the facility should have reported the new pain on 5/19/2025 and before they provided catheter care on 5/21/2025 so Resident 49 did not have any unnecessary pain. On 5/21/2025 at 1:03 P.M., the DON provided an undated policy titled, Pain Management, and identified it as the policy currently used by the facility. The policy indicated, .The facility must ensure that pain management is provided to residents who require such services . Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: . b. Evaluate the resident for pain and the cause upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain.) .2 . j. Facility staff will notify the practitioner, if the resident's pain is not controlled by the treatment regimen 3.1-37(a)

Based on observation, record review and interview, the facility failed to wear personal protective equipment (PPE) while providing Foley catheter (indwelling urinary catheter) care for 1 of 4 residents reviewed for Enhanced Barrier Precautions (EBP). (Resident 49) Finding includes: During an observation on 5/19/2025 at 9:34 A.M., the Unit Manager (UM) put on gloves, but did not put on a gown and assessed Resident 49's urinary catheter. The UM put the leg strap onto the resident's leg and repositioned the catheter. There was an Enhanced Barrier Precaution sign hanging on Resident 49's door and a three drawer cart with PPE supplies noted outside of the resident's room. Resident 49's record review was completed on 5/21/2025 at 9:26 A.M. Diagnoses included, but were not limited to: neurogenic bladder, schizophrenia, anxiety disorder, dysphagia, and major depressive disorder. A current Physician's order, dated, 5/23/2025, indicated Resident 49 was in EBP related to an indwelling catheter and gown and gloves should be worn for high contact resident care. During an interview with the UM on 5/21/2025 at 11:03 A.M., the UM indicated she had only worn gloves while repositioning the resident's Foley catheter and should have worn a gown as well. On 5/27/2025 at 10:30 A.M., the Director of Nursing (DON) provided an undated policy, titled, Enhanced Barrier Precautions and identified it as the policy currently used by the facility. The policy indicated, .b. an order for EBP will be obtained for residents with any of the following: Wounds and/or indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO . 4. High-contact resident care activities include: . g. Device care or use: central lines, urinary catheters 3.1-18 (a)

Based on record review and interview the facility failed to ensure resident grievances were responded to promptly and acted upon for 4 of 21 residents reviewed for grievances. (Residents 52, 30, 70 & 128) Findings include: Review of 21 resident grievance forms, on 7/12/2024 at 9:38 A.M., indicated there was no documentation of response and outcomes for 4 of the 21 grievances reviewed. 1. During an interview, on 07/12/2024 at 10:49 A.M., Resident 52 indicated he had waited about an hour on every shift to get care and he has had staff come in, turn the call light off and never came back. The grievance discussed his concerns related to having to wait an hour every shift to get the care he needed, staff turning his call light off, without meeting his care needs and never coming back to give him care. Resident 52 indicated he had not received any response, written or verbal regarding his grievances. On 6/7/2024 Resident 52 filed a personal grievance indicating he had asked for help to use the bathroom and had to wait over 40 minutes for help. The grievance was reviewed by the Executive Director and resolved on 6/10/2024. 2. During an interview, on 7/12/2024 at 10:54 A.M., Resident 30 indicated he had waited 2 hours for care, he had pressed his call light and staff would turn it off and not come back to provide care. Resident 30 filed a personal grievance and had never been told the outcome of any of his grievances or received a written copy. On 6/30/2024, Resident 30 filed a personal grievance indicating it took too long for care and was specifically complaining about the care he received on 6/29/2024. The grievance was reviewed by the Executive Director and resolved on 7/13/2024 3. During an interview, on 7/12/2024 at 11:05 A.M., Resident 70 indicated she had waited approximately 20 minutes for her call light to be answered, staff would come in and turn her call light off and then leave. She stated most of the time staff did not come back after turning off the call light. Resident 70 indicated she had filed a grievance and had never received any outcome or response to her grievances or a written copy. On 6/8/2024 Resident 70's significant other filed a grievance indicating the resident was not receiving care as soon as she asked for help. The grievance was reviewed by the Executive Director and resolved on 6/10/2024. During an interview, on 7/12/2024 at 1:10 P.M., the Administrator indicated the facility never provided residents with written responses to their grievances and they should have provided responses. 44111 4. During an interview, on 7/9/2024 at 9:49 A.M., Resident 128 indicated he was missing $20.00 from his wallet. This had occurred sometime between midnight and 4 A.M. on a date near the end of June 2024. A staff member had filled out a grievance form but he had not been informed of the outcome. Review of the grievance log indicated there was an entry, dated 6/27/2024, for Resident 128 regarding missing money. The report indicated he was missing $20.00 out of his wallet. A record review was completed on 7/9/2024 at 3:02 P.M., for Resident 128. An admission Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated he had no cognitive impairment. During an interview, on 7/10/2024 at 10:55 A.M., the Administrator indicated the grievance process included the following: once the facility heard a complaint from a Resident, the concern/grievance was assigned to a department head and they were responsible to interview and resolve the complaint/grievance. She indicated the Admissions Director had been assigned Resident 128's grievance. During an interview, on 7/10/2024 at 11:04 A.M., the Admissions Director indicated she had been assigned to Resident 128's grievance. She had spoken to the resident and asked him if he had possibly spent the money or had given it to his family. She had left a telephone message for his family but had not received a return call. The resident did have some take out food, undated from a local delivery service in the pantry refrigerator at the time of the investigation. The Admissions Director indicated she had not gone back to follow up on the grievance, nor did she inform the resident of any outcome In addition, she had not documented any resolution to the complaint/grievance. She preferred to have the forms completed within 24 hours after she received them. On 7/10/2024 at 11:10 A.M., the Administrator provided a policy titled, Resident and Family Grievances, dated 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .10. Procedure: c. Forward the grievance form to the Grievance Official as soon as practicable. e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concerns(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decisions was issued . 3.1-3(2)(l)

Based on interview, observation and record review, the facility failed to follow the physician's orders for 1 of 17 residents whose physician's orders were reviewed (Resident 11), and failed to accurately assess and document a wound for 1 of 7 residents reviewed for non pressure skin conditions. (Resident 5). The facility failed to obtain treatment orders for a new admission (Resident 127) and failed to transcribe and administer prescribed treatment orders from a follow-up post operative appointment. (Resident 63) for 1 of 17 residents reviewed for quality of care. Findings include: 1. During an interview and observation, on 7/8/2024 at 2:18 P.M., Resident 11 indicated he had problems with water retention in both of his lower legs and feet, and was not on a fluid restriction and was given as much to drink as he wanted. He indicated he did not wear any devices to help with the fluid retention. The resident had a full 20 ounce cup of water,dated 7/8/2024 and his lower legs and feet were observed to be swollen. During an observation, on 7/9/2024 at 11:05 A.M., Resident 11 had a 20 ounce cup of water, dated 7/9/2024, on his bedside table and his lower legs and feet remained swollen. During an observation, on 7/10/2024 at 9:55 A.M., Resident 11's lower legs and feet remained swollen. He had a 20 ounce cup of water, dated 7/10/2024, that was half empty and a second 20 ounce cup full of water without a date. A record review was completed on 7/10/2024 at 1:11 P.M. for Resident 11. Diagnoses included, but were not limited to, dementia, stage 3 chronic kidney disease, hypertension, post traumatic stress disorder, anxiety disorder, major depressive disorder, glaucoma and benign prostatic hyperplasia. A current Physician's Order, indicated the resident was on an 1800 mL (milliliter) fluid restriction. Dietary was to offer 1080 mLs a day and nursing staff could offer 240 mL per shift. A Quarterly MDS (Minimum Data Set), dated, 6/26/2024 indicated Resident 11's cognition was intact. A current Care Plan, dated 6/25/2021, indicated Resident 11 had history of significant weight gain and losses throughout his stay and was on daily diuretic medication which could contribute to weight changes. The goal was to have no significant undesirable weight changes. Interventions to the Care Plan included, but were not limited to, provide fluid restriction as ordered and diet as ordered. An interview was completed on 7/11/2024 at 9:43 A.M. CNA 2 indicated she was responsible for taking care of Resident 11. Water should be passed at the beginning of every shift and then refilled as needed. CNA 2 was not aware the resident had a fluid restriction and gave him a full cup of water. Staff typically knows a resident is on a fluid restriction because fluid restrictions were posted on a list in the kitchenette, but Resident 11 was not on the fluid restriction list. The cups that were used to pass water contained 20 ounces or 591 mL. Resident 11 should not have been given a cup of water with 591 mLs. During an interview, on 7/11/2024 at 9:45 A.M., CNA 2 indicated she was assigned to care for Resident 11. Water was to be passed at the beginning of every shift and then refilled as needed. CNA 2 was not aware Resident 11 had a fluid restriction and had given him full cup of water. She indicated staff were notified of any fluid restrictions from a list posted in he kitchenette and Resident 11 was not on he list of residents with fluid restrictions. The water cups used to pass ice water were 591 ml and residents on fluid restrictions were not to have full cups of ice water. On 7/11/2024 at 9:50 A.M., the Regional Nurse Consultant provided an undated policy, titled, Fluid Restriction, and identified it as the policy currently used by the facility. The policy indicated, .It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders . 2. The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes . 4. Water will not be provided at the bedside unless calculated into the daily total fluid restriction 47419 2. During an observation of Resident 5, on 7/8/2024 at 10:11 A.M., dark reddish/brown scabs were noted on Resident 5's left foot 2nd and 3rd toes. A record review was completed on 7/9/2024 at 1:48 P.M. for Resident 5. Diagnoses, included but were not limited to, peripheral venous insufficiency and type 2 diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 5/3/2024 indicated the resident was moderately cognitively impaired, had not exhibited any behavioral issues, was dependent on staff for bathing, transferring and toielting needs, was frequently incontinent of his bladder and always incontinent of his bowels, was at risk for pressure ulcers but had none, had a pressure reducing mattress and cushion for his wheelchair and had creams and ointments applied to his skin other than his feet. The Physician's Order Summary's included the following orders: elevate legs and float heels while in bed. A current Care Plan problem, initiated on 8/27/2019, indicated the resident was at risk for pressure ulcers. The interventions included, but were not limited to, conduct a weekly skin inspection and check skin during bathing. A Weekly Skin Assessment, dated 7/8/2024, indicated his skin was intact and there were no orders for wound care. During an interview, on 7/11/2024 at 2:58 P.M., the Unit Manager indicated she did not think Resident 5 currently had any wounds. After the Unit Manager was made aware of Resident 5's wounds, she indicated the wounds should have been noted during the weekly assessment. During an interview, on 7/11/2024 at 2:59 P.M., LPN 4 indicated he did not know about any wounds for Resident 5. On 7/1//2024 at 8:30 A.M., the Executive Director provided a current, undated, policy titled, Skin Integrity-Skin Tears. The policy indicated, .a. Licensed nurses will conduct skin assessments in accordance with facility policy 44111 3. During an interview on 7/8/2024 at 2:56 P.M., a family member indicated Resident 63 had back surgery on 6/13/2024. On 6/26/2024 following a post-operative visit, she returned with treatment orders and the orders did not get initiated for a couple days afterwards. A record review was completed on 7/12/2024 at 7:45 A.M. for Resident 63. Diagnoses included, but not limited to, status post lumbar decompression/discectomy tube based right L 2-3, low back pain and type 2 diabetes with chronic kidney disease. A Physician Progress Note, dated 6/26/2024, indicated to see wound care and betadine was tot be applied daily with a light dressing. A Treatment Administration Record (TAR), dated 6/1/2024 - 6/30/2024, indicated an order was initiated on 6/28/2024 on the evening shift to cleanse the surgical wound, pat dry and apply betadine twice a day. During an interview on 7/11/2024 at 2:42 P.M., the Wound Nurse indicated Resident 63 had returned from her post operative appointment on 6/26/2024 with an order for betadine and a dressing. During an interview on 7/12/2024 at 11:00 A.M., the Regional Nurse Consultant indicated she did not know why the order was not written until 6/28/2024. On 7/12/2024 at 1:14 P.M., a policy was requested, the Regional Nurse Consultant indicated the facility did not have one. 4. During an interview and observation on 7/8/2024 at 11:23 A.M., Resident 127 indicated his right hip surgical site dressing had not been changed every day and the staff just peeked under his skin tear dressing to the right wrist and layed the dressing back down. The hip dressing had visible bloody drainage and was undated, and the right wrist dressing was undated. A record review was completed on 7/10/2024 at 9:46 A.M., for Resident 127. Diagnoses included, but were not limited to, fracture of unspecified part of neck of right femur and initial encounter for closed fracture. He was admitted to the facility on [DATE]. During an observation on 7/9/2024 at 1:26 P.M., Resident 127 indicated his dressings had been changed, and he had told them to date the hip dressing, but they did not date the wrist. A Nursing Admission General Note, dated 7/3/2024, indicated there was a skin issue to the right anterior wrist and redness and bruising to the right hip. There was no mention of the surgical wound to Resident 127's right hip. The current Physician's Order Summary, for July 2024, indicated there were no treatment orders for the right wrist skin tear nor the right hip surgical site. During an interview on 7/10/2024 at 1:08 P.M., the Wound Nurse indicated the treatment orders for the skin tear and the right hip surgical site should have been obtained upon admission and when a dressing was changed, it should be dated with the nurse's initial. On 7/10/2024 at 1:44 P.M., the Wound Nurse provided a policy titled, Wound Treatment Management, undated, and indicated the policy was the one currently used by the facility. the policy indicated, .Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse . 3.1-37(a)

Based on interview and record review the facility failed to ensure the Medical Director or his designee attended the quarterly Quality Assurance and Performance Improvement (QAPI) meeting during the past year. Finding includes: During an interview on 7/12/2024 at 1:56 P.M., the Administrator indicated the Medical Director had not attended the quarterly meetings, but she reviewed them with him or sent the minutes from the meeting to the Medical Director via an e-mail. The Nurse Practitioner attended some facility meetings, such as the nutrition at risk/wound, behavior, morning meeting or stand down meetings, but the QAPI signature log did not indicate she had attended any QAPI meetings during the past year. On 7/12/2024 at 2:00 P.M., the Administrator provided a policy titled, Quality Assurance and Performance Improvement, undated and indicated the policy was currently the one used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines: 2. The QAA Committee shall be Interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services ii. The Medical Director or his/her designee iii.At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role; and iv. The Infection Preventionist. b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program,such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary . 3.1-52(a)

Based on observation, record review and interviews, the facility failed to ensure physician orders regarding dressing changes were followed for 1 of 1 residents reviewed for intravenous fluids. (Resident 128) Finding includes: During an observation and interview on 7/9/2024 at 10:14 A.M., Resident 128 indicated his peripheral inserted central catheter (PICC) line dressing had only been changed once since he was admitted . The date on the dressing was 6/29. The dressing had gauze tape applied around the edges of the dressing. A record review was completed on 7/9/2024 at 3:02 P.M., for Resident 128. Diagnosis included but not limited to, paraplegia, osteomyelitis of vertebra, sacral and sacrococcygeal, region, residual foreign body in soft tissue pressure ulcer of unspecified site, unspecified stage, pressure ulcer of sacral region, unstageable. An Admission Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated he had no cognitive impairment. A Physician's Order, dated 6/21/2024, indicated to the PICC line dressing was to be changed upon admission, then weekly and as needed, on the night shift every Sunday. A Medication Administration Record (MAR), dated 6/1/2024-6/30/2024, indicated the dressing was changed on 6/23/2024, and 6/30/2024. A Medication Administration Record, dated 7/1/2024 - 7/31/2024 indicated the dressing was changed on 7/7/2024. A Nursing Progress Note, dated 6/29/204 at 7:28 P.M., indicated the Access RN was in the building and the PICC line dressing changed was completed. A Care Plan, dated 6/21/2024, indicated the resident had a potential risk for infection at the PICC line site with an intervention for dressings to be changed as ordered. During an interview on 7/9/2024 at 3:30 P.M., LPN 15 indicated the date on the PICC line dressing was 6/29. She indicated it looked like someone re-enforced the dressing with tape and it was not ok to leave the dressing on that long. During an interview on 7/12/2024 at 12:47 P.M., the Infection Preventionist (IP) Nurse indicated that the dressing was not changed and the MAR was inaccurately signed on 7/7/2024. During an interview on 7/10/2024 at 10:16 A.M., the IP (Infection Preventionist) Nurse indicated she could not find any documentation the dressing had been changed upon the resident's admission to the facility. She could not find that it was required in the facility policy and did not know why it was ordered to be changed upon admission. On 7/10/2024 at 8:25 A.M., the IP Nurse provided a policy titled, PICC/Midline/CVAD Dressing Change, undated, and indicated the policy was the one currently used by the facility. The policy indicated . Policy: It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type and frequency of changes . 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure residents were made aware of the facility's bed hold policy upon transfer to a hospital for 2 of 2 residents reviewed for hospitalization s. (Residents 28 and 64) Findings include: 1. A record review for Resident 28 was conducted on 7/9/2024 at 3:04 P.M., Diagnoses included, but were not limited to, type 2 diabetes mellitus and anxiety disorder. An Annual Minimum Data Set (MDS) assessment, dated 5/8/2024, indicated Resident 28 had moderate cognitive impairment. Nursing Progress Notes, dated 4/22/2024, indicated Resident 28 was admitted to the hospital due to a methicillin resistant staph aureus infection. The record indicated her family had been notified but did not indicate the bed hold policy was explained and/or a copy given to the resident. 2. A record review for Resident 64 was conducted on 7/11/2024 at 9:32 A.M. Diagnoses included, but were no limited to, acquired absence or right and left leg below the knee and type 2 diabetes mellitus. An Admission Minimum Data Set assessment, dated 5/9/2024, indicated Resident 64's cognition was intact. A Nursing Progress Note, dated 5/16/2024, indicated the resident was transferred to the hospital for congestive heart failure. The family was notified of the resident's transfer but the record did not indicate the resident or the resident's family was made aware of, or given a copy of the facility's bed hold policy. During an interview on 7/10/2024 at 1:42 P.M., LPN 11 indicated copies of the Advance Directive, face sheet, current order summary, bed hold policy, and any pertinent labs or x-rays were given to EMS personnel when residents were transferred to the emergency room . A copy of the bed hold policy given to the resident should have been placed in the medical record. During an interview on 711/2024 at 1:40 P.M., the ED (Executive Director) indicated there was no documentation of bed hold policies being given to Residents 28 and 64 when they were transferred to the hospital. On 7/11/2024 at 1:50 P.M., the Regional Nurse 14 provided a current, undated, policy titled, Transfer and Discharge (including AMA). The policy indicated, .Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated 3.1-12(a)(25)(26)

Based on observation, record review and interview, the facility failed to provide nail care for dependent residents for 3 of 5 residents who were reviewed for activities of daily living needs. (Residents 35, 5, & 28) Findings include: 1. During an observation on 7/8/2024 at 10:06 A.M., Resident 35's right hand was contracted and his fingernails were long and curled downward on both hands. During an observation on 7/9/2024 at 11:30 A.M., Resident 35's right hand was contracted and his nails were long and curled downward on both hands. During an observation on 7/11/2024 at 10:04 A.M., Resident 35's right hand was contracted and his nails were long and curled downward on both hands. Resident 35's record review was completed on 7/11/2024 at 10:40 A.M. Diagnoses included, but were not limited to, conversion disorder with seizures and convulsions, diabetes insipidus, bipolar disorder, dysphagia, anxiety, and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated, 5/8/2024, indicated Resident 35 was severely cognitively impaired and was dependent on staff for bathing and personal hygiene needs. A June 2024 TAR (Treatment Administration Record) indicated Resident 35 was given a full bed bath on: 6/13/2024, 6/17/2024, 6/20/2024, 6/21/2024, 6/23/2024, and 6/24/2024. Resident 35 received a shower on 6/27/2024 and 6/29/2024. He refused a shower on 6/12/2024, 6/16/2024, 6/19/224, 6/22/2024, 6/26/2024, and 6/29/2024. A July 2025 TAR indicated Resident 35 received a partial bed bath every day from 7/1/2024 through 7/12/2024 and refused a shower on 7/3/2024 and 7/5/2024. Resident 35's record lacked the documentation to indicate he was offered nail care after refusing baths or showers. Resident 35 did not have a current Care Plan to address the rejection of care. A Care Plan, dated, 2/10/2020, indicated the resident had a physical functioning deficit related to self care impairment. He had a goal of maintaining his current level of physical functioning. Interventions included, but were not limited to, personal hygiene assistance and nail care. During an interview on 7/10/2024 at 1:09 P.M., CNA 2 indicated nail care was included in shower and bath care. If a resident refused care, care was to be attempted at a later time. If the resident still refused care, the nurse was notified and a third attempt was made. Refusals were to be documented in the resident's Electronic Medical Record (EMR). During an interview on 7/11/2024 at 10:42 A.M, the Unit Manager indicated Resident 35's fingernails were too long on both hands but she was not able to provide any documentation indicating why nail care had not been provided during his baths or showers. 47419 2. During an observation on 7/9/2024 at 8:59 A.M., Resident 5's fingernails were long with dark yellowish/brown matter under them and his toenails were very long. During a record review conducted on 7/9/2024 at 1:48 P.M., a Quarterly Minimum Data Set assessment, dated 5/3/2024, indicated Resident 5's cognition was moderately impaired. No behavior issues were noted. He was dependent for bathing, transfers, and toileting. He required supervision or touch assist for personal hygiene. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and type 2 diabetes mellitus. A record review for Resident 5 was completed on 7/9/2024 at 1:48 P.M. Diagnosis, included but were not limited to, chronic obstructive pulmonary disease and type 2 diabetes mellitus. A Quarterly Minimum data Set (MDS) assessment, completed on 5/3/2024, indicated Resident 5's cognition was moderately impaired, he had not exhibited any behavioral issues, was dependent on staff assistance for bathing, transferring and toileting needs and required supervision and/or touch assistance from staff for personal hygiene needs. The current care plan and facility documentation regarding activities of daily living lacked any reference for nail care. During an observation, on 7/10/2024 at 10:58 A.M., Resident 5's toenails had been trimmed but his fingernails remained long and had dark yellowish/brown matter under them. During an observation and interview, on 7/10/2024 at 2:28 P.M., QMA 10 indicated that Resident 5's fingernails should have been clean and trimmed. 3. During an observation on 7/8/2024 at 11:40 A.M., Resident 28's fingernails were very long and had dark yellow matter under them. The record for Resident 28 was reviewed on 7/9/2024 at 3:04 P.M. Diagnoses, included but were not limited to, generalized osteoarthritis, firbromyalgia and type 2 diabetes mellitus. An Annual Minimum Data Set (MDS) assessment, completed on 5/8/2024, indicated Resident 28 had moderate cognitive impairment, had not exhibited any behavioral issues and required substantial to maximal assistance from staff for toileting, bathing and personal hygiene needs. The current care plan and facility documentation regarding activities of daily living needs lacked any reference for nail care. During an interview, on 7/10/2024 at 1:30 P.M., CNA 16 indicated a shower should include hair washing and nail care. If the resident was diabetic, she would soak their fingernails and clean under them with an orange stick. If their fingernails or toenails need to be trimmed she would notify the nurse. She indicated shaving was done if the resident agreed and/or requested it. If they did not want to be shaved, she would document it as a refusal on the shower sheet and in the chart and report it to the nurse. During an observation and interview, on 7/10/2024 at 2:28 P.M., QMA 10 indicated Resident 28's fingernails should have been cleaned and trimmed. During an interview, on 7/10/2024 at 2:35 P.M., the Unit Manager indicated fingernails should be cleaned and trimmed. Nurses provided nail care for diabetics. On 7/11/2024 at 1:36 P.M. the ED provided a current, undated, policy titled, Activities of Daily Living (ADLs). The policy indicated, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care 3.1-38(a)(3)

Based on observation, interview and record review the facility failed to ensure a catheter was anchored to prevent excessive tension on the catheter for 1 of 1 resident reviewed for urinary catheters. (Resident 128) Finding includes: During an interview, on 7/9/2024 at 9:58 A.M., Resident 128 indicated he had asked multiple times for several days on all three shifts for a catheter strap. He had an issue with blood in his catheter and was fearful of it getting pulled out. A record review was completed on 7/9/2024 at 3:02 P.M., for Resident 128. Diagnosis included but not limited to: paraplegia, osteomyelitis of vertebra in the sacral and sacrococcygeal region, residual foreign body in soft tissue, pressure ulcer of unspecified site, unspecified stage, and unstageable pressure ulcer of sacral region. An Admission Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated the resident had no cognitive impairment. During an observation of Resident 128's urinary catheter, on 7/10/2024 at 10:23 A.M., 7/11/2024 at 1:25 P.M., there was no catheter strap in place. A current Care Plan, dated 7/3/2024, indicated the resident had a foley catheter related to a stage 4 sacral wound. Interventions, included but were not limited to, anchor catheter to avoid excessive tugging on the catheter during transfers and delivery of care. During an interview, on 7/11/2024 at 1:27 P.M., LPN 3 indicated, to avoid excessive tugging on a urinary catheter during care and transfers, staff should make sure the urinary collection bag and tubing was unhooked from the bed and chair and fastened down with a catheter strap. If the tubing was not secured, the catheter could get pulled out and cause trauma to the urethra. LPN 3 indicated the physician's orders batched for the care of urinary catheters did not have a specific order regarding providing catheter straps, but it would help Resident 129 if a catheter strap was provided and applied. On 7/11/2024 at 1:01 P.M., the Regional Nurse Consultant provided a policy titled, Indwelling Catheter Use and Removal, undated, and indicated the policy was the on currently used by the facility. The policy indicated .7. Additional care practices include: d. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter . 3.1-(2)

Based on observation, record review and interviews, the facility failed to ensure physician orders regarding tube feeding orders were followed for 1 of 1 residents with tube feeding. (Resident 53) Finding includes: During an observation, on 7/11/2024 at 10:45 A.M., Resident 35 had a container of Jevity 1.5 (Brand of food used in feeding tubes) with 350 mL of formula remaining in the bag. The bag was still connected to a feeding tube pump that was turned off. Resident 35's record review was completed on 7/11/2024 at 11:40 A.M. Diagnoses included, but were not limited to, conversion disorder with seizures and convulsions, diabetes insipidus, bipolar disorder, dysphagia, anxiety, and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 5/8/2024, indicated Resident 35 was severely cognitively impaired and had a feeding tube. A current Physicians Order indicated the resident was to receive 1050 mL (milliliters) of Jevity 1.5 daily. A July 2024 Medication Administration Record (MAR) indicated the resident had received the full amount of Jevity 1.5 on 7/11/2024. A current Care Plan, indicated Resident 35 was dependent on tube feeding. The goals of the care plan were to have no undesirable weight changes, be free from discomfort, and be free from dehydration. Interventions included, but were not limited to, enteral formula and feedings as ordered, monitor ins and outs, and water flush. During an interview, on 7/11/2024 at 2:06 P.M., the Unit Manager indicated Resident 35 did not get all of his prescribed tube feed that day. On 7/11/2024 at 1:36 P.M., Regional Nurse 14 provided an undated policy, titled, Care and Treatment of Feeding Tubes, and identified it as the policy currently used by the facility. The policy indicated, . e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders 3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to provide a safe mechanically lifted transfer to prevent a major injury (Resident C), and safe activities of daily living (ADL) during a bed bath requiring bed mobility to prevent injury (Resident B) for 2 of 3 residents reviewed for accidents. Findings include: 1. A clinical record review was completed on 3/13/2023 at 11:18 A.M. Diagnoses included, but were not limited to: necrotizing fasciitis, left lower extremity below the knee amputation, sepsis, anemia, and chronic kidney disease. An Admission Minimum Data Set (MDS) Assessment reviewed on 1/16/2023, indicated Resident C had moderate cognitive impairment. She required extensive assistance with two or more staff members for bed mobility, transfers, and toileting. She had range of motion impairment on one side of the lower extremities. Her vision and hearing were adequate, and she was able to be understood and understood others. Resident C was receiving occupational and physical therapies since 1/9/2023, and speech therapy since 1/12/2023. A Care Plan initiated on 1/10/2023, indicated Resident C had a physical functioning deficit. A Physical Therapy Evaluation on 1/9/2023, indicated Resident C was dependent with transferring and required a mechanical lift for the transfers. A Physical Therapy Progress Report for 1/9/2023 through 1/20/2023, indicated Resident C required substantial/maximal assistance for sit to stand, chair/bed-to-chair transfer, and toilet transfer. She continues to have no weight bearing to the left lower extremity. On 1/30/2023, a Physical Therapy Treatment Encounter Note, indicated Resident C had worked on wheelchair to mat table transfers using a sliding board with moderate assistance to complete the task, sit to stand inside the parallel bars with moderate assistance for 20 second standing tolerance. A Change of Condition Nurse's Note on 1/31/2023 at 6:27 A.M., indicated Resident C was complaining of severe pain and the inability to lift her left shoulder. The assessing nurse noted the left shoulder with swelling, deformity, and bruising, and bruising to the left wrist. Resident C was sent to the Emergency Department via EMS (Emergency Medical Services). On 1/31/2023 at 7:02 A.M., a Nurse's Note indicated Resident C stated a (mechanical) lift was being used to complete a transfer, and that's when the injury occurred, around 8:00 P.M. on 1/30/2023. A Hospital Triage Note on 1/31/2023 at 7:18 A.M., indicated, .Patient states she resides at [facility name] and they were using the lift on patient around 2000 [8:00 P.M.], patient states her arm was stuck and they continued to move her, and she heard a pop. EMS placed her in a arm sling, and received 25 mcg [micrograms] of Fentanyl and 4 mg [milligrams] Zofran. Patient rates pain 8/10 A Hospital Emergency Note on 1/31/2023 at 7:48 A.M., indicated, .the left shoulder appears to be internally rotated and adducted with swelling to anterior aspect. Pain with movement of the left shoulder A computer tomography scan (CT scan) was performed in the Emergency Department. The CT scan results indicated, .hematoma and questionable tear of the left pectoralis major muscle and possible tear of the supraspinatus tendon. Resident was admitted to the hospital to the Orthopedic Unit A Hospital Social Worker (SW) Note on 1/31/2023 at 11:42 A.M., indicated, .SW was asked to assist with disposition and follow up. SW notified by forensics that this patient had concerns regarding her care last night at the facility .She was using the stand lift when she experienced pain in her L [left] shoulder and asked the staff to stop. They didn't and she continued to have pain overnight in her L [left] arm. This morning she was sent out for evaluation of the arm .Spoke with nurse at [facility's name] regarding the concerns. Explained that we would be filing a report with the state .The family does not want the patient to return to the facility On 2/1/2023 at 5:49 P.M., an Oncology Consultation Note indicated the CT scan from 1/31/2023 showed, .within the left pectoralis major muscle, there is a heterogeneous mass identified measuring 6.8 cm x 12.2 cm x 8.4 cm. Given the history of recent injury, this most likely represents an intramuscular hematoma possibly from a tear of the pectoralis major muscle A facility-initiated investigation was completed on 1/31/2023. CNA (Certified Nursing Assistant) 8 indicated she assisted CNA 5 with a transfer in Resident C's bathroom. She indicated when she walked into the bathroom CNA 5 and Resident C were in the middle of a transfer over the toilet, and Resident C was slipping down like she couldn't hold her weight. She indicated Resident C was lowered and the stand-up waist belt was resituated, and the transfer was completed. In a separate written statement, CNA 8 indicated she had gotten the call light string caught in the waist belt of the sit-to-stand lift and the call light string made a popping noise when it snapped. She indicated Resident C got anxious during the transfer, and she informed Resident C to calm down and breathe. CNA 5 was also interviewed for the facility-initiated investigation. He indicated he was in the bathroom with Resident C standing up from the lift in front of the toilet and her incontinence brief got stuck between the toilet and Resident C's legs. CNA 5 indicated CNA 8 came to assist when Resident C began yelling, she was going to fall. On 3/14/2023 at 11:57 A.M., a telephone call was placed to Resident C's son. He indicated the facility Administrator informed him an investigation would be completed related to the injury. He indicated his mother was able to describe what happened with the male and female that assisted her with her transfers, and the female employee was suspended. He indicated the staff was using a Hoyer lift (non-weight bearing mechanical lift) and his mom's arm got caught in the transfer. During an interview on 3/14/2023 at 1:23 P.M., the Director of Nursing indicated, a Lift/Transfer Assessment will be completed at admission, and then quarterly. The assessment does not take the place of therapy recommendations. She indicated staff would know a resident's transfer needs by the report provided by the transferring facility, and then therapy would give recommendations after that time. During an interview on 3/15/2023 at 11:28 A.M., PTA (Physical Therapy Assistant) 6 indicated that the therapy department communicated with the nursing department regarding the safest transfer of residents on their services. A Therapy to Nursing Communication Form was used at one time to communicate to the Unit Manager to ensure the care plan was updated, but that eventually went to verbal communication. She indicated the therapy department has been asked to use the communication form again from the facility management. On 3/15/2023 at 11:30 A.M., COTA (Certified Occupational Therapy Assistant) 7 indicated that Resident C was to use a Hoyer mechanical lift. She indicated therapy had tried to use the sit-to-stand lift, and Resident C was not safe using that mechanical life. COTA 7 indicated staff continued to use the sit-to-stand lift, despite the safety issue, and Resident C's injury occurred when using the sit-to-stand lift. On 3/14/2023 at 3:11 P.M., the Director of Nursing provided a policy titled, Safe Resident Handling/Transfer. The policy indicated, .It is the policy if this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .13. Resident lifting and transferring will be performed according to the resident's individual plan of care .14. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device 2. A clinical record review was initiated on 3/13/2023 at 1:17 P.M. Diagnoses included, but were not limited to: quadriplegia, contractures, and adult failure to thrive. A Care Plan initiated on 10/17/2022, indicated Resident B had an active diagnosis of complete quadriplegia with a goal of no issues related to hygiene and ADLs (activities of daily living). The Care Plan goals indicated Resident B required total assistance with bed mobility, transfers, and toileting related to spinal injury. A Significant Change Minimum Data Set (MDS) Assessment was completed on 12/27/2022. The assessment indicated Resident B was cognitively intact. She was dependent with two or more staff members assistance for bed mobility, transferring, toileting, and bathing. A Nurse's Note on 3/1/2023 at 10:55 A.M., indicated Resident B rolled out of bed while she received a bed bath. Resident B was found on the floor between the bed and wall on her left side. Resident B sustained a bruise to her left forehead, that measured 4 cm (centimeters) by 3.2 cm. On 3/1/2023 an Education/Inservice Form was completed and signed by 18 staff members. The form indicated, .Resident B - Air mattress setting should be checked for proper weight setting when rolling, to side position patient in the center of the bed, ensure that her bolsters are in place as needed when rolling and repositioning An Interdisciplinary Team (IDT) Note on 3/2/2023 at 9:33 A.M., indicated interventions put in place post-fall included education to staff and bolsters applied to the mattress for tactile boundaries. A Care Plan initiated on 3/2/2023, indicated Resident B was at risk for falls. Interventions for falls initiated on 3/1/2023 included education given to staff. During an observation and interview on 3/13/2023 at 3:22 P.M., QMA (qualified medication assistant) 1 indicated Resident B was not able to move her upper or lower extremities, or reposition herself. Both feet were observed to have foot drop, and the upper extremities had contractures at the elbow and wrist. Resident B had a heel floating device in place to keep her heels off the bed. She was on an air mattress and no bolsters were present. On 3/14/2023 at 9:47 A.M., LPN (licensed practical nurse) 3 indicated Resident B needed total assistance and one staff member could complete the assistance. She indicated Resident B could not move her arms or legs. During an observation and interview on 3/14/2023 at 9:57 A.M., Resident B indicated she was receiving a bed bath by CNA 4, when he stopped holding onto her, and she fell out of bed. She indicated CNA 4 had her too close to the edge of the bed. She indicated sometimes she received assistance of two CNA's and other times one CNA. She was on an air mattress and no bolsters were present. On 3/14/2023 at 1:42 P.M., the Director of Nursing indicated staff would find assistance required on the electronic medical record's Kardex system. She indicated the care plan should follow the MDS Assessment unless the resident has had a change with the MDS Assessment or change to the plan of care. A review of the Kardex report was completed on 3/14/2023 at 1:54 P.M. The Kardex did not have assistance required for bathing and/or bed baths. The Kardex indicated Resident B required complete dependence on staff for bed mobility. During an interview on 3/15/2023 at 10:27 A.M., CNA 4 indicated a resident's assistance level can be found on the Kardex, and if the information was not in that location he would speak with a nurse. He indicated Resident B required a Hoyer lift, and was totally dependent for bed mobility with the assistance of two staff members as Resident B cannot move on her own. CNA 4 indicated he was providing a bed bath on his own when Resident B fell from the bed, and he should have waited for another staff member to complete the bed bath. He indicated he was provided education on air mattresses, proper bed mobility, transfers, and bathing the next day after the incident. On 3/15/2023 at 1:12 P.M., the Director of Nursing provided the policy titled, Activities of Daily Living (ADLs). The policy indicated, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .4. The facility will maintain individual objectives of the care plan and periodic review and evaluation This Federal tag relates to Complaint IN00401294. 3.1-45(a)(2)

Based on record review and interview the facility failed to prevent burns from hot liquids by serving it at an inappropriate temperature resulting in a partial thickness to full thickness burn.(Resident D). Finding includes: An Incident Report, dated 1/20/23, indicated .Description added: Resident was in room and yelled. Staff responded and noted resident had spilt her hot tea .Action Taken: Resident assessed, NP [Nurse Practitioner] notified with new orders .Type of injury: Belly area has a 48 cm [centimeter] by 22 cm open blister area with redness noted by nurse During an interview, with Resident D, on 2/1/23 at 9:55 A.M., Resident D indicated she was sitting in her wheelchair with the overbed table across her lap, she was served hot tea in a Styrofoam cup that did not have a lid. She indicated she prefers not to have a lid on her cup because she cannot open the lid because she has contracted hands. She indicated that when the tea spilled it landed on her abdomen and she pulled her shirt away and she yelled for help. Staff came right away to assist her. During an interview and observation, on 2/1/23 at 10:00 A.M., with LPN 3 and Resident D, he said the area to Resident D's abdomen was better, it was healing. During the observation of Resident D's abdominal area, the skin to the abdomen had multiple brown scabs on her skin with the surrounding tissue a slightly reddened color. At that time, it appeared to be a healing wound. The multiple scabbed areas presented about the size of a nickel or dime. The clinical record for Resident D, was reviewed on 2/1/23 at 10:40 A.M. Diagnoses included, but not limited to: paraplegia unspecified, muscle weakness generalized and other lack of coordination. A Quarterly MDS (Minimum Data Set) assessment, dated 12/20/22 indicated the resident was cognitively intact and required supervision of 1 with eating. The MDS did not indicate any use of assisted devices for eating. A Nurse Practioner for Wound Care-Progress Notes, dated 1/23/23, indicated the resident was seen for a new abdominal burn .New areas of partial [epidermis& dermis damage] and full thickness [ includes all 3 layers of skin damage] tissue loss across abdomen with multiple fluid-filled blisters. Unable to sense pain; had spilled hot tea across her abdomen and couldn't remove clothing fast enough due to hand contractures. Will manage burn with thin layer Silvadene cream the cover with single layer xeroform; protect with ABD [abdominal type of dressing] and secure with medipore tape outside of wound boarders; change every 48 hrs. [hours] and prn[as needed] saturation. Keep site clean and dry and protect from further tissue damage A Tissue Analytics, dated 1/23/23 , indicated the burn wound measured 9.04cm x 4.05cm x0.20. The wound has scant serious fluid, with no odor with epithelium intact. Wound dressing to be completed 3 x's per week. A Tissue Analysis, dated 1/26/23, indicated the burn wound measured 7.07cm x 3.07 cm x 0.01 cm. Another Tissue Analysis dated 1/30/23 indicated the burn wound measured 7.49 cm x 7.19 cm x.0.10 cm. The Treatment Administration Record (TAR) for January 2023, indicated a treatment for the burn was started on 1/19/23 and included .clean area with normal saline and pat dry, apply medihoney every shift. The TAR indicated the first treatment was first documented on 1/20/23 on night shift. The last date and time the treatment was completed was on 1/24/23, day shift. The TAR indicated there was treatment change, on 1/24/23, to apply Silver Sulfadiazine Cream 1% to the abdominal wound. During an interview, on 2/3/23 at 10:58 A.M., the Unit Manager indicated when hot liquids are served to residents it is supposed to have a lid on it. During an interview, on 2/3/23 at 11:34 A.M., CNA7 indicated she was the one who brought the hot tea to the resident. She indicated hot tea was served to the resident in a Styrofoam cup without a lid, per the resident's request. During an interview, with the Dietary Manager, conducted on 2/1/23 at 11:30 A.M., she indicated they have a commercial coffee urn that they take water from and pour into a carafe for Residents tea and hot chocolate. The water temperature she said, had to be at 164 degrees Fahrenheit in order for the tea and hot chocolate to be palatable. During an inteview, with CNA 6 on 2/1/23 at 2:45 P.M., indicated she would get a cup from the kitchen or Styrofoam cup as most residents like larger cups. She indicated she would get the hot water from the machine in the kitchen and take it to the Resident. Hot water in a Coffee Carafe on the 200 unit on 2/1/23 at 11:30 A.M., was 144 degrees Farenheit. The temperature was retreived by the Dietary Manager 10 minutes after being brought to the unit. Hot water in a Coffee Carafe, dated 1/20/23 through 2/2/23, indicated temperatures of the hot water were 162 degrees Fahrenheit. Hot water from the Coffee/Hot Water Machine, dated 1/20/23 through 2/2/23, indicated the temperatures of the hot water were 162 degrees Fahrenheit to 165 degrees Fahrenheit. A form titled, Hot Beverage Safety, undated, indicated .Guideline Statement: A hot beverage is something many of our residents look forward to. These beverages must be served at a temperature that is both palatable and safe for the resident The form indicated water from commercial coffee urns .will be in the 185 to 200 degree range, which is recommended temperature for brewing tea Serving Resident section indicated .Do not use styroform cups for hot beverage .Residents who travel in a wheelchaie with hot beverages should be provided with a wheelchair cup holder . The form stated .All residents should be evaluated for Hot Beverage Safety on admission, with any change of conditon and annual assessment using the Hot Liquid Safety Evaluation . On 2/3/23 At 3:18 P.M , the Administer indicated the above form and its information was used for education only and is not a policy. Causation of Cutaneous Burns, retrieved from the National Center of Biotechnology Information (NCBI) website on 2/3/23 at https://www.ncbi.nlm.nih.gov/articles/PMC 1934304/?page=16 indicated the time and temperture relationship to serious burns with the following temperatures and the time required for a 3rd degree burn (full thickness burn going through the dermis and affecting deeper tissue) to occur: 155 degrees Fahrenheit (F)-1 second 148degrees F-2 seconds 140 degrees F-5 seconds 133 degrees F-15 seconds On 2/3/23 at 11:08 AM ., The Unit Manager provided a policy titiled, Hot Liquid Safety, dated 2022 and indicated it was the one currently used by the facility. The policy indicated .Policy Explanation and Cimpliace Guidelines: 1. Hot liquids can cause scaling and burns 2. The temperature of hot liquids will be checked in the dietary department prior to distrubution to th nursing units. If the temperature is greater than 140 Fahrenheit, hold the liquid in the dietary department until it reaches an apporiate temperature .4. Staff shall respond to immediately to spills or other accidents with hot liquids to minimize the risk for burns. Follow procedures regarding incidents/accidents should anyone experience exposure to hot liquids . The policy contained additional information regarding the time and tempurture requided for 3rd degree burn to occur. The policy indicated, at 155 degrees, it would take 1 second to recieve a third-degree burn. This Federal tag relates to complaint IN00399787. 1.3-21(a)(1)(2)

A. Based on interview and record review, the facility failed to ensure physician orders were carried out in a timely manner for a resident who was admitted to the facility after ventral hernia repair surgery as a result the resident required hospitalization for debridement and IV therapy for 1 of 3 Residents reviwed (Resident G) B. Based on record review and interview, the facility failed to ensure admission orders for surgical treatment and timely physician follow up appointment for a resident with fracture of neck of left femur, and surgical treatment for a resident with a left below the knee amputation for 3 of 3 charts reviewed for physician orders. (Resident E, F, G) Findings include: 1. The clinical record review for Resident G was conducted on 2/1/2023 at 9:00 A.M. Resident G was admitted to the facility on [DATE] following ventral hernia repair. Diagnosis included, but not limited to: ventral hernia repair, and encounter for surgical aftercare following surgery on the skin an subcutaneous tissue. The Hospital Discharge form titled, After Visit Summary, dated 12/15/2022, indicated the resident had a post operation visit scheduled for 12/22/2022, a list of medications to be administered and instruction to read the attachments on surgical drain care and abdominal hernia repair. The attached form titled, Surgical Drain Care, indicated after surgery, fluid may collect inside your body and could make infection problems more likely. A Jackson-[NAME] (JP) drain carried the fluid into a collection bulb. The form indicated to empty the JP collection bulb when it appeared to be half full and the measure the amount of fluid removed from the drain. Then squeeze the bulb until it is flat, as this removes air and wound create a suction that pulls fluid into the drain. Another attached form titled, Abdominal Hernia Repair, indicated to .wash area with warm soapy water, and pat dry. Don't use hydrogen peroxide or alcohol, which can slow healing. You may cover the area with gauze bandage if it weeps or rubs against clothing. Change the bandage every day The antibiotics listed for administration included Amoxicillin 875-125 mg two times a day for 7 days (last dose was in A.M.) and Linezolid 600 mg two times a day (last doses was in A.M.) The Medication Administration Record (MAR) order date 12/15/2022, indicated .Linezolid 600 mg (milligrams), give 1 tablet by mouth two times a day for infection, discontinue on 12/30/2022 . On the following dates/times the MAR indicated by a code of 7 referencing see Nurses Notes, the following were missed doses 12/16/2022 at 9 A.M. and 9 P.M. dose, 12/19/2022 at 9 A.M., 12/20/2022 at 9 A.M., 12/21/2022 at 9 A.M. and 9 P.M., 12/26/2022 at 9 P.M. (3-hold/see nurses notes), 12/27/2022 at 9 A.M. and 9 P.M., 12/28/2022 at 9 A.M. and 9 P.M., 12/29/2022 at 9 A.M. She received doses on 12/17/2022 at 9 A.M. and 9 P.M., 12/18/2022 at 9 A.M. and 9 P.M., 12/19/2022 at 9 P.M., 12/20/2022 at 9 P.M., 12/22/2022 at 9 A.M., 12/23/2022 at 9 A.M. and 9 P. M., 12/24/2022 at 9 A.M. and P.M., 12/25/2022 at 9 A. M. and 9 P.M., 12/26/2022 at 9 A.M. The MAR, order date 12/15/2022, indicated .Amoxicillin-Pot Clavulanate tablet 875-125 mg, give 1 tablet by mouth every 12 hours for bacterial infection related to encounter for surgical aftercare following surgery on the skin and subcutaneous tissue for 7 days On 12/15/2022 the 6 P.M. dose and 12/17/2022 - 9 A.M. dose was missed. The Treatment Administration Record (TAR) did not indicate an order was put into place for the abdominal incision site upon admission or JP drains. A Treatment Administration Record (TAR) indicated .Record output from drain-LLQ [left lower quadrant] (1 of 2) every shift ., dated 12/19/2022. The TAR indicated the first time an output was documented was on 12/20/2022, on the evening shift with 10 milliliters of drainage, but did not describe the drainage. There was no documentation indicating the amount of drainage from the LLQ-JP drain on the following dates/shifts: 12/21-evening and night shift, and 12/27-day and-night shift. A TAR indicated .Record output from drain-RLQ [right lower quadrant] (2 of 2) every shift ., dated 12/19/2022. The TAR indicated a nurse had recorded her initials only on the night shift, no indication of the amount fluid, had been documented. The recorded output, for RLQ was, on 12/20/2022, and indicated there was 75 milliliters of drainage. There was no documentation indicating the amount of drainage from the RLQ JP drainage on the following dates/shifts: 12/20-evening and night shift, 2/22-night shift, 12/23-day shift and 12/27-day and night shift. The post-surgery follow up appointment, dated 12/22/2022, contained the following orders, Keflex 500 mg every 8 hours for 14 days at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and Bactrim DS 800/160 mg, twice a day at 6:00 A.M. and 6:00 P.M. Both medications had a start date of 12/22/2022 and stop date of 1/5/2023. And daily dry dressing changes over incision. After the resident seen the surgeon the Medication Administration Record (MAR), for December 2022 indicated the resident was administered the Keflex, on 12/22/2022 at 10:00 P.M., on 12/24/2022 at 2:00 P.M. and 10:00 P.M. The missed doses were on 12/23/2022 at 6:00 A.M., and on 12/24/2022 the MAR indicated the Keflex was discontinued. The Bactrim DS missed doses were on 12/23/2022 at 6:00 A. M., 12/24/2022 at 6:00 A.M. and 6:00 P.M., and 12/25 /2022 at 6:00 A.M. The Bactrim DS was documented as administered as administered on 12/30/2022 when the resident was admitted to the hospital on 12/29/2022. The Treatment Administration Record indicated the resident received a dressing change on 12/24/2022, 12/25/2022, 12/26/2022, 12/28/2022, 12/29/2022 and 12/30/2022. The missed treatments were on 12/23/2022 and 12/27/2022. A Surgeon's Progress Note, dated 12/29/2022, indicated, . Pt last seen on 12/22/2022 for a PO appointment with Dr. Folstein. Pt resides at a home and it was noted that her bandages were not being changed as a result of moist dressing on her incision and infection. Bactrim and keflex prescribed for 14 days. Our office spoke to the nurse at home for specific instructions regarding incision care-daily dry dressing changes--keeping site clean, dry, and intact. Upon assessment, pt has a very dirty and wet dressing on incision. The result of poor dressing changes, cleanliness, and keeping incision dry led to skin breakdown along surgical incision site and now may result in surgical debridement. Leading to admission to the ER A Care Plan, dated 12/16/2022, indicated the resident had altered skin integrity related to a post-surgical wound with JP drain. The interventions included but were not limited to: JP drain as ordered, monitor for signs/symptoms of infection, treatments as ordered and weekly wound assessments. During a phone interview, on 2/3/2023 at 11:19 A.M., the pharmacy tech from Alixa RX, indicated that the Linezolid came from CVS the backup pharmacy on 12/17/2022 with a 5- day supply/total of 10 pills. On 12/28/2022 the pharmacy sent another 5-day supply/total of 10 pills. During an interview, on 2/3/2022 at 12:11 P.M., the Director of Nursing (DON) indicated the process for obtaining new admission medication is to enter the order in Pointclick care and if med is not in the EDK (Emergency Drug Kit) they receive it from the backup pharmacy CVS. She indicated that Bactrim, Amoxicillin and Keflex are in the EDK box and should have been obtained from there. If the medication is not available, then a call is made to the Physician to clarify the new start date with an entry documented in the progress notes. The Linezolid was delivered on 12/17/2022 at 12:12 P.M. and the documentation in the electronic medical record (EMR) indicated awaiting delivery from pharmacy. On 12/19/2022, the documentation in EMR indicated that it was not given and was in the cart (nurse no longer works here). On 12/20/2022 at 9 A.M. and 12/21/2022 at 9 A.M. and 9 P.M. documenting indicated not given. On 12/26/2022 thru 12/28/2022 documentation indicated pending pharmacy run. She indicate that the doctor should have been notified of all the dates it was missing and documented in the progress notes. And no documentation on why the Keflex was not administered on 12/23/2022 and 12/24/2022 at 6:00 A.M. in the EMR. During a phone interview, on 2/3/2023 at 3:12 P.M., the Nurse Practitioner indicated she did not discontinue the Keflex on 12/24/2022. During a phone interview, on 2/3/2023 at 3:24 P.M., the Registered Nurse indicated she does not know why she discontinued the Keflex order. During an interview, on 2/3/2023 at 12:47 P.M., the DON indicated the abdominal wound was not on the admission assessment with measurements and description of it until 12/19/2022 and should have been completed within 24 hours of admit. And she indicated the treatment for the abdominal hernia repair was for a home patient and did not feel it was an order to clean and change daily. She did indicated she should have a treatment order for the JP sites and the emptying of the drains which began on 12/19/2022. There was no documentation in the EMR on way there was no record of output of the drains on 12/20, 12/21, 12/22, 12/23, and 12/27; and no reason for not doing the treatment to abdominal wound on 12/23/2022 and 12/27/2022. 2. The clinical review for Resident E was reviewed on 1/31/2023 at 11:00 A.M. The diagnoses included, but not limited to, necrotizing fasciitis, orthopedic aftercare following surgical amputation, and acquired absence of left leg below knee(L BKA) Resident was admitted to the facility on [DATE]. A Care Plan, dated 1/12/2023, indicated the resident has altered skin integrity related to BKA surgical wound to left stump. The interventions included but were not limited to: conduct weekly skin inspection, monitor for signs and symptoms of infection, treatments as ordered. Physician Order Sheet - Sanctuary of Holy Cross dated 12/21/2022, indicated wound-incision care left BKA apply betadine and cover with dry gauze or ABD only twice a day. The Treatment Administration Record, dated 1/2023, indicated on 1/13/2023 an order of betadine external solution 10% apply to the left BKA topically every evening shift for surgical site. May cleanse with NS or wound wash , apply betadine cover with ABD and secure with gauze or border dressing. During an interview, on 2/2/2023 at 2:47 P.M., the Director of Nursing indicated that the treatment order for the left below the knee was not transcribed upon admission and should have been. 3. The clinical record for Resident F was reviewed on 1/31/2023 at 2:00 P.M. The diagnoses included, but not limited to, fracture of unspecified part of neck of left femur, muscle weakness and abnormalities of gait and mobility. Resident was admitted to the facility on [DATE]. The Hospital Discharge form titled, After Summary Instructions, dated 1/12/2023, indicated Wound/Incision Care for patient instructions: Daily dressing changes. Cover with ABD and tape. May leave open to air after post op day 7 if healed and no longer draining. And schedule an appointment with J. Yeargler, MD as soon as possible for a visit in 2 weeks, specialty: Orthopaedic. The Hospital Discharge Summary, dated 1/6/2023 indicated Resident F underwent hemiarthroplasty on 1/8/2023. A Care Plan, dated 1/13/2023 indicated altered skin integrity related to surgical wound to left hip. The interventions included but were not limited to: treatment as ordered, monitor for signs and symptoms of infection, weekly wound assessment. During an interview, on 1/31/2023 at 3:30 A.M., the Director of Nursing indicated that she was following up on scheduling his follow up appointment with the surgeon yesterday, which should have been made when he admitted . And indicated the treatment depends what day he came out of post op whether he could be open to air or not. On 1/31/2023 at 4:24 P.M., the DON indicated that he did not have an order for dressing change when he admitted and should have because he was 4 day post op. On 2/2/2023 at 11:40 A.M., the Regional Nurse indicated they have no orders no policies or procedures on physician orders or transcribing of, and the admission process. On 2/1/2023 at 11:40 A.M., the Director of Nursing provided a policy titled, Wound Treatment Management, dated 2022, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with current standard of practice and physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .6. Guidelines for dressing selection may be utilized in obtaining physician orders .c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatment will be monitored through ongoing assessment of the wound. Considerations for needed modification include: a. Lack of progression towards healing. B. Changes in the characteristics of the wound This Federal tag related to compalint IN00400017. 3.1-37(a)(b)

Based on interview and record review, the facility failed to develop and implement a complete and adequate policy regarding falls/accidents which addressed post fall assessments. The facility also failed to follow up with changes of condition for a resident after a witnessed fall. This deficient practice resulted in the resident experiencing a right [CONDITION(S)] for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: On 8/23/21 at 10:50 A.M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE], with a re-admission on 8/14/21, after a hospital stay for a fractured hip. The resident's diagnoses included, but were not limited to: [CONDITION(S)] (inability to communicate), [CONDITION(S)], malnutrition and scoliosis. An Admission Minimum Data Set (MDS) Assessment, dated 7/17/21, indicated the resident was rarely and/or never understood, he was an extensive assist of 2 persons with transfers, an extensive assist of 1 person with toileting, dressing, personal hygiene and with locomotion on the unit. He weighed 90 pounds and was receiving physical and occupational therapy. A Fall Risk Assessment was completed, on 7/9/21, in which the resident's score was 12. The assessment indicated .if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan An at risk for falls care plan, dated 7/30/21, indicated the resident had impaired safety awareness related to his intellectual disability. The inventions included : .Call light or personal items available and in easy reach or provide reacher , dated 7/30/21.Revision on: 08/02/2021 NS [nonskid] Footwear to prevent slipping. Res [Resident] to leave non-skid socks on while in bed as tolerated A care plan for impaired ability to make self understood, dated 8/2/21, indicated the resident had .unclear speech, sometimes understood, sometimes understands The interventions included, but were limited to : .Anticipate patient needs Date Initiated: 08/02/2021, Encourage patient to verbalize needs Date Initiated: 08/02/2021, Listen carefully, validate verbal and non verbal expressions Date Initiated: 08/02/2021 .Resident does not demonstrate s/s [sign/symptoms] of pain non-verbally in the same fashion as other non-verbal persons: persons who come near his hand he will hold their hands and squeeze it for an inappropriately long period of time Date Initiated: 08/18/2021 A care plan for pain management and monitoring, related to resident was non-verbal and may not be able to express pain needs-right [CONDITION(S)], dated 08/02/21. The interventions included but were not limited to: administer pain medication as ordered and coordinate with patient/Family/Patient Representative to identify patient's favorite items/activities that could serve to distract from pain. A Progress Note, dated 7/11/21, indicated the resident was alert to self and nonverbal at this time, unable to answer questions. appears to hear adequately, he had poor safety awareness and was up and ambulating in his room with unsteady gait, therefore the resident had to be redirected, with assist of 1 person to bed. A Post Fall Evaluation/Change of Cognation Progress Noted, dated 8/2/21, indicated the resident had a witnessed fall at 6:53 P.M., when resident was ambulating independently in the hallway toward a QMA (Qualified Medication Assistant), who told him to turn around and go back to his room. Resident B turned towards his room and roommate was coming out of the room and startled Resident B, he lost his balance, landing on his right side. The note indicated the resident was not wearing socks with grippers and required assistance with walking. The resident was assessed head to toe, no injuries were observed. An IDT (Interdisciplinary Team) Note, dated 8/3/21 at 12:39 P.M., indicated the following .IDT Fall note for residents fall that occurred on 8/2/2021 1853 [6:53 P.M.] resident witnessed standing in hall, startled and slipped, landing on right side. Resident was alert and yet due to his baseline cognition. Nurse completed a head to toe assessment, no s/s [signs/symptoms] of pain or discomfort noted. ROM WNL [Range of Motion Within Normal Limits] with no redness, bruising or open skin present from this fall. [Resident B's name] was assisted up and care provided. Provider and guardian notified. Fall care plan reviewed and revised. [Resident B's name] to wear non skid socks or shoes when out of bed There were no other documented post fall assessments or notes from the nursing staff until 8/9/21. A Physical Therapist Aide (PTA) note, dated 8/3/21 documented by PTA 2, indicated . pt [patient] declined transfer from sba [stand by assist], nursing staff notified A Nurse Practitioner Note, dated 8/4/21, indicated resident was being evaluated for a fall which occurred on 8/2/21. The Note indicated the following .Pt [patient]otherwise appears well today. Pt is seen in their room. VSS [vital signs stable]. Pt denies cough SOB [shortness of breath] .chills, fever, nausea, vomiting, diarrhea, sore throat, malaise, loss of smell/taste. No other sxs [sign or symptoms] of infection present. Nursing does not report new sxs [signs or symptoms] or change in condition at this time .The musculoskeletal exam indicated limited range of motion noted in extremities A Physical Therapist note, dated 8/6/21, documented by PT 3, indicated . PT [Physical Therapist] spoke with nursing regarding pt's [patient's] decline in function . He was unable to follow commands and needed moderate assist of 2 persons to assume standing. A Nurse Practitioner Note, dated 8/6/21, indicated resident was being seen today for a fall that occurred on 8/2/21. The Note indicated the following: .Per nursing doc [documentation], pt [patient] did not appear to have injuries during head to toe assessment. Pt seen by this writer as well and no apparent injuries were noted. Due to his mental status he was seen as slightly less communicative, however this is baseline. No sxs [signs or symptoms] of fractures of lower or upper extremities noted .Pt is difficult to assess given his contractured status. No pain illicited during the exam. The muschuloskeletal exam indicated limited range of motion noted in extremities. Contracted. Plan indicated .Monitor condition closely. Will review notes on how pt progresses and order imaging if warranted .Nursing does not have further questions or concerns at this time A Physical Therapy (PT) Daily Treatment note, indicated on 8/3, 8/4, 8/5, 8/6 & 8/9/21 there was no gait training completed. A Progress Noted, dated 8/9/21 at 3:36 P.M., indicated .Physical therapist tech informed me that resident has not attempted to stand up since he had fallen on 8/2. Also that he has been vomiting while on new tubefeeding rate .Orders taken to x ray hips/pelvis and decrease tubefeeding to previous rate/timeframe A Progress Noted, dated 8/10/21 at 3:58 P.M., indicated .Received results of Hip xray with pelvis. Results: Acute impaction type fracture at the base femoral neck inter trochanter region. Acute Right [CONDITION(S)].[Name of physician] notified of results. New order to send to ER [emergency room ] for eval [evaluate] and treat. Left message for [name of guardian] on cell phone and home phone with message to return call Self reported facility incident #403 ,dated 8/10/21, indicated . 8/2/21 Res [resident] had a recent witnessed fall when ambulating in the hallway. Although res [resident] is non-verbal, showed no s/s [signs/symptoms] of pain after fall and ROM [range of motion] was WNL [within normal limits]. Resident is currently receiving therapy services and it was reported resident has not been ambulating as he had been previous to fall. MD [Medical Doctor] notified with new order for bilateral hip x-rays X-ray revealed a right [CONDITION(S)] and the resident was sent to ER for an evaluation. The Follow-up, dated 8/17/21, indicated resident returned to the facility and was a non-surgical candidate for a hip repair. Emergency and Urgent Care Note dated 8/10/21 indicated .Patient is a [AGE] year old male with history of stroke, mental handicap, [CONDITION(S)], coming from an extended care facility with son [was his guardian] for concerns of [CONDITION(S)] and lethargy. The patient was apparently getting physical therapy .he had a fall. Since the fall he has not been wanting to ambulate and has appeared to be weaker. In addition, apparently at some point throughout the past week the nursing facility had to add nasal cannula oxygenation because he became hypoxic. The son [guardian] reports that the patient does have a history of prior aspirations. The son [guardian] requested an x-ray of the patient's hips at the facility and apparently they did an x-ray at some point which revealed a right [CONDITION(S)] emergency room Progress Note, dated 8/10/21 at 4:53 P.M., indicated .Pt's [patient's] legal guardian [name of guardian] here and expressing concern and confusion as to why it took over a week to get pt [patient] evaluated as well. [Name of guardian] had requested the xray today after he had visited pt [patient] and he wasn't acting like himself-also pt [patient] does not require oxygen and has been on 4 L[liters] since arrival here and does have a known hx [history] of aspiration emergency room Progress Note, dated 8/10/21 at 5:24 P.M., indicated .Spoke with POA [Power of Attorney] with [name of protective services director]. Updated on plan of care. POA states that he visited patient the day after the fall and pt seemed fine then. He then visited him again in 8/6 during a physical therapy session where pt [patient] was not participating much and unable to bear weigh then, POA suggested an xray to be done then, POA went back to nursing home 8/9 to find out diagnostic imagines were done and went to speak with the director of the facility who arranged xray to be done for POA's peace of mind. Xray came back positive for a fracture today Hospital H&P (History & Physical), dated 8/10/21, indicated imaging in the emergency room revealed a right intertrochantieric [CONDITION(S)] and chest x-ray demonstrated a right basilar infiltrate. Breath Sounds auscultation revealed crackles in the bases of the lungs. During an interview, on 8/23/21 at 1:52 P.M., Physical Therapist 3 indicated she had been on vacation and didn't see the resident until 8/6/21, a Friday. On 8/6/21, she noted the resident was having difficulty bearing weight. His POA was with him and POA indicated the resident had had a fall on 8/2/21, a Monday. She indicated it was hard to tell if the resident was in pain due to his inability to talk so she reported her findings to the resident's nurse - LPN 4 and to Unit Manager 5. During an interview, on 8/23/21 at 1: 55 P.M., the Physical Therapist Aide (PTA) 2, indicated she spoke with LPN 4 and the Unit Manager 5, on 8/3/21, a Tuesday to report a decline in the residents ability to transfer. PTA 2 stated she was unable to attempt any gait training, with Resident B, after that date. During an interview, on 8/23/21 at 2:15 P.M., Unit Manager 5 indicated she could not recall if LPN 4 or the therapists had reported to her Resident B's decline. She did remember it was discovered he had a [CONDITION(S)] sometime after his fall. She indicated the nurses for the resident should of done post fall and pain assessments. During an interview, on 8/24/21 at 10:10 A.M., the Nurse Consultant indicated the facility had no ongoing post fall evaluations/documentations, after 8/2/21. She stated the staff had completed, on the day of fall, a Post Fall Evaluation form, along with, a pain assessment and fall risk evaluation. There was no other assessments/documentation available to review. During an interview, on 8/24/21, at 11:15 A.M., the MDS Coordinator indicated the pain and impaired inability to make himself understood care plans were updated, on 8/2/21, due to a conversation with his guardian and a fall. The pain care plan, dated 8/2/21 was updated when the fracture was identified and resident returned to the facility after a hospital stay. MDS coordinator indicated she should of put a date next to the note indicating right [CONDITION(S)]-since the fracture wasn't identified until a later date. The MDS Coordinator indicated the change in the care plans would have been communicated to Unit Manager 5, who would then communicate the updated care plans to the nurses. During a telephone interview, on 8/24/21 at 12:08 P.M., Resident B's guardian indicated he was notified on 8/2/21, a Monday, when the resident had fallen. He came to the facility after the fall and seen the resident and had no concerns. On Friday, 8/6/21 he returned to the facility and the resident was in the therapy room. The therapist indicated to him the resident had not wanted to go on walks and he usually enjoyed the walks. He told the therapist if the resident was hurting he would not cry out. The therapist then tried to stand the resident and the resident could not complete the task. The therapist left the area to tell the nurse about her findings. On 8/9/21, a Monday, the guardian spoke with the DON (Director of Nursing) to find out if an x-ray had been order and was told the facility would obtain an order for an x-ray. The guardian was not sure why they waited until Monday to get the order. Then on 8/10/21, a Tuesday, the guardian indicated he was notified the x-ray showed a fracture of the hip and they were sending the resident to the hospital. The guardian indicated the facility staff tried to excuse the delay and said he was just hard to read but why was no one noticing he wasn't walking/standing, which was his usual, and had been communicated to the nursing staff, by the therapist, on Friday. On 8/23/21 at 2:45 P.M., the Administrator provided a policy titled, Accidents and Supervision undated, and indicated the policy was the one currently used by the facility for post fall evaluations. The policy had no indications of practice or expectations for post fall evaluations and/or assessments. During an interview, on 8/24/21 at 10:10 A.M., the Nurse Consultant indicated the facility had no policy, in regards to fall follow-up assessments and the policy did not indicate what nurses should do or how to proceed after a resident fall. On 8/23/21 at 10:15 A.M., the Nurse Consultant and the Administrator provided a current policy titled, Pain Management, undated. The policy indicated .Policy: The facility must ensure that pain management is provided to residents who require such services, consist with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain upon admission, during ongoinng scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status ' 2.Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: a. Change in gait (e.g.limping), skin color, vital signs (e.g. increased heart rate respirations and/or blood pressure, perspiration . e. Behavior such as: resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical activities and/or social activities . j. Decline in activity level This Federal tag relates to Complaint IN 333. 3.1-45(a)

Based on record review and interview, the facility failed to follow their policy for weekly skin assessments and monitoring for a resident with a wound to the top of her right foot, which resulted in a delay of treatment and the resident being hospitalized for [REDACTED]. (Resident B) Finding includes: The clinical record for Resident B was reviewed on 10/8/19 at 11:00 [NAME]M [DIAGNOSES REDACTED]. A care plan for altered skin integrity was updated on 8/18/19 to reflect an open area to right dorsal foot. Interventions included conduct weekly skin inspection, meds as ordered, monitor for signs and symptoms of infection such as swelling, redness, warmth, discharge, or odor and notify physician of significant findings and treatments as ordered. A Progress Note, dated 8/18/19 at 7:50 P.M., indicated .Change in Condition .Situation: Resident approached nurse's station to notify of wound to top of R (Right) foot .Background: Resident has hx (history) of amputation to same foot. Resident currently attends [MEDICAL TREATMENT] 3x (times) weekly and is unable to identify origin of wound .Assessment: Area is reddened surrounding wound. Actual wound is 1cm (centimeter) x 1 cm with 100% (percent) slough noted to wound bed. No apparent pain/discomfort noted to foot .Response: MD (Medical Doctor) notified and n/o (new order) received for santyl/[MEDICATION NAME] and rolled gauze to be changed daily. Resident/POA (Power of Attorney)/pharmacy aware. MD will be in this week to assess wound/address orders as needed A Physician's Progress Note, dated 8/22/19, indicated .Skin: right dorsal foot with a small opened area with serosanguenous drainage. There is no surrounding [DIAGNOSES REDACTED], warmth or drainage. Prior surgical site is healed, heels are intact A Physician's Progress Note, dated 8/29/19, indicated .New wound top of Right foot, pt. (patient) had resection 4/2019. Wound full thickness right (sic) dorsal. No drainage, no redness, no swelling. Grade 2 ulcer right (sic) foot likely from rubbing of shoe A Wound Note, dated 8/30/19 at 11:40 [NAME]M., indicated .Resident currently being followed r/t (related to) venous wound to top of R foot measuring 1.2 cm x 1.3cm. Wound bed has slough present with scant drainage present to previous dressing. Resident being followed by podiatrist for tx (treatment) management A Wound Note, dated 9/6/19 at 8:34 [NAME]M., indicated .Resident currently being followed r/t venous wound to top of R foot measuring 1.3 cm x 1.2 cm. Wound bed continues with slough present and scant drainage present to previous dressing. Resident being followed by podiatrist for tx management A Wound Note, dated 9/12/19 at 10:23 [NAME]M., indicated .Resident currently being followed r/t venous wound to top of R foot 1.0 cm x 1.1 cm. Wound appears to improving. Resident being followed by podiatrist for tx management. A General Progress Note, dated 9/13/19, at 1:03 P.M., indicated . it was reported to me this morning that (name of resident) refused to go to [MEDICAL TREATMENT] today as she did not feel well. (name of resident) was physically aggressive toward staff, yelling, kicking and cussing at them, as she did not want to get out of bed or get changed. As of this writing (resident) is still in bed. No other issues have ensued. Will continue to observe A General Progress Note, dated 9/13/19, at 8:50 P.M., indicated .Tx (treatment) changed to R dorsal foot this shift. Resident tolerated well. Bilateral feet assessed and noted to be intact, except for open area to R dorsal foot. Resident continues to be seen by podiatry A Weekly Skin Review, dated 9/14/19 at 10:06 P.M., indicated the resident's skin was intact with no skin issues noted. The clinical record lacked documentation of any wound assessment between 9/14/19 and 9/23/19. A weekly skin assessment was due on 9/21/19 but had not been completed. Resident B received treatments to her right foot of [MEDICATION NAME] and wrap with kerlix every evening between 9/13/19 and 9/23/19, with the exception of 9/21/19 where nothing was documented. A Progress Note, dated 9/23/19 at 6:00 [NAME]M., indicated .Change in Condition .Situation: Resident complaining of pain to Rt.leg and toes. Upon assessment Rt. leg noted to be red and warm to touch. Inspection of known wounds to dorsum of feet between toes, reveals myiasis (infestation of maggots) .Background: History of wound to rt. dorsal foot. Res has been getting (sic) treatment for [REDACTED].Assessment: B/P 123/66, R18, P78 T.98.4 Resident is alert and oriented. She describes her pain now at 3 after prn (as needed) pain meds were given earlier. Redness to rt. leg and toes. Myiasis to wounds between her rt. toes .Response: (name of physician) notified and order received to send res to ER (emergency room ) for evaluation. Resident in agreement A local hospital, History and Physical, dated 9/23/19, indicated .History of Present Illness: admitted with increasing pain swelling and redness bilateral feet has been found to have right leg [MEDICAL CONDITION] with maggots in between the toes. She has been diagnosed to have acute [MEDICAL CONDITION] of the right foot probably secondary to [MEDICAL CONDITION] and subsequently I was asked to admit this patient for further evaluation and management. On further questioning she claims that she had some low-grade temperature and also increasing pain and swelling in the bilateral feet .Physical Exam: Extremities trace [MEDICAL CONDITION] present in bilateral legs. Posterior tibial dorsalis pedis pulses are not palpable very well. She has wounds in between her webspaces especially fourth and fifth webspaces and also on the plantar aspect of the toes bilaterally. Right worse than the left. She also has some cellulitic changes on the right dorsum foot. The popliteal pulses are palpable bilaterally but feeble .Assessment/Plan: Acute [MEDICAL CONDITION] of the bilateral feet right worse in the left probably due to underlying [MEDICAL CONDITION]. Patient has already gotten 1 dose of [MEDICATION NAME] (an antibiotic) but with history [MEDICAL CONDITION] (a antibiotic resistant infection) in the past I would like to initiate/start her on [MEDICATION NAME] plus cefapine (antibiotics). Panclultures have been done [MEDICAL CONDITION] markers have been ordered. X-rays of the foot has been gotten and it did not show any evidence of osteomylitis During an interview, on 10/8/19 at 3:20 P.M., the interim DON (Director of Nursing) indicated she was new to the facility and was not familiar with this residents wounds, as she was no longer admitted there, but she would expect the facility staff to follow the policy and procedures implemented by the company for skin assessments and monitoring. During an interview, on 10/9/19 at 3:30 P.M., RN 1 indicated he was assisting another nurse and went in to assess Resident B and found that she had an acute change in condition related to her wound and proceeded to notify the resident's physician and send her out to the hospital for further evaluation. He indicated he was not aware of any changes in the residents condition prior to 9/23/19 at 6:00 [NAME]M. During an interview, on 10/9/19 at 3:40 P.M., QMA (Qualified Medication Aide) 1 indicated she had been in charge of care for Resident B prior to her hospitalization . Resident B was very independent and didn't often want assistance but on this particular day she wanted assistance using the restroom and reported that her foot hurt. She indicated the resident did not want to change her clothing and she was screaming her foot hurt she passed it on to the nurse for further evaluation and by the next day the resident was gone. A policy, titled Skin Integrity Guideline, with an effective date of 1/28/2019, was provided by the Executive Director of the facility on 10/9/19 and reviewed at 4:00 P.M. The policy indicated .Documentation of Weekly Skin Evaluation/Observations: Licensed nurse will be responsible for performing a skin evaluation/observation weekly This Federal tag is related to Complaint IN 361 and IN 030. 3.1-40(b)

Based on record review, observation and interview, facility failed to notify the physician of wound changes and implement interventions to prevent the developement of pressure areas to right buttock (Resident 72), and worsening of a left heel wound from a deep tissue injury to an unstageable pressure ulcer and development of a right heel pressure ulcer (Resident 35) in 2 of 4 resident reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident 35 was reviewed on 9/10/18 at 12:22 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 4/15/18, indicated Resident 35 did not have any pressure areas but was at risk for the developement of pressure areas. The quarterly MDS assessment, dated 7/16/18, indicated Resident 35 required extensive assist with 2 people for bed mobility and transfers and had developed one unstageable deep tissue injury. A Progress Note, dated 6/27/18 at 7:04 A.M., indicated a CNA (certified nurse aide) reported a new area to Resident 35's left heel. The area was classified as a DTI (deep tissue injury) that was soft and black measuring 1.6 cm (centimeters) x 1.8 cm x UTD (unable to determine). Surrounding tissue with blanchable [DIAGNOSES REDACTED] (redness). A low air mattress had been present and there were no other changes noted to resident's condition. The physician was notified and new orders were received to apply sure-prep to wound every shift and cover with foam heel cup, secured with foam netting. Prevalon boots were applied to bilateral heels. A pressure ulcer care plan, dated 6/17/18, indicated there was a DTI to left heel that changed to unstageable on 8/29/18 and a right heel DTI on 7/24/18 and included interventions, but were not limited to, prevalon boots to bilateral heels (6/28/18), low air loss mattress (6/28/18) and sand sure-prep and foam heel cup (6/27/18). The Wound Evaluation Flow Sheet, dated 6/27/18 through 9/4/18, indicated the left heel presented with the following measurements with wound descriptions: 6/27/18 wound was staged at DTI measuring 1.6 cm x 1.8 cm x UTD, no drainage and tissue base was necrotic. 7/3/18 wound measured at 1.5 cm x 2.5 cm x UTD, no drainage and tissue base was necrotic. 7/11/18 wound measured at 1.6 cm c 2.2 cm x UTD, no drainage and tissue base was necrotic. 7/18/18 wound measured at 1.5 cm x 2.3 cm x UTD, no drainage and tissue base was necrotic. 8/7/18 wound measured 2.0 cm x 2.8 cm x UTD, no drainage. 8/16/18 wound was staged as DTI measuring 2.0 cm x 3.0 cm x UTD, no drainage noted. 8/23/18 wound was staged asDTI, measuring 2.3 cm x 2.3 cm x UTD, no drainage noted. 8/29/18 wound was staged as unstageable, measuring 2.5 cm x 4.0 cm x UTD with purulents drainage and slight odor, tissue base was slough and necrotic. 9/4/18 wound measured 4.5 cm x 4.5 cm x UTD with serosanguineous drainage and had an musty odor. A Radiology Report, dated 8/29/18, indicated there was moderate diffuse soft tissue swelling noted to left heel but no osteo[DIAGNOSES REDACTED]. The Wound Evaluation Flow Sheet, dated 8/30/18, indicated the left heel wound was 10% slough and 90% necrotic tissue. The wound bed had changed significantly within the week and physician was notified and x-rays were completed, physical therapy was aware of order to evaluate. A Progress Note, dated 8/30/18, indicated left heel was now unstageable and measured 2.5 cm x 4.0 cm x UTD. Hard necrotic dark brown tissue remained to center, edges have separated and yellow/tan slough noted to all edges. Small to moderate amount of greenish brown purulent drainage noted to previous dressing. The medial side of the wound has noted changes to surrounding tissue, surrounding tissue appears to be a cloudy white with light purple color. The change was noted in the measurements and appeared to be the beginning of expanding wound bed or tunneling. Order were received for therapy to evaluate and treat. The right heel remained a DTI that measured 1.0 cm x 0.7 cm x UTD with color a light purple. The Wound Evaluation Flow Sheet, dated 8/7/18 to 9/4/18, indicated right heel presented with the following measurements and wound descriptions: 8/7/18 wound measures at 0.7 cm x 0.7 cm x UTD, no drainage noted 8/16/18 wound was staged as DTI and measured 0.6 cm x 0.7 cm x UTD, no drainage present. 8/23/18 wound was staged as DTI and measured 1.0 cm x 0.6 cm x UTD, no drainage present. 8/29/18 wound measured 1.0 cm x 0.7 cm x UTD, no drainage present. 9/4/18 wound measured 0.7 cm x 0.6 cm x UTD, no drainage present. The Wound Evaluation Flow Sheet, dated 8/10/18, indicate the wound to the right heel was first identified on 7/24/18. There was no documentation available for physician notification. There was no order present for treatment to right heel. During an observation, on 9/4/18 at 10:09 A.M., Resident 35 was sitting in wheelchair with no foot pedals and her feet dangling above the floor in the dining area on the unit. During an observation, on 9/5/18 at 9:40 A.M., Resident 35 was sitting in wheelchair with no foot pedals and her feet dangling above the floor in the dining area on the unit. During in observation, on 9/6/18 10:11 A.M., Resident 35 was sitting in wheelchair with no foot pedals and her feet dangling above the floor in hallway by nursing station. During an interview, on 9/10/18 at 10:04 A.M., CNA 9 and CNA 10 indicated they had not been educated on low air mattress settings and were not sure what they were suppose to be set at. During an interview, on 9/10/18 at 10:16 A.M., Resident 35's daughter indicated she was not aware that her mother had a pressure area to her right heel and that the facility had not been notifying her of changes to the left heel. She indicated the facility had notified her a few months ago about the wound to the left heel and she had not heard anything until 9/3/18 or 9/4/18 and that she came to the facility on [DATE] to observe the wound with the doctor but the doctor did not have time to see the resident. During an observation, on 9/10/18 at 10:45 A.M. the wound nurse removed the dressing to the right heel to observe the DTI that presented with dark dry eschar. She indicated the wound appear to have worsened from the last time she saw it. She indicated the the wound measured 1.7 cm x 1.5 cm and was staged as a deep tissue injury with a dark brown center and the dark purple outer edges. The wound nurse removed the dressing to the left ankle, strong foul odor was noted and green purulent draingage was noted to removed dressing. The left heel presented with dark brown/black dry necrotic tissue to the outer region, with tan/green moist slough noted around the edges of the dark dry tissue. the inner portion of the heel presented with loose flap of skin and purple/red tissue. The wound nurse indicated the wound had worsened. She indicated the was more redness and warmth to the surrounding tissue. She indicated the wound was staged as unstageable, measured 8.0 cm x 8.3 cm x UTD with center necrotic tissue, yellow/tan slough around the edges of the necrotic tissue and the skin was peeling over the the inner region the purple/red from DTI. The resident was on a low air loss mattress set at rotating and the prevalon boots on the resident upon entering room were worn. During an interview, on 9/10/18 at 11:30 A.M., the wound nurse indicated all air mattresses were to be set on alternating and the lowest firmness setting because that is when they are the most soft. During an interview, on 9/10/18 at 11:50 A.M., the ED (Executive DIrector) indicated there was no therapy documentation available in regards to the wound to left heel. During an interview, on 9/10/18 at12:42 P.M., the wound nurse indicated the wound to the left heel first presented on 6/27/18 and the resident had already been on a low air loss mattress and the new orders were for prevalon boots to bilateral heels, sure-prep to left heel, covered with foam heel cup and secured with a netting. She indicated there was no documentation present for physician notification on 7/3/18 or 7/18/18 when the area to the left heel became larger in size. She indicated there was no wound documentation present from 7/18/18 to 8/10/18 because she was on vacation and was unsure of who took over wounds while she was out. She indicated there was no changes made in interventions until today when a new device was delivered to keep heels of the bed. She indicated her and the ED have been looking at different options for a while but nothing had been ordered. She indicated no cultures had been ordered for the wound since the odor and drainage began on 8/29/18 and that only an xray had been order to rule out osteo[DIAGNOSES REDACTED], and the first time the physician had assessed the wound was on 9/5/18. She indicated more interventions should have been implemented to alleviate pressure to Resident 35's heels. 2. During an interview, on 9/4/18 at 1:54 P.M., Resident 72 complained of pain to buttocks, and indicated she wanted a pad for her wheel chair because her bottom was sore and no one would give her one. There was no cushion currently present in her electric wheelchair. The clinical record for Resident 72 was reviewed on 9/7/18 ar 9:20 A.M. The [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) assessment, dated 8/19/18, indicated Resident 72 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact and was at risk for pressure area development. A care plan for at risk for pressure ulcer, dated 8/7/18, indicated Resident 72 had bladder and bowel incontinence and required assistance with bed mobility and included interventions, but were not limited to, pressure reducing cushion to w/c and provide thorough skin care after incontinence episodes. The Clinical Health Status, dated 7/17/18, indicated Resident 72 had a reddened area noted to buttocks that measures 3.0 cm (centimeter) x 2.5 cm. The Clinical Health Status, dated 7/26/18, Resident 72 had reddeness to right and left buttock. There was no care plan in place for current pressure area. There was no wound documentation available. A Progress Note, dated 7/30/18 at 11:37 P.M., indicated Resident 72 had an open area on right buttock measuring 1.0 cm x 1.2 cm x 0.1 cm. A Wound Evaluation Flow Sheet, dated 8/16/18, indicated Resident 72 had an open area to right buttock measuring 1.0 x 1.0 x 0.1 cm, classified as incontinence [MEDICAL CONDITION] that was first noticed on 8/12/18 and that area would be followed to healed and wheelchair cushion would be in place. A Progress Note, dated 8/16/18, indicated Resident 72 had an open area to her right sacrum. A Progress Note, dated 8/24/18, indicated Resident 72 had an open area to her right sacrum There was no further wound documentation provided. During an interview, 9/10/18 at 11:35 A.M., Resident 72 indicated she had requested to have her depends changed because she was soak with urine. She indicated she had been waitng 30 minutes to be changed and had but her light on twice, but CNA 11 just came in and shut it off with out providing care. She indicated she still had not received a cushion for her electric wheelchair that she has recently been using and the pressure area to her buttocks has been there for 1 week or so. During an observation, on 9/10/18 at 11:40 A.M., the wound nurse measured the pressure area noted to Resident 35's right buttock at the ischial tuberosity. She indicated she was not aware that the resident had a pressure area and the area measured1.5 cm x 1.5 cm x 0.2 cm, staged at a Stage 2 pressure ulcer. She indicated she had forgot about the electric wheelchair needing a cushion. On 9/7/18 at 1:15 P.M., the ED (Executive Director) provided the Skin Intergity Guideline, dated 3/1/18, and indicated this was the policy currently being used by the facility. The policy indicated its purpose was to decrease pressure ulcer, pressure injury, and/or wound formation by identifying those patients/residents who were at risk, and implementing appropriate interventions. The facility was to develop a routine schedule to review residents with wounds or at risk on a weekly basis and document findings. The interdisciplinary care plan would address problems, goals, and interventions directed toward prevention of pressure ulcers and/or skin intergity concerns. Residents utilizing a wheelchair as primary mode of transportation would have a pressure redistrubution device in place. If there was a decline in skin intergity, pressure redistrubution surfaces would be reviewed for appropriateness and implemented. Reposition every two hours, or as tolerated, taking into consideration resident tolerance, and choice, tissue tolerance, current skin condition, level of activity, mobility, general medical treatment and overall treatment objectives. Refer to therapy for positionind, special devices, restorative plan and wound care. Care plans would be implemented, evaluated and revised based on the needs of the resident. On 9/7/18 at 1:15 P.M., a policy on wound care and assessment was requested and the ED indicated there was no policy available. 3.1-40(a) 3.1-40(b)

Based on record review and interview, the facility failed to ensure the plan of care was followed for a resident who required follow up laboratory testing to rule out urinary tract infections (Resident B), and for a resident with a history of urinary tract infections who was experiencing an acute change in condition which resulted in the resident being sent to the hospital for evaluation and subsequent intravenous antibiotic therapy. (Resident C) Findings include: 1. On 11/29/16 at 11:00 A.M., the clinical record for Resident B was reviewed. [DIAGNOSES REDACTED]. A care plan indicated .Urinary Tract Infection, potential to: Urinary Incontinence, Recurrent Urinary tract infections .Date Initiated: 01/28/2015 .Goal: Urinary tract infection will resolve without complication .Date Initiated: 01/28/2015 .Revision On: 09/14/2016 .Interventions: Labs as ordered A physician's orders [REDACTED]. UA (Urinalysis) C&S (Culture and Sensitivity) in one wk (week) then wkly (weekly) for 3 weeks one time a day every Mon (Monday) for 3 weeks A Nurses Progress Note dated 9/13/16 indicated . Resident was seen by (name of primary physician) today with orders to check UA one wk from today then wkly x 3 wks A Nurses Progress Note dated 10/3/16 indicated . Attempted to get urine for urinalysis x 2, once straight cath (catheter) and once clean catch. Resident had no output either time. Will have day shift get On 11/29/16 at 11:30 A.M., review of Medication Administration Records and Treatment Administration Records lacked documentation to indicate the 3 Urinalysis with Culture and Sensitivity labs that had been ordered on [DATE] had been collected and sent to the lab by the facility. During an interview on 11/30/16 at 11:30 A.M., the Director of Nursing (DON) indicated the labs had not been collected and sent to the lab as ordered. During an interview on 11/30/16 at 2:30 P.M., the Unit Manager (UM) indicated the Urinalysis had not been collected as ordered. On 11/30/16 at 2:26 P.M., the policy titled Lab Processing/Tracking Guidelines was provided by the Executive Director of the facility and reviewed. The policy indicated . Guideline Statement: To ensure that Diagnostic tests are processed, ordered, obtained, performed, and results received timely. Test results are communicated to the physician in a timely manner with documentation present in the medical record 2. On 11/30/16 at 1:00 P.M., the clinical record for Resident C was reviewed. [DIAGNOSES REDACTED]. A nursing progress note dated 11/7/16 and titled October IDT (Interdisciplinary Team) Behavioral MGT (management) Review indicated Resident C had episodes of depression, anxiety, delusions and inconsolable episodes of attention seeking behaviors and was subsequently admitted to a local hospital for evaluation of her behaviors. She was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident C was being treated with an antibiotic for the UTI, at the time of readmission. A Physician's progress note dated 10/25/16 indicated .Awake and oriented, incontinent, wheelchair bound, appetite 65%. Blood Sugars are reviewed again today .She is having diarrhea, some nausea and vomiting, not doing well clinically here this morning at this time A physician's orders [REDACTED]. CBC (Complete Blood Count), BMP (Basic Metabolic Panel),UA (Urinalysis) C&S (Culture and Sensitivity) IV NS (Intravenous line with Normal Saline) 75/hr (per hour) 24 hrs (hours) if labs show dehydration Clear liquid diet x (times) 3 days A nursing progress note dated 11/10/16 at 12:15 P.M., indicated .11 a.m. family here to visit, very angry stated resident is having a stroke, unit manager went to room to assess resident. Family yelling, cursing at staff making accusations that resident is not being cared for. 7 am resident was sleeping in recliner chair (which is her normal place to sleep) blood sugar checked 122, alert to name, denied any pain, asking who was her cna (certified nursing assistant) today. Refused breakfast, offered to get her something else, but refused, took all med po (by mouth) with glass of water, no difficulty swallowing .DON (Director of Nursing) was called to address family issues, md (Medical Doctor) was notified of family concerns, new order to send to ER (emergency room ) for eval (evaluation) .Noted left arm [MEDICAL CONDITION] was resting comfortably in recliner sleeps off and on, which is her usual functioning. Family remains in room giving resident grapes to eat, and liquids A nursing progress note dated 11/10/16 at 6:03 P.M. indicated .Returned from (name of local hospital) at 1800 (6:00 P.M.), resident has new orders for IV (intravenous) ABT (antibiotic) with peripheral line with 1 loom in right arm. ABT to continue for 7 days per hospital clarification and follow up visit with (name of primary physician) A Physicians order dated 11/10/16 indicated .IV [MEDICATION NAME] 1gm (gram) qd (every day) x 7 days During an interview on 11/30/16 at 2:00 P.M., the UM indicated the UA that was ordered on [DATE] had not been collected and sent to the lab for evaluation. During an interview on 11/30/16 at 2:20 P.M., the DON indicated the order for the Urinalysis had not been completed as ordered. On 11/30/16 at 2:26 P.M., the policy titled Lab Processing/Tracking Guidelines was provided by the Executive Director of the facility and reviewed. The policy indicated . Guideline Statement: To ensure that Diagnostic tests are processed, ordered, obtained, performed, and results received timely. Test results are communicated to the physician in a timely manner with documentation present in the medical record These Federal tags are related to Complaint IN 170 and Complaint IN 693.

Based on record review and interviews, the facility failed to ensure medications were ordered and administered timely following admission for 1 of 3 residents in a sample of 5 reviewed for medication orders. The resident was admitted to the facility at 3:00 p.m. and did not receive the scheduled medications after admission. The resident was noted to be in distress, a code blue was called and the resident was sent back to the hospital by EMS (Emergency Medical Services) 7 hours after admission. (Resident C) Finding includes: The record of Resident C was reviewed on 05/11/15 at 1:00 p.m. Resident C was admitted to the facility, on 04/10/15 at 3:00 p.m., from a local ACF (Acute Care Facility: hospital), with [DIAGNOSES REDACTED]. The resident was discharged back to the ACF, by EMS (Emergency Medical Service), 7 hours after admission, at approximately 10:00 p.m. on 04/10/15. The Progress Notes indicated: 04/10/15 23:17 (11:17 p.m.) admitted to this facility at 3:00 p.m. this date via (by way of) (Company name) ambulance. Daughter present. Alert/orientated x 3-capable of making needs known.Denies discomfort at this time. 04/10/15 23:21 (11:21 p.m.) MD (Medical Doctor) paged to verify hospital orders that accompanied resident at 3:25 p.m. 4/10/15 23:25 (11:25 p.m.) Daughter requesting that all scheduled meds due be given to (Resident's name). This RN explained that some medications will be arriving from pharmacy on the midnight shift that are ot (SIC) available in the EDK (Emergency Drug Kit) . Daughter crying, visibly upset and stating that she was informed that everything would be here waiting for her mother. This RN tried to re-explain that some meds would be coming from Indianapolis but that I could call the pharmacy to see if a dispense through a closer pharmacy was possible. Daughter then stated that her mother was having trouble breathing. (Resident's name) was in bed with HOB (Head of Bed) up without respiratory distress at this time. Daughter yelling, crying. This RN left room to attempt to contact pharmacy.Pharmacy states that they will get narcotics processed. 04/10/15 23:32 (11:32 p.m.) (Resident name) with noted increase and difficulty in respirations. Pursed-lipped breathing. O2 (Oxygen) on at 5L (Liter)/min (Minute) NC (Nasal Cannula) per MD orders. Staff repositioned (Resident name) to sit on edge of bed per her request. SPO2 (saturation of Oxygen) 85%. Nurse started breath TX (Treatment) via mask and [MEDICAL CONDITION] (mask for O2 administration) was set up. [MEDICAL CONDITION] used after breathing tx. SPO2 increased to 92% and resident calmer. Nurse asked if resident wanted to go to hospital. Daughter wants resident to go but resident did not answer. Resident much calmer at this point. SPO2 93%. 04/10/15 23:36 (11:36 p.m.) .This RN went to page MD when another nurse called out to call 911, that resident was losing ability to breath (SIC). 911 was notified by the RN during which time a code blue was called by other staff with the resident. All facility responded. 04/10/15 23:41 (11:41 p.m.) (at) Approximately 2135 (9:30 p.m.), 911 arrived and assumed care of resident.911 left facility with (Resident name) at approximately 2200 (10:00 p.m.). The ACF PHYSICIAN SUMMARY & TRANSFER ORDERS TO ECF (Extended Care Facility) with the Discharge Medication List orders, included, but were not limited to, the following: Scheduled /Routine Medication(s), to be administered on 04/10/15: [MEDICATION NAME] (antidepressant) 100 mg (milligram) 1 tab (tablet) orally once a day for 30 days.Next Due Dose: 04/101/15 9:00 p.m. aspirin (blood thinner) 81 mg orally 2 times a day.Next Dose Due: 04/10/15 9:00 p.m. atorvastatin (control cholesterol) 40 mg orally once a day.Next Dose Due: 04/19/15 9:00 p.m. [MEDICATION NAME] (asthma)160 mcg (microgram)-4.5 mcg.2 puffs inhalation 2 times a day.Next Dose Due: 04/10/15 9:00 p.m. [MEDICATION NAME] (heart failure) 6.25 mg 1 tab oral 2 times a day.Next Due Dose: 04/10/15 9:00 p.m. Cipro (antibiotic) 250 mg 1 tab orally every 12 hours for 1 day.Next Due Dose: 04/10/15 11:00 p.m. [MEDICATION NAME] (stool softener) 100 mg 1 cap orally 2 times a day.Next Due Dose: 04/10/15 9:00 p.m. [MEDICATION NAME] (diuretic) 40 mg 1 tab orally 2 times a day.Next Due Dose: 04/10/15 5:00 p.m. [MEDICATION NAME] (high blood pressure) 50 mg 2 tabs orally 3 times a day.Next Due Dose: 04/10/15 10:00 p.m. insulin [MEDICATION NAME] ([MEDICATION NAME]).7 units subcutaneous with meals.Next Dose Due: 04/1/10/15 6:00 p.m. insulin detemir ([MEDICATION NAME] Flex Pen.) 30 units subcutaneous 2 times a day.Next Dose Due: 04/1/10/15 9:00 p.m. magnesium oxide 400 mg orally 2 times a day.Next Dose Due: 0410/15 9:00 p.m. As Needed Medication(s):. [MEDICATION NAME] (anxiety) 0.25 mg.1 tab orally every 8 hours for 7 days. Last dose taken: 04/10/15 00:38 (12:38 a.m.). [MEDICATION NAME] (pain) 5 mg oral tablet: 1.5 tabs orally every 4 hours for 10 days. Last Dose Taken: 04/10/15 1:05 p.m. [MEDICATION NAME]-[MEDICATION NAME] (shortness of breath) ([MEDICATION NAME] 0.5mg-2.5 mg.every 2 hours.Next Dose Due: 04/10/15 6:00 p.m. Review of the MAR (Medication Administration Record), dated 04/2015, indicated the resident's blood glucose was not recorded for sliding scale insulin coverage. Resident C did not receive 9 scheduled medications due within hours of admission and which were available in the automated medication dispensing system at the time. The Unit Manager was interviewed on 05/12/15 at 3:00 p.m. The Unit Manager indicated RN#4, who was the nurse for Resident C on 04/101/15, was no longer employed at the facility. The Unit Manager indicated the facility had initiated an investigation following Resident C being discharged to the ACF as related to the incident. This included a review of orders and correlating with the facility's automated medication dispensing system, which contains a formulary of medications routinely ordered for residents, including scheduled and PRN (as needed) medications. During the interview, the automated dispensing system's formulary was observed for inventory on a computer screen. A review of medications as ordered for Resident C indicated all but 2 of the medications were noted to be routinely stocked and available in the dispensing system. The Unit Manager indicated [MEDICATION NAME] the [MEDICATION NAME] were ordered from the pharmacy but were not delivered prior to the resident's discharge back to the ACF. The Unit Manager indicated all but 2 ordered medications for Resident C were available on site and should have been administered during the short time the resident was in the facility. This Federal tag relates to Complaint IN 201. 3.1-25(b)(9)

Based on observation, record review, and interviews, the facility failed to ensure interventions were implemented and adequate supervision was provided to prevent falls for 3 of 5 residents reviewed for falls in a sample of 9. (Resident "C", Resident "D", and Resident "F") Findings include: 1. The clinical record for Resident C was reviewed on 01/16/13 at 1:30 P.M. Resident C was admitted to the facility, on 01/17/12, with diagnoses, including but not limited to, history of neoplasm of the lung, chronic obstructive pulmonary disease, history of a deep vein thrombosis, and ishcemic heart disease. The most recent Minimum Data Set (MDS) assessment for Resident C, completed on 11/29/12, indicated the resident was was nonambulatory, required extensive staff assistance for transfer needs, dressing needs, and toileting needs. The current health care plans for Resident C indicated a plan, initiated on 10/17/12, regarding the resident risk for falls. The plan included interventions for the bed to be in the low position, call light or personal items available an din easy reach, footwear to prevent slipping, therapy referral, transfer assistance, transfer pole at bedside, wheelchair available, and gait belt. On 01/17/13 from 9:10 A.M. - 4:00 P.M., Resident C was observed to spend his time in his room seated in a wheelchair. At 4:00 P.M. on 01/17/13, CNA #16 instructed and minimally assisted the resident to stand and hang onto the transfer pole at his bedside while she changed the resident's brief and provided minimal personal hygiene. The CNA did not use a gait belt during the procedure. Interview on 01/17/13 at 2:30 P.M., prior to the observation, with CNA #16 indicated she was new and had only worked at the facility a few months. She indicated she had an assignment worksheet for the residents she was responsible for in her pocket. Observation of the assignment sheet indicated she was to provide the care for Resident C. The assignment sheet for Resident C indicated he was "incontinent, "used a "Sara lift (mechanical standing lift)", a wheelchair, and had chair alarms. There was no indication of the assignment form to utilize a gait belt. CNA #16 indicated the resident usually stood for her and had a transfer pole in his room. She indicated she did not utilize a Sara Lift for Resident C, did not utilize a gait belt for Resident C, and did not think he had a chair alarm on his wheelchair. She indicated she at times had observed Resident C wheeling himself out of the bathroom and thought perhaps he toileted himself at times but she was not sure about the issue. Interview with CNA #15, on 01/17/13 at 2:05 P.M., indicated she sometimes took care of Resident C on the day shift. She indicated although the assignment sheet had a "Sara lift" for Resident C he actually transferred with a transfer pole and one assist in his room. She indicated he also tried to toilet himself at times. She indicated there was no chair alarm and no special instructions to utilize any type of equipment while transferring the resident. Nursing progress notes, dated 11/02/12 at 10:10 A.M., indicated the CNA had informed the nurse she had to lower the resident to the floor during a transfer because the resident had become "unstable" when she (the CNA) was transferring the resident from the bed into the wheelchair. Review of the interdisciplinary fall review investigation, completed on 11/02/12, indicated the recommendation was for a gait belt and non-skid footwear to be utilized when transferring Resident C. Interview with the Administrator and the Director of Nursing, on 01/18/13 at 12:00 P.M., indicated the facility had "a lot" of new staff. There was no indication how the new staff were supposed to know the fall interventions to be utilized if the interventions on the assignment sheets were not being followed and/or were not of the form. 2. The record of Resident "D" was reviewed on 01/18/13 at 8:30 a.m. Resident "D" was admitted to the facility, on 12/31/10, with [DIAGNOSES REDACTED]. Review of the record indicated Resident "D" had incurred a fall, on 09/07/12, when the resident was found seated on the floor next to the bed. Review of the most recent MDS (Minimum Data Set: a tool to assist in residents plan of care) indicated the resident required assist from bed to chair. Review of a care plan to address fall risk for resident "D" indicated, "01/08/13 Transfer assistance (up to two person if needed)." Review of the "CNA Assignment Sheet: 01/11/13", indicated the resident as "IND" for independent for transfers. Interview with the LPN-Unit Manger, on 01/14/13 at 10:00 a.m. during initial resident review, indicaed the CNA worksheets were accurate and up to date. 3. The record of Resident "F" was reviewed on 01/18/13 at 10:00 a.m. Resident "F" was admitted to the facility, on 02/21/04, with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set: a tool to assist in residents plan of care), dated 11/19/12, indicated the resident was cognitive, and required assistance with transfers, eating, dressing and toileting. Review of the record indicated Resident "F" had incurred 8 falls between 11/02/12 and 01/12/13. Review of the fall investigations indicated: "11/02/12 14:45 (2:45 p.m.)... found laying in front of recliner...No injury." "11/04/12 18:30 (6:30 p.m.)....resident reported sliding from recliner to floor... No injury." "11/24/12 19:10 (7:10 p.m.)....found...leaning to the raised recliner...No injury." "12/08/12 12:30 (12:30 p.m.)...near recliner...2 cm laceration to right eye brow." "12/18/12 12:20 (12:20 p.m.)...fell in room...reaching for glasses...No injury." "12/31/12 20:00 (8:00 p.m.)...next to recliner...No injury." "01/12/13 04:20 (4:20 a.m.)...on floor by bedside...sitting position...No injury." Review of the "Provide Summary..." area of the fall investigations indicated various suggestions to family but no family input or involvement. A review of the Social Service notes indicated no documentation in regards to a care plan meeting in regards to the resident's frequent falls. The most recent fall resulted in injury. Review of the Fall Investigation included, but was not limited to: "01/12/12 18:15 (6:15 p.m.) DESCRIPTION OF EVENT: ...B wing dining room...skin tear right forehead, 0.7 cm (centimeters) X (by) 1.26 cm X 20.1 cm. @ hematomas (R) (right) forehead and right temple, 6 cm X 4.5 cm and 3 cm X 3 cm. RESIDENT INTERVIEW SUMMARY: Could not explain how she got on the floor. SPECIFY RECOMMENDATIONS/INTERVENTIONS TAKEN TO PREVENT REOCCURRENCE:...Therapy screen and personal alarm." PROVIDE SUMMARY AND OUTCOME OF INVESTIGATIVE FINDINGS: Resident c (with ) multiple falls. Very poor safety awareness. Hx (history) of refusing therapy. Attempts to stand, ambulate s (without) assistance. Multiple interventions in place. Resident safety concern - Plavix & ASA (anticoagulants: blood thinners) use, large hematoma c fall. Neuro (neurology) checks WNL (within normal limits). Staff state family refused room change to bring closer to Nurses station. Transfer w/c (wheelchair) used ...." Review of care plans indicated the care plan addressing "Self care impairment" indicated: "01/16/13 Transfer assistance up to x2 extensive assist. Utilize mechanical lift as needed." "01/16/13 Toileting assistance at least every two hours and as needed." Review of the "At risk for falls..." care plan indicated initiation date of "12/06/12" and "Interventions:...RESOLVED: Transfer pole at bed side and in bathroom, and by recliner. Resolved 12/06/12." Review of the "CNA Assignment Sheet: 01/11/13", for Resident "F" indicated: "Toileting: cont/incont (continent/incontinent)" "Transfers: X1 assist/ind (independent) at times" "Mobility: AMB/WC (ambulatory/wheelchair)" "Safety: Fall risk. Transfer pole by bed, NSS walk way, call light @ recliner." Resident "F" was observed, on 01/17/13 at 8:30 a.m., for a transfer with 1 assist by CNA #5. CNA #5 did not use a transfer belt. Resident "F" was observed with mask like facial bruising in various stages of healing, and varying in color from purple to pinkish yellow. Review a Policy & Procedure, "Transfer Activities: 2006", provided by the DNS (Director Nurses Services) on 01/22/13 at 9:00 a.m., indicated: "...5. Apply transfer belt..." Resident "F" was observed throughout the survey with mask like facial bruising in various stages of healing, and varying in color from purple to pinkish yellow. The investigation of the 01/12/13, fall in the dining room did not indicate why the resident was in the dining room unattended or address how the facility would address the fall to prevent further occurrences. Review of the facility Policy and Procedure, "Verification of Investigation of Alleged Mistreatment, Abuse, Neglect, Injuries of Unknown Source and Mispronunciation of Resident Property Guideline: 01/2011", and provided by the Administrator on 01/14/13 at 11:00 a.m., indicated: "...Investigation:..The investigation includes interviews of employees, visitors or residents who may have knowledge of the alleged incident. Only factual information is documented... Corrective action:...The center makes reasonable efforts to determine the cause of the alleged violation and takes corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident...Appropriate steps are taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. The steps taken are documented...." This Federal tag refers to Complaint IN 8 and Complaint IN 1. 3.1-45(a)(2)