Every finding on record at Brickyard Healthcare - Woodbridge Care Center

Based on observation, interview, and record review, the facility failed to ensure care plans were developed and implemented for 1 of 4 residents reviewed for falls and 1 of 1 residents reviewed for catheters and activities. Fall interventions were observed out place, catheter interventions were observed out of place, and a resident did not have an activities care plan. (Resident 5 and Resident 3)Findings include:1. On 7/23/25 at 10:36 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 6/27/25, indicated Resident 5 had severe cognitive impairment, was dependent on staff (staff does all of the work) for transfers, and had no falls since the prior assessment. A care plan conference was completed 7/23/25 at 2:29 P.M. A care plan conference note indicated that care plans were reviewed and were up to date. A risk for falls care plan, initiated 3/8/24, included, but were not limited to, the following interventions:Place Call Don't Fall sign in room, dated 8/14/24 On 7/24/25 at 9:15 A.M., there was not a Call Don't Fall sign observed in Resident 5's room. On 7/24/25 at 9:28 A.M., Registered Nurse (RN) 3 indicated there was not a Call Don't Fall sign in Resident 5's room and she was not sure if that intervention was in his plan of care. On 7/24/25 at 10:03 A.M., Regional Support 9 indicated that she found the Call Don't Fall sign on the floor behind some furniture. She indicated the tape used was not sticky enough to hold it and it must have fallen down at some point. 2. On 7/21/2025 at 11:44 A.M., Resident 3's catheter bag was observed laying across the resident's leg while the resident was sitting in a wheelchair in the activities room. At that time, Resident 3 indicated he did not like sitting around all day and he felt like there were not enough age-appropriate activities. On 7/24/25 at 9:00 A.M., Resident 3's catheter bag was observed sitting on the edge of the extended left leg peddle while the resident was sitting in the activities room On 7/23/2025 at 2:09 P.M., Resident 3's clinical record was reviewed. Diagnoses included but were not limited to neurogenic bladder and Diabetes Mellitus Type 2. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 6/13/25, indicated Resident 3 had mild cognitive impairment. Resident 3 required setup assistance from staff for eating and was dependent on staff for hygiene, dressing, and mobility. The resident had a suprapubic catheter. Current physician orders included, but were not limited to:Foley catheter care every shift and PRN (as needed) every day and night shift, dated 6/2/25. Catheter type 16 French (FR) with 10 Cubic Centimeters (cc) Balloon Size related to pressure ulcer of unspecified buttock stage 4 every day and night shift, dated 12/26/24. May participate in activities by per individual Plan of Care (POC), dated 12/23/24. A care plan conference was completed on 7/11/24 and the care plan was reviewed. A suprapubic catheter care plan, initiated 12/31/24, included, but were not limited to, the following interventions: Position catheter bag and tubing below the level of the bladder and away from entrance room door, dated 12/31/24 The clinical record lacked a care plan related to activities for Resident 3. During an interview on 7/23/25 at 3:50 P.M., the Activities Director indicated each resident should have a care plan for activities upon admission, significant change, quarterly, and annually. During an interview on 7/23/25 at 3:50 P.M., the Activities Director indicated each resident should have a care plan for activities upon admission, significant change, quarterly and annually. On 7/24/24 at 2:36 P.M., the Administrator provided a current non-dated policy Comprehensive Care Plan. The policy indicates .the care planning process will describe a minimum .the services that will be furnished to attain or maintain the resident's highest physical, mental psychosocial well-being . On 7/24/25 at 2:36 P.M., the Administrator provided a current Comprehensive Care Plan, dated 2025, that indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 3.1-35(a)3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure proper infection practices and standards were followed for 1 of 2 residents with catheters and 2 of 2 random observations. Staff did not perform adequate hand hygiene during catheter care and multi-resident use glucometers were not cleaned according to manufacture instructions. (Resident 47, Resident 17, and Resident 31)Finding includes: 1. During a random observation on 7/23/25 at 6:40 A.M., Qualified Medication Aide (QMA) 5 was observed cleaning a multi-resident use glucometer with an alcohol preparation pad after performing an Accu-Chek on Resident 17. 2. During a random observation on 7/23/25 at 7:00 A.M., Qualified Medication Aide (QMA) 5 was observed cleaning a multi-resident use glucometer with an alcohol preparation pad after performing an Accu-Chek on Resident 31. During an interview on 7/25/25 at 9:00 A.M., the Regional Director indicated glucometers were cleaned for 1 minute using cleaning wipes per manufacture's instruction. The facility used Micro Kill 1 Germicidal Wipes. 3. During an observation of catheter care on 7/24/25 at 10:06 A.M., LPN 17 put on a gown and gloves, entered Resident 47's room. LPN 17 and QMA 15 positioned Resident 47 and removed her brief. QMA 15 removed her gloves and washed her hands for 12 seconds. QMA 15 put new gloves on and cleaned around Resident 47's suprapubic catheter then downwards, and then dried in same motions. QMA 15 and LPN 17 bagged up dirty linens, emptied wash basins, and removed gowns and gloves. QMA 15 washed her hands for 7 seconds and exited Resident 47's room. LPN 15 exited Resident 47's room then used hand sanitizer, rubbing her hands together for three seconds before carrying dirty linens away. On 7/23/25 at 10:47 A.M., Resident 47's clinical record was reviewed. Resident 47 was admitted on [DATE]. Diagnoses included, but were not limited to, incontinence. The most recent Annual Minimum Data Set (MDS) Assessment, dated 5/20/25, indicated Resident 47 was cognitively intact and was dependent on staff (staff does all of the work) for toileting, bathing, and transfers. Physician orders included, but were not limited to: Foley catheter care every shift; start date 10/8/24 Enhanced Barrier Precautions: Sign outside resident's room, gown and gloves for high contact resident care activities, used for residents with known MDRO (multi-drug resistant organism) or have an increased risk of MDRO acquisition (residents with wounds or indwelling medical devices), face shield should be used for any tasks that have a high potential of splash or spray; Start date 5/9/25 Care plans included. but was not limited to:History of urinary tract infection related to having an indwelling catheter; Date initiated 9/13/24 Resident requires contact isolation; Date initiated 6/20/25 On 7/24/25 at 2:36 P.M., the Administrator provided a policy titled Hand Hygiene, dated 2025, that indicated Hand hygiene technique when using alcohol based hand rub: apply to palm of one hand the amount of product recommended by the manufacturer. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. This should take about 20 seconds. Hand hygiene technique when using soap and water: Wet hands with water . Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all of the surfaces of the hands and fingers. Rinse hands with water. On 7/24/25 at 2:36 P.M., the Administrator provided a current undated Glucometer Disinfection policy that indicated .glucometers will be cleaned and disinfected after each use based on the manufacturer's instructions whether they are intended for single or multiple resident use . 3.1-18(b)(1)3.1-18(l)

Based on interview and record review, the facility failed to ensure dialysis care was provided for 1 of 3 residents reviewed for dialysis. Routine assessments were not completed as ordered and the physician was not notified when a resident refused or stopped dialysis treatments early. (Resident B) Finding includes: During record review on 3/6/25 at 10:30 A.M., Resident B's diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. Resident B's most recent admission Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the resident was cognitively intact and received dialysis services. Resident B's physician orders included, but were not limited to, dialysis treatment on Tuesdays, Thursdays, and Saturdays (started 2/1/25), monitor dialysis dressing for bleeding, every day and night shift for left dialysis permacath (started 2/1/25). Resident B's care plan included, but was not limited to, resident needs dialysis due to renal failure (started 2/21/25). Interventions included, but were not limited to observe permacath for placement routinely. Resident B's Treatment Administration Record (TAR) for February & March, 2025 indicated no monitoring of the resident's left dialysis permacath occurred on 2/14/25 night shift, 2/18/25 day shift, or 3/2/25 night shift. Resident B's dialysis//observation communication forms contained the following: 2/6/25 - Resident only stayed 1.5 hours. Resident left against medical advice (AMA). 2/8/25 - Resident refused to stay. Resident left early AMA. 2/13/25 - Resident requested early termination from dialysis treatment. 2/15/25 - Resident refused dialysis treatment. Resident B's progress notes contained no documentation that the physician was notified on 2/6/25, 2/8/25, 2/13/25, or 2/15/25 when the resident refused or left dialysis AMA. During an interview on 3/7/25 at 11:15 A.M., LPN 4 indicated nursing staff assess a resident's dialysis access site daily and documented in the TAR or nurse's progress notes. If a resident refused dialysis or left dialysis before their treatment was completed, the resident's physician should be notified and the notification should be documented. On 3/7/25 at 9:20 A.M., the facility administrator supplied a facility policy titled, Hemodialysis dated, 2024. The policy indicated, 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications . 10. The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record . 16. Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled . This citation relates to complaint IN00454852. 3.1-37(a)

Based on interview and record review, the facility failed to prevent the misappropriation of resident's narcotic medication for 1 of 3 residents reviewed for misappropriation of property. A resident's narcotic pain medication was missing. (Resident B) Finding includes: During record review on 12/17/24 at 10:39 a.m., Resident B's diagnoses included, but were not limited to, dysphagia following cerebral infarction, type 2 diabetes mellitus with hyperglycemia, aphasia following cerebral infarction. A MDS (Minimum Data Set) assessment dated [DATE], indicated cognition was severely impaired. Care plans were reviewed and included, but were not limited to: Pain : I am at risk for pain related to Hx (history) of Cva (cerebral infarction). Interventions included, but were not limited to: Administer pain medications as ordered, date initiated, 6/26/24. A progress note dated 12/5/24 at 4:48 p.m., indicated Facility nurse noticed when checking to see if resident needed refill on Norco during hospice visit that medication was not in the cart and count sheet was missing. ED, DNS, and Unit Manager. Resident was immediately assessed for pain and psychosocial distress. Not (sic) s/s noted. Hospice aware and initiated refill request. [name of pharmacy], resident's emergency contact, Medical Director, and [name], NP notified. Head to toe assessment completed. No injury or skin issues noted. Resident placed on psychosocial and pain monitoring x 72hrs(sic). December 2024 physicians orders included, but were not limited to: Norco (pain medication) oral tablet 5- 325 MG (milligram) (Hydrocodone- Acetaminophen * Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain, order date 11/20/24. On 12/17/24 at 1:57 p.m., a state reportable with an incident date of 12/4/24, was reviewed and included, but was not limited to: Description added- 12/5/24 During hospice visit, hospice nurse inquired if patient needed a refill on his Norco script. When facility nurse was checking quantity of Norco, the facility nurse noticed that the card of 57 Norco and associated count sheet was missing and could not be accounted for. Follow up added- 12/12/2024 All follow up was completed with no further issues. [Resident B] did not display any signs of psychosocial distress while being monitored by social services. [Resident B] did not display any signs of increased pain or discomfort. Staff and resident interviews completed with no concerns of narcotics not being available or not given per MD orders. All nurses were drug tested with no concerns identified from the drug tests. Full reconciliation of all narcotics in the building completed with no discrepancies. [name of police department] notified and case number # [number] was provided. Staff education completed on narcotic administration and abuse reporting and prohibition. On 12/18/24 at 10:15 a.m., the Administrator indicated the incident with Resident's B's missing narcotics was noticed on 12/5/24, she mistakenly put the date of 12/4/24 on the State Reportable as the incident date. On 12/17/24 at 12:15 p.m., the Administrator provided the current policy on abuse, neglect, and exploitation with copyright date of 2024. The policy included, but was not limited to: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . The deficient practice was corrected on 12/9/2024 after the facility implemented a systemic plan that included the following actions: Ad HOC QAPI meeting was held on 12/6/2024 an action plan included inservice review of policy for controlled substances with staff, staff drug testing on 12/5/24, the completion of IDT meeting for resident on 12/9/24 and the on-going monitoring of the controlled substances for all residents. This citation relates to Complaint IN00448621 3.1-28(a)

Based on observation, record review, and interview, the facility failed to provide timely showers for 4 of 4 dependent residents reviewed for ADL (Activities of Daily Living (Resident 4, Resident 2, Resident 13, and Resident 7) Findings include: 1. On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy and flaccid neuropathic bladder, not elsewhere specified. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE]. The MDS indicated Resident 4 was cognitively intact and was dependent on transfer, mobility, eating, and hygiene. Physician orders included but not limited Weekly skin review on Saturdays on Day Shift dated 10/11/23 Showers are scheduled for Wednesday and Saturday and the day shift is 7-3 P.M. The current care plan indicated that Resident 4 has a self-care deficit related to primary diagnosis of cerebral palsy. Interventions included bathing assistance of dependent dated 10/20/23. The current care plan also indicated Resident 4 has incidents of being uncooperative/refusal of showers dated 5/6/24. Interventions included but are not limited to explaining all risks of not cooperating with care in simple terms and offer bed bath when showers refused dated 5/6/24. During an interview on 7/9/24 at 10:22 A.M., Resident 4 indicated that showers were not given on shower days of Wednesday and Saturday. On 7/12/24 at 9:00 A.M., the Administrator provided showers recorded from the Task Charting in the facility charting program that the CNA(Certified Nurse Aide) do when care is provided from January 2024 until July 2024 Showers dates missed: 2/7/24- Wednesday no shower 3/6/24 Wednesday no shower 3/27/24 Wednesday no shower 4/24/24 Wednesday no shower 6/12/24 Wednesday no shower 6/22/24 Saturday no shower During an interview on 7/11/24 at 9:19 A.M., CNA 7 indicated Resident 7 will refuse a lot but should be encouraged to take and will offer alternative. 48057 2. On 7/11/24 at 10:13 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and dementia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 13 was cognitively intact and required moderate assistance from staff for toileting and bathing. A physical functioning deficit care plan, dated 7/1/22, indicated Resident 13 had self-care impairment and required substantial assistance of one staff for bathing. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Tuesdays and Fridays. Resident 13 did not receive or refuse a shower on the following days in 2024: January 2, 12, 26 May 24, 31 June 14, 18, 24 3. On 7/12/24 at 8:52 A.M., Resident 2's clinical record was reviewed. Resident 2's diagnoses included, but were not limited to, dementia, weakness, and intellectual disabilities. The most recent Quarterly MDS (Minimum Data Set Assessment, dated 6/3/24, indicated Resident 2 was severely cognitively impaired, required substantial assistance of staff with toileting and transfers, and was dependent on staff for bathing. A physical functioning deficit care plan, dated 4/27/17, indicated Resident 2 had self-care impairment and required total assistance of one staff for bathing. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Wednesdays and Saturdays. Resident 2 did not receive or refuse a shower on the following days in 2024: January 31 February 3, 7, 17, 28 March 2, 6, 20 May 4, 25 June 1, 8 July 6 48147 4. On 7/9/24 at 9:44 A.M., Resident 6 indicated she was supposed to get her showers on Wednesdays and Saturdays but hadn't received a shower for the past 2 weeks. On 7/9/24 at 2:58 P.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated Resident 6 was cognitively intact, was dependent on staff for bathing, and had no rejection of care during the 7-day look back period. A Preference Evaluation, dated 6/25/24, indicated Resident 6 preferred showers at any time of the day. An Activities of Daily Living (ADL) care plan, dated 12/20/22, indicated Resident 6 had a self-care deficit and was dependent on one staff for bathing assistance. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Wednesdays and Saturdays. Resident 6 did not receive or refuse a shower on the following days in 2024: January 3, 6, 10, 20, 27 February 10, 14, 17, 24 May 4, 25 June 1, 5, 22, 26 On 7/10/24 at 9:51 A.M., the Administrator indicated the facility did not use shower sheets. If a resident refused a shower, it was documented in POC Tasks. On 7/15/24 at 8:53 A.M., the Administrator provided a Resident Rights policy, dated 2024, that indicated The resident has .the right to receive the services and/or items included in the plan of care. 3.1-38(a)(3)(B)

Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents, staff, and the public for 17 random observations on 5 of 6 days. Urine smells in unit hallways, conference rooms, common areas, stairwells.(100 Unit Hallway, 200 Unit Hallway, Basement Hallway, Conference Room, Stairwell off 100 Unit, Stairwell off 200 Unit) Findings include: 1. On 7/8/24 at 8:14 A.M., the smell of urine was observed in the 100 Unit Hallway. On 7/8/24 AT 8:15 A.M., the smell of urine was observed in the Stairwell off the 100 Unit Hallway. On 7/8/24 at 8:16 A.M., the smell of urine was observed in Basement Hallway. On 7/8/24 at 10:30 A.M., the smell of urine was observed in the 200 Unit Hallway and into the Common Area of the unit. 2. On 7/9/24 at 8:05 A.M., the smell of urine was observed in the 100 Unit Hallway. On 7/9/24 at 8:06 A.M., the smell of urine was observed in the Stairwell off the 100 Unit Hallway. On 7/9/24 at 8:17 A.M., the smell of urine was observed in Basement Hallway. On 7/9/24 at 10:30 A.M., the smell of urine was observed in the Basement Hallway. 3. On 7/11/24 at 8:10 A.M., the smell of urine was observed in the 100 Unit Hallway. On 7/11/24 at 8:11 A.M., the smell of urine was observed in the Stairwell off the 100 Unit Hallway. On 7/11/24 at 8:12 A.M., the smell of urine was observed in Basement Hallway. On 7/11/24 at 10:30 A.M., the smell of urine was observed in the 200 Unit Common Area. On 7/11/24 at 1:00 P.M., the smell of urine was observed in the 200 Unit Hallway. 4. On 7/12/24 at 10:04., the smell of urine was observed in the elevator going to the 200 Unit Hall. On 7/12/24 at 10:05 A.M., the smell of urine was observed in 200 Unit Hallway. On 7/12/24 at 10:23 A.M., the smell of urine was observed in 200 Unit Common Area. During an interview on 7/15/24 at 11:14 A.M., LPN (Licensed Practical Nurse) 8 indicated the facility should be free of smells. On 7/15/24 at 8:54 A.M., the Administrator produced a current, nondated policy Safe and Homelike Environment. The policy indicated .the facility will provide a safe, clean . environment .housekeeping and maintenance services will be provided as necessary to maintain a sanitary,orderly, and comfortable environment .minimize odors by disposing of soiled linens promptly and reporting lingering odors . needing cleaning to Housekeeping Department. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs by transporting a resident in an improperly fitted wheelchair for 1 of 1 residents reviewed for mobility. (Resident 8) Findings include: During an observation on 7/9/24 at 9:46 A.M., Resident 8 was observed sitting in a manual wheelchair in the hallway. Resident 8 indicated he was ready to get out of the wheelchair and go to bed. During an interview on 7/10/24 at 9:47 A.M., RN (Registered Nurse) 3 indicated the manual wheelchair was not Resident 8's personal wheelchair and was the one staff used for transportation due to Resident 8's personal electric wheelchair not being able to fit in the facility's mobility van. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers. Current orders included, but were not limited to:OT (Occupational Therapy) screen attempted due to reports of poor positioning in wheelchair however pt (patient) LOA (leave of absence/out of building) at this time Order date 7/10/24 During an interview on 7/12/24 at 9:29 A.M. Occupational Therapist 10 indicated she was not aware until this week Resident 8's trunk was not being supported in the manual wheelchair nursing staff had been using to transport Resident 8 in the mobility van. On 7/15/24 at 3:04 P.M., the Regional Support Consultant provided a document titled Functional Mobility and Wheelchair Assessment, dated 4/24/24, that indicated manual wheelchair use was contraindicated for Resident 8 by diagnoses, the only mobility device that met the needs for safety independent functional ambulation/mobility was a power wheelchair due to quadriplegia and impairment in arms, legs, and trunk, and stage 4 pressure wounds on the sacral region, and inability to achieve repositioning for pressure relief in a standard wheelchair. On 7/15/24 at 12:10 P.M. the Administrator provided a policy titled Therapy Evaluation, dated 2023, that indicated The Licensed Therapist will perform an initial evaluation upon physician referral and any re-evaluation where indicated. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to notify a resident's physician of treatments not provided for 1 of 2 residents reviewed for pressure ulcers. (Resident 8) Finding includes: On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers. Current physician orders included, but were not limited to: Dakins external solution (sodium hypochlorite) Apply to coccyx topically every day and night shift for wounds, start date 7/3/24. Cleanse with Dakins Solution, apply silver alginate to the wound bed and cover with superabsorbent dressing every day and night shift for Stage three pressure area to right dorsal foot. Wound #1 left gluteal pressure treatment recommendations: Cleanse with 0.25% Dakins solution, apply silver alginate to base of the wound, secure with superabsorbent (dressing), change BID (twice a day) every day and night shift for stage three pressure area to left gluteal/buttock. Wound #2 coccyx pressure treatment recommendations: Cleanse with 0.25% Dakins solution. apply silver alginate to base of the wound, secure with superabsorbent (dressing), change BID, every day and night shift for stage four pressure area to coccyx. Wound #3 right gluteal pressure treatment recommendations: Cleanse with 0.25% Dakins solution, apply silver alginate to base of the wound, secure with superabsorbent (dressing), change daily, every day and night shift for stage four pressure area to right gluteal/buttock. Current care plans included, but were not limited to: (Resident) has personal preference to be changed on his time and not when staff come in to do it. Honor personal preference as safely able. Notify MD (doctor) of resident preference; Date initiated 1/18/24. The following progress notes indicate times and dates during the past month when Resident 8 refused treatment, while sleeping, and further attempts to change dressings during wake hours were not documented. 7/11/24 4:37 A.M. (Resident) is currently asleep and does not want this nurse to change dressings on foot or buttocks and coccyx. 7/8/24 11:50 P.M. (Resident) states he just got comfortable and doesn't want to move. 7/6/24 5:34 A.M. Resident refused this nurse to do treatment stating he was trying to sleep and didn't feel like doing it. 6/30/24 12:35 A.M. Resident refused to have treatments done. Wanted to sleep. 6/29/24 4:21 A.M. Resident did not want this nurse to complete dressing changes while resident trying to sleep. 6/23/24 10:41 P.M. (Not administered) Resident sleeping 6/22/24 2:21 A.M. (Resident) refused to have treatments done. Resident was tired and just wanted to go to sleep. During an interview on 7/12/24 at 9:23 A.M. Physician 12 indicated she had not been notified of wound treatment refusals or change in preference time of treatments for Resident 8. During an interview on 7/12/24 at 11:09 A.M., the Regional Support Consultant read results, from the MRI performed on Resident 8 on 7/9/24, and indicated Resident 8 was positive for osteomylitis (bone infection) and the results had not yet been sent to Resident 8's physician, but she would send them at this time. On 7/15/24 at 12:10 P.M., the Administrator provided a policy titled Promoting/Maintaining Resident Self-Determination, dated 2024, that indicated The facility will accommodate the resident preferences to the extent possible and as agreed upon by the resident sponsor and physician. A policy relating to physician notification was requested but was not provided. 3.1-5(a)(3)

Based on record review and interviews, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 1 resident's reviewed for facility reported incidents of staff to resident physical contact. (Resident 8) Finding includes: On 7/9/24 at 8:45 A.M., a facility reported incident, dated 3/13/24 at 3:01 A.M., was reviewed. The incident form indicated Resident 8 reported that during PM (evening) care, Employee 13 made contact to Resident's head. Employee 13 was immediately suspended pending investigation. A follow up added 3/21/24 indicated Resident 8 showed no signs of distress and Employee 13 chose not to participate in the investigation and resigned from employment. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers. During an interview on 7/9/24 at 8:55 A.M., the Administrator provided clarification that the verbiage made contact was intended to mean Resident 8's head bent forward and touched Employee 13's chest when Employee 13 was assisting Resident 8 with changing Resident 8's shirt. The investigation file was provided and the following was included: A screenshot of a text message from QMA 15 reads I was passing meds (medications) with my back to (employee 13) and (Resident 8). (Resident 8) all of a sudden says why did you slap me? So I turned around and said what? (Employee 13) instantly started to apologize saying I thought you bit me. An email from the Social Service Director dated 3/15/24 at 4:00 P.M. indicated on 3/12/24, while Resident 8 was being provided care, Employee 13 was attempting to remove Resident 8's shirt when Resident 8 involuntarily moved forward and his head touched Employee 13's nametag, and Employee 13 immediately took her hand and hit Resident 8's face. A statement dated 3/13/24, signed by Employee 13, indicated she was helping Resident 8 change his shirt when Resident 8 acted like he was going to bite Employee 13 so she put her hand up to his face and pushed him back and he stated wow I just got slapped. During an anonymous interview on 7/10/24 at 8:31 A.M., the anonymous person indicated an incident that happened on 3/12/24 between Employee 13 and Resident 8, where Employee 13 slapped Resident 8 in the face. The anonymous person indicated since Employee 13 was fired, she and her spouse had harassed Resident 8 about reporting the the incident while Resident 8 was out in the community with family. During an interview on 7/15/24 at 8:59 A.M., the Administrator indicated she didn't recall the timeline of the incident that happened, that she was gone from the building for training at that time because administration was switching and there wasn't great communication between the old administrator about incidents going on in the building. The Regional Support Consultant states she is the one who made the report and even though employee 13 had given a written statement, she reported on the State Incident Form that Employee 13 had not given a statement because Employee 13 would not come to the building to talk to administration in person. On 7/9/24 at 9:45 A.M., the Administrator provided a policy titled Abuse, Neglect, and Exploitation, dated 2022, that indicated The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of residents property, and exploitation. The facility will have written procedures that include reporting of alleged violations to the Administrator, state agency, adult protective services and all other required agencies (law enforcement when applicable) Immediately, but not later that 2 (two) hours after the allegation is made, even if the events that cause the allegation involve abuse or result in serious bodily injury. Assuring that reporters are free from retaliation or reprisal. 3.1-27(a)(1)

Based on interview and record review, the facility failed to transport residents with proper documents, or transfers residents with legible documents for 2 of 3 residents reviewed for hospitalization s. (Resident 8 and Resident 54) Findings include: 1. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers. The clinical record indicated during the past year, Resident 8 was discharged from the facility and admitted to the hospital on 9/4/23 and 5/10/24. A progress note dated 5/10/24 at 9:39 A.M., indicated Resident (was) sent to ER (emergency room ). Transfer log, order summary, post form, and bed hold policy sent with resident. During an interview on the Regional Support Consultant indicated there were no documents sent with Resident 8 during the hospital visit on 9/4/23. The transfer/discharge forms sent with Resident 8 on the 5/10/24 hospital visit were provided, however, the Administrator and Regional Support Consultant were unable to read the documents and indicated the paperwork sent with Resident 8 was not legible, and new forms would have to be printed to be able read them. 46758 2. On 7/11/24 at 2:49 P.M., Resident 54's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease and essential (primary) hypertension, The current Admission MDS (Minimum Data Set) Assessment, dated 5/1/24, indicated Resident 54 was cognitively intact and needed supervision for eating, dressing, and mobility. A Significant Change Nurse's Progress Note, dated 5/27/24 at 2:26 P.M., indicated the resident was having chest pain and shortness of breath. Vital signs indicated Blood Pressure 224/125, Pulse 86, Respirations 18, and Oxygen Saturation of 92%. Nurse Practitioner was called, and the new orders were received to transfer the resident to the emergency room . The record lacked an order to transfer and paperwork for transfer, discharge, and bed hold. During an interview on 7/15/24 at 8:53 A.M., the Regional Support Person indicated that the facility could not locate any transfer/discharge/ bed hold information requested for 5/27/24. On 7/15/24 at 8:53 A.M. the Administrator provided a policy titled Transfer and Discharge, dated 2024, that indicated the facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. For transfer to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner who is responsible for the care of the resident; Resident representative information, including contact information; all advanced directive information; all other information necessary to meet the residents needs . The original copies of the transfer form and Advance Directive accompany the resident. Provide a notice of transfer and the facility's bed hold policy to the resident and representative. The Social Services Director will provide copies of notices for emergency transfers to the Ombudsman. 3.1-12(a)(16)

Based on record and interview the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 2 residents reviewed for unnecessary medications and bladder.(Resident 4) Findings include: On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy and flaccid neuropathic bladder, not elsewhere specified. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE]. The MDS indicated Resident 4 was cognitively intact and was dependent on transfer, eating, and mobility. The Bowel and Bladder section indicated Resident 4 had an indwelling, suprapubic and external catheters with a colostomy. A Significant Change MDS dated [DATE] indicated that Resident 4 had an indwelling, suprapubic catheter and no external catheter or colostomy. Physician orders included but were not limited to: Change suprapubic catheter drainage bag weekly and PRN ( As Needed) dated 3/27/2024. Change catheter as needed (occlusion, dislodgement, possible infection, etc.) as needed for catheter use dated 10/10/2023. During an interview on 7/10/24 at 9:47 A.M., the MDS nurse indicated the MDS was wrong for Resident 4 and needed to be corrected. During an interview on 7/15/24 at 11:40 A.M., the Regional Support Person indicated the facility would follow the RAI (Resident Assessment Instrument) and may have a policy for the accuracy of MDS. A current, nondated policy Conducting an Accurate Resident Assessment. The policy indicated .an assurance that all residents receive and accurate assessment, reflective of the resident's status at the time of the assessment .qualified staff who knowledgeable about thee resident will conduct and accurate assessment addressing each resident's status, needs, strengths, and areas of decline .information provided by the initial comprehensive assessment establishes baseline data the ongoing assessment of resident progress.

Based on observation, record review, and interview, the facility failed to implement physician orders or develop care plans for 3 of 5 resident's reviewed for unnecessary medications. (Resident 4, Resident 9, Resident 15) Findings include: 1. On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder, anxiety state, unspecified, chronic pain, essential primary hypertension and osteoarthritis. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 4 was cognitively intact and was dependent on transfer, eating, and mobility. During the 7 days look back period the resident was noted to be on the following types of medications: Antidepressant, Antianxiety, Antipsychotc, Opioid, and Diuretic. Current physician orders included: Norco Oral Tablet 7.5-325 MG (Milligrams) (Hydrocodone-Acetaminophen)(pain medication).Give 1 tablet by mouth every 6 hours as needed for Pain related to PRIMARY GENERALIZED (OSTEO)ARTHRITIS dated 4/8/24. Pain monitoring q(every) shift, record any interventions (Pharmacological and Non-pharmacological every shift related to OTHER CHRONIC PAIN dated 1/1/24. ClonazePAM Tablet 0.5 MG (Anti-Anxiety Medication).Give 1 tablet by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED dated 10/10/2023. Monitor for side effects and report to physician: Anti-anxiety/Hypnotic medications-drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss and dependence every shift related to ANXIETY DISORDER, UNSPECIFIED dated 10/11/23 Dyazide Oral Capsule 37.5-25 MG (Triamterene and Hydrochlorothiazide)(Diuretic). Give 1 capsule by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION dated 5/27/24. Monitor for S/S (Signs and Symptoms) of electrolyte imbalance related to diuretic use Q shift. Document and notify MD of Irregular Heartbeat, increased heart rate, fatigue, lethargy, convulsions/seizures, N/V/D( Nausea/Vomiting/Diarrhea), Constipation, muscle/abdominal cramping, confusion, headache every shift for Dyazide medication therapy related to ESSENTIAL (PRIMARY) HYPERTENSION dated 1/2/2024. Sertraline HCl Tablet 100 MG (Antidepressant).Give 200 mg by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE dated 10/11/23. Trazodone HCL Oral Tablet 200 MG (Antidepressant). Give 1 tablet at bedtime related to MAJOR DEPRESSIVE , RECURRENT, MODERATE dated 10/10/23. Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain every shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE dated 10/11/23. Risperidone Tablet 1 MG (Antipsychotic).Give 2 tablets by mouth two times a day related to MAJOR DEPRESSIVE DISORDER; RECURRENT, MODERATE,UNSPECIFIED MOOD [AFFECTIVE] DISORDER dated 10/10/23. Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (Extrapyramidal Symptoms), weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention every shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE dated 10/11/23. The current care plan indicated that the resident has a potential for drug related complications associated with the use of antidepressant, antianxiety, and antipsychotic medications. Interventions included, but were not related to, Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (Extrapyramidal Symptoms), weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention, Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain, Monitor for side effects and report to physician: Anti-anxiety/Hypnotic medications-drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss dated 10/12/23 The resident takes hypertension medication and will remain free of complications. Interventions include Monitor for S/S (Signs and Symptoms) of electrolyte imbalance related to diuretic use Q shift. Document and notify MD of Irregular Heartbeat, increased heart rate, fatigue, lethargy, convulsions/seizures, N/V/D( Nausea/Vomiting/Diarrhea), Constipation, muscle/abdominal cramping, confusion, headache dated 10/20/23. The resident is at risk for pain related to osteoarthritis and adequate pain level will be maintained date 10/20/23. Interventions included but were not limited to administering pain medications as ordered and utilize pain monitoring tool to evaluate effectiveness of interventions dated 10/20/23. On 7/11/24 at 2:10 P.M ., the June MAR (Medication Administration Record) and TAR (Treatment Administration Record) was reviewed, and the following dates and shifts lacked documentation: MAR AND TAR reviewed for June 2024 indicated: Lacked documentation for antianxiety interventions evenings 6/8/34 Lacked documentation for electrolyte imbalance interventions evenings-6/8/24 Lacked documentation for antipsychotic interventions evenings-6/8/24 Lacked documentation for antidepressant interventions evenings 6/8/24 Lacked documentation of pain monitoring interventions evenings 6/8/24 and 6/9/24 TAR and MAR for April 2024 Lacked pain monitoring q shift interventions days 4/5/24 and 4/19/24 evenings 4/6 4/10 days 4/8 4/18 Lacked monitoring for electrolyte monitoring interventions even 4/6 night 4/5 4/19 days 4/8, 4/10 4/15 Lacked monitoring documentation for antianxiety interventions evenings 4/6/24 nights 4/6/24 and 4/19/24 days 4/8/24, 4/10/24 and 4/15/24 Lacked monitoring documentation for antidepressant interventions nights- 4/5/24 and 4/19/24 evening- 4/6/24 days- 4/8/24, 4/10/24, and 4/15 /24 Lacked monitoring documentation for antipsychotic interventions nights- 4/5/24 and 4/19/24 evening -4/624 days- 4/8/24, 4/10/24, and 4/15/24 MAY MAR AND TAR Lacked documentation of monitoring for electrolytes interventions days 5/2/24 nights 5/1024 Lacked documentation of antianxiety interventions days 5/2/24 nights 5/10/24 Lacked documentation of antidepressant interventions days- 5/2/24 nights- 5/10/24 Lacked documentation of antipsychotic interventions days 5/2 nights 5/10 Duplicate pain monitoring days 5/2/10 nights 5/10/24 During an interview on 7/11/24 at 2:05 P.M., the DON (Director of Nursing) indicated if there is a refusal or reason the medication was not given should be documented in the progress notes. 2. On 7/11/24 at 9:27 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to non-specified dementia, unspecified severity, with other behavioral disturbance, generalized anxiety order, bipolar disorder, and major depressive disorder, recurrent. The current Quarterly MDS assessment dated [DATE] indicated Resident 9 was cognitively impaired and needed supervision with eating, dressing, toileting, and transferring. During the 7 days look back period the resident was on the following types of medication antipsychotic, antianxiety, antidepressant, and opioid. No behaviors were exhibited during this time. Current physician orders included but not limited to: Diazepam Oral Tablet 5 MG (Milligrams) (Diazepam) (antianxiety).Give 1 tablet by mouth three times a day related to GENERALIZED ANXIETY DISORDER,BIPOLAR DISORDER, UNSPECIFIED dated 4/22/2024. Monitor for side effects and report to physician: Anti-anxiety/Hypnotic medications-drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss and dependence every shift for Diazepam related to GENERALIZED ANXIETY DISORDER dated 3/9/2024. Risperdal Oral Tablet 3 MG (Risperidone)(Antipsychotic).Give 1 tablet by mouth in the morning related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE dated 4/15/2024 Risperdal Oral Tablet 2 MG (Risperidone)(Antipsychotic). Give 1 tablet by mouth in the evening related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE dated 4/15/2024. Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention every shift for side effect monitoring for antipsychotic dated 7/31/23. Zoloft Oral Tablet 100 MG (Sertraline HCl)(Antidepressant).Give 200 mg by mouth one time a day related to BIPOLAR DISORDER, UNSPECIFIED.MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD dated 2/4/2024. Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain every shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD dated 3/9/24. Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen)(Pain medication).Give 1 tablet by mouth two times a day for Pain dated 7/27/2023. Rivastigmine Transdermal Patch 24 Hour 13.3 MG/24HR (Rivastigmine).Apply 1 patch transdermal in the morning related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE and remove per schedule dated 7/3/24. Namenda Oral Tablet 10 MG (Memantine HCl)(Dementia).Give 1 tablet by mouth two times a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MILD, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY dated 2/8/2024. Behavior monitoring for: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE Interventions: 1-1 on 1, 2-Activity, 3-Adjust room temperature, 4-Backrub, 5-Change position, 6-Give fluids, 7-Give food, 8-Redirect, 9-Refer to nurse's notes, 10-Remove resident from environment, 11-Return to room, 12-Toilet, 13-Other: Outcomes: I(Improved), S(Same), W(Worsened) every day and night shift dated 7/6/24. The current care plan indicated the resident take any psychotropic, antianxiety, and antidepressant medications and is at risk for side effects. Interventions included, but not limited to, observe for side effects and report to physician: Anti-anxiety/Hypnotic medications drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss and dependence dated 12/13/2022. Observe for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain dated 12/13/22. Observe for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention dated 12/13/22. There is a current care plan indicated the resident has impaired cognitive function, dementia or impaired thought process related to dementia. Interventions include but not limited to administer medications as ordered dated 12/13/22. On 7/11/24 at 2:00 P.M., the MAR (Medication Administration Record) and TAR (Treatment Administration Record) was reviewed Rivastigmine Transdermal Patch used for Dementia was not administered on 6/3/24, 6/4/24, 6/5/24, 6/9/24, and 6/22/23 for administration and removal was administered on 6/28/24 but not removed at 6:30 P.M. on 6/29/24 there was no reason for not administration noted in progress notes. Diazepam 5 mg not given on 6/7/24 at 2:30 P.M ,6/22/24 at 6:00 A.M. and 6/29/24 at 2:30 P.M. there was no reason for not giving in the progress notes. Lack documentation to monitor for side effects 6/8/24 evening shift- antianxiety, antidepressant, antipsychotic and mood stabilizer. Lacked documentation to monitor for side effects of mood stabilizer for 6/9/24 evening shift. During an interview on 7/11/24 a 11:27 P.M., RN (Registered Nurse) indicated there has to be some indication why the medication was not given. During an interview on 7/15/24 at 12:10 P.M., the Regional Support Person indicated the facility did not have policy for following physician order but would follow the physician written orders. 48147 3. On 7/11/24 at 10:13 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but was not limited to, nonrheumatic aortic valve stenosis. The most current Annual Minimum Data Set (MDS) Assessment, dated 6/3/24, indicated Resident 15 was cognitively intact, required supervision for eating, and received an antiplatelet medication during the 7-day look back period. Current physician orders included, but were not limited to: Aspirin (an antiplatelet medication) 81 mg (milligrams) Oral Tablet Delayed Release - Give 81 mg by mouth one time a day, dated 2/8/24 The clinical record lacked an order to monitor for side effects for an antiplatelet medication including bleeding. The clinical record lacked a care plan for an antiplatelet medication or bleeding. On 7/12/24 at 2:30 P.M., the Director of Nursing (DON) indicated monitoring for side effects of an antiplatelet medication would be in the orders. On 7/15/24 at 8:44 A.M., the MDS Coordinator indicated care plans would include a care plan for antiplatelets or to monitor for bleeding if the resident received an antiplatelet. On 7/15/24 at 10:50 A.M., the Administrator provided a Comprehensive Care Plans policy, dated 2023, that indicated The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 3.1-35(a) 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure medication was being properly administered for 1 of 1 random observations of insulin administration. (Resident 25) Finding includes: On 7/10/24 at 12:06 P.M., Registered Nurse (RN) 3 was observed preparing a Humalog Insulin Kwikpen for insulin administration for Resident 25. An AccuCheck (blood glucose test) indicated the resident had a blood sugar of 200. RN 3 indicated the resident received sliding scale insulin and was to receive 4 units of insulin lispro (a fast acting insulin) for a blood glucose reading of 200. RN 3 set the insulin pen to 6 units and indicated the resident got 4 units of insulin plus 2 units of insulin to prime the pen. She cleaned the tip of the pen, attached the needle, and administered 6 units of insulin to Resident 25 in her left arm. On 7/12/24 at 11:51 A.M., Licensed Practical Nurse (LPN) 6 indicated insulin pens do not have to be primed and she had never primed an insulin pen before. On 7/12/24 at 1:46 P.M., the Humalog Kwikpen user manual was reviewed. It indicated Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 8 times. If you still do not see insulin, change the needle and repeat priming steps 6 to 8. On 7/12/24 at 2:30 P.M. the Director of Nursing (DON) indicated that an insulin pen should be primed with 2 units before administration of the required insulin dose. On 7/12/24 at 12:46 P.M., the Administrator provided an Insulin Pen policy, dated 2024, that indicated Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. 3.1-35(g)(1)

Based on interview, and record review, the facility failed to ensure residents who required restorative services received services in their plan of care for 3 of 4 residents reviewed for restorative nursing. (Resident 2, Resident 7, Resident 13) Findings include: 1. On 7/12/24 at 8:52 A.M., Resident 2's clinical record was reviewed. Resident 2's diagnoses included, but were not limited to, dementia, weakness, and intellectual disabilities. The most recent Quarterly MDS (Minimum Data Set Assessment), dated 6/3/24, indicated resident 2 was severely cognitively impaired, required substantial assistance of staff with toileting and transfers, and was dependent on staff for bathing. Care plans included, but were not limited to: Nursing rehab/restorative AROM (active range of motion) program: AROM to BLE (bilateral lower extremities), hips, knees, and ankles, 20 reps 1-2 sets daily; date initiated 9/13/22. On 7/12/24 at 12:14 p.m., the Administrator provided restorative nursing minutes documented in the clinical record for Resident 2. The following dates were documented with no restorative active range of motion provided in 2024: January 3, 5, 26 February 4 March 10, 17, 23 April 3, 5, 7, 26, 29 May 4, 6, 9, 10, 14, 16, 18, 19, 21, 25, 26 June 1, 8, 11, 13, 14, 20, 25, 28, 29 July 5, 6, 7, 8, 9, 11 2. On 07/11/24 at 9:08 A.M., Resident 7's clinical record was reviewed. Resident 7 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease and dementia. The most recent Annual MDS (Minimum Data Set) Assessment, dated 5/31/24, indicated Resident 7 was cognitively intact, required moderate assistance from staff for bathing, and required supervision of staff for eating, toileting, and transfers. Care plans included, but were not limited to: I will perform (1) set of (20) reps of AROM (active range of motion) to (BLE) extremities daily; date Initiated: 5/1/23. On 7/12/24 at 12:14 p.m., the Administrator provided restorative nursing minutes documented in the clinical record for Resident 7. The following dates were documented with no restorative active range of motion provided in 2024: January 5, 7, 10, 12, 14, 16, 18, 29, 30 February 1, 5, 8, 13, 15, 16, 24, 25 March 2, 5, 9, 14, 23 April 3, 6, 7, 26, 30 May 5, 6, 15, 25, 26, 28, 31 June 8, 28, 29, 30 July 1, 3, 6, 8, 11 3. On 7/11/24 at 10:13 A.M., Resident 13's clinical record was reviewed. Resident 13 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and dementia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 13 was cognitively intact, required moderate assistance from staff for toileting and bathing, and was receiving hemodialysis. Current care plans included, but were not limited to: Nursing rehab/restorative AROM (active range of motion) program: AROM seated AROM of BUE/BLE (bilateral upper and lower extremities) 20 reps 6 days a week; date initiated 3/13/24. On 7/12/24 at 12:14 p.m., the Administrator provided restorative nursing minutes documented in the clinical record for Resident 13. The following dates were documented with no restorative active range of motion provided in 2024: April 1, 2, 3, 4, 5, 6, 7, 8, 26, 27, 28, 29 May 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 28, 29, 30 June 20, 21, 24, 25, 26, 29, 30 July 5, 6, 7, 8, 9, 11 During an interview on 7/10/24 at 2:45 P.M., Occupational Therapist 10 indicated it is a nursing staff task to perform restorative therapy and provided active range of motion exercises. On 7/15/24 at 8:53 A.M. the Administrator provided a policy titled Restorative Nursing Program, dated 2023, that indicated The restorative nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented. 3.1-42(a)(2)

Based on interview and record review, the facility failed to reduce the risk of falling for 1 of 3 residents reviewed for falls. Falls were not accurately documented, and the care plan was not updated with new interventions for a resident with multiple falls. (Resident 6) Finding includes: On 7/9/24 at 9:49 A.M., Resident 6 indicated she had recently fallen and broken her nose because she could not reach her call light. On 7/9/24 at 2:58 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and history of falling. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated Resident 6 was cognitively intact, was dependent on staff for transfers, and had 1 fall with major injury since the previous assessment. A Fall Risk Assessment, dated 6/11/24, indicated the resident was at risk for falls. A falls care plan, dated 12/20/22, indicated the resident was at risk for falls due to deconditioning, gait/balance problems, incontinence, poor safety awareness, psychotropic drug use, hearing problems, and clutter in room, and included an intervention for the call light to be within reach. A Post Fall Evaluation, dated 7/20/23 at 5:57 A.M., indicated Resident 6 had an unwitnessed fall while reaching for an item in her room. An Interdisciplinary Team (IDT) Note, dated 7/20/23 at 12:51 P.M., indicated staff were to lay clothes out for the resident the night before to prevent reaching. The care plan was not updated with a new intervention. A nurse's progress note, dated 8/14/23 at 11:54 P.M., indicated Resident 6 was complaining of persistent stiffness and soreness following recent incident where resident was lowered to the floor by staff. The doctor was notified, and new orders were received for ibuprofen (a pain reliever) 800 mg (Milligrams), 1 tablet by mouth two times a day for inflammation. The clinical record lacked a post fall evaluation, IDT note, progress note, follow up, or updated care plan related to this fall. A Post Fall Evaluation, dated 9/3/23 at 7:43 P.M., indicated Resident 6 had an unwitnessed fall while reaching for an item in her room. Room ergonomics was added to the care plan on 9/5/23. A Post Fall Evaluation, dated 9/5/23 at 2:52 A.M., contained a physical assessment with vitals, but had no other details regarding the fall. The clinical record lacked an IDT note, progress note, follow up, or updated care plan related to this fall. A nurse's progress note, dated 1/12/24 at 7:36 A.M., indicated that a 2nd shift CNA (Certified Nurse Aide) dropped the resident while putting her to bed the previous evening. An IDT Note, dated 1/15/24 at 5:14 P.M., indicated the fall happened on 1/12/24 at 9:00 A.M. The IDT Note indicated staff were educated on safe and proper transferring of the resident. The care plan was not updated with a new intervention. A Change of Condition note, dated 6/11/24 at 10:10 P.M., indicated Resident 6 had an unwitnessed fall while waiting for staff to assist her into bed. The resident sustained a laceration to the bridge of her nose and it was evident resident had suffered head trauma and required immediate assistance. The on-call Nurse Practitioner (NP) was notified, and the resident was sent to the emergency room (ER) for evaluation and treatment. An IDT note, dated 6/12/24 at 10:18 A.M., indicated the resident returned to the facility with Dermabond (a liquid skin adhesive) for closure of laceration to the bridge of the resident's nose and a fracture to the tip of the nose. Resident indicated to the Administrator during an interview that she fell because she was not able to reach her call light. Staff educated to keep call light within reach was added to the care plan on 6/12/24. A nurse's progress note, dated 6/13/24 at 12:38 P.M., indicated an inservice was provided to staff members for proper call light placement. On 7/12/24 at 12:13 P.M., a handwritten post it note from the Administrator indicated [Resident 6] 1-12-24 was staff assisted to the floor. A Post Fall Evaluation for the fall on 1/12/24 was not provided. On 7/12/24 at 2:30 P.M., the Administrator indicated that an intervention got added to the care plan every time a resident fell . On 7/15/24 at 8:44 A.M., the MDS Coordinator indicated every time a resident fell , an intervention was added to the care plan after the IDT met. The IDT met every morning where new falls were discussed. If education was provided to the staff or resident, that got added to the care plan, too. On 7/15/24 at 8:53 A.M., the Regional Support indicated she could not find any documentation about the resident's fall on 8/14/23 and was not sure about the circumstances surrounding that progress note. At that time, she indicated that the resident did not fall on 9/5/23 and that the nurse must have opened a new event and forgotten that the Post Fall Evaluation was triggered automatically after a resident fell . On 7/15/24 at 8:53 A.M., the Administrator provided a Care Plan Revisions Upon Status Change policy, dated 2023, that indicated The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . The care plan will be updated with the new or modified interventions. On 7/15/24 at 8:53 A.M., the Administrator provided an Accidents and Supervision policy, dated 2023, that indicated Fall refers to unintentionally coming to rest on the ground, floor, or other lower level . Both the facility-centered and resident-directed approaches include evaluation hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk . implementation of interventions - using specific interventions to try and reduce a resident's risk from hazards in the environment. The process includes . documenting interventions . ensuring that the interventions are put into action. 3.1-45(a)(2)

Based on record review and interview, the facility failed to follow physician orders and implement plan of care relating to dialysis services for 1 of 1 resident's reviewed for hemodialysis. (Resident 13) Finding includes: On 7/11/24 at 10:13 A.M., Resident 13's clinical record was reviewed. Resident 13 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and dementia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 13 was cognitively intact, required moderate assistance from staff for toileting and bathing, and was receiving hemodialysis. Current physician orders included, but were not limited to: Obtain weight after dialysis treatments one time a day every Monday, Wednesday, Friday; start date 6/21/24. Monitor left upper extremity for (signs and symptoms) of infection. Every day and night shift for fistula; start date 6/5/24. Dialysis diet, Regular texture; start date 5/27/24. Current care plans included, but were not limited to: Alterations in kidney function due to end stage rental disease; date initiated 8/22/22. Do not take blood pressure, blood samples, or insert IV in arm with access site; date initiated 8/22/22. Resident is on a dialysis diet; date initiated 7/15/22. Monitor weight per MD order; date initiated 7/15/22. During an interview on 7/12/24 at 11:04 A.M. LPN 14 indicated Resident 13 had a new fistula placed in the left upper extremity on 6/4/24. On 7/12/24 at 12:14 P.M., the Regional Support Consultant provided Resident 13's documented blood pressure readings. The following dates/times indicated staff obtained a blood pressure reading in Resident 13's restricted limb (left upper arm) since her fistula placement in June 2024: 6/5/24 10:07 A.M. 6/8/24 9:15 A.M. 6/13/24 9:09 A.M. 6/14/24 4:32 P.M. 6/14/24 5:30 P.M. 6/15/24 9:02 P.M. 6/20/24 3:20 P.M. 6/27/24 3:23 P.M. 6/29/24 5:59 P.M. 7/3/24 1:57 P.M. 7/4/24 10:44 P.M. 7/5/24 2:59 P.M. 7/6/24 1:44 A.M. 7/6/24 9:11 P.M. On 7/12/24 at 12:14 P.M., the Regional Support Consultant provided Resident 13's recorded weights. The following dates/times indicated staff failed to record a weight when Resident 13 returned from dialysis in the past month: 6/21/24 6/24/24 6/28/24 7/1/24 7/3/24 7/5/24 7/10/24 7/12/24 On 7/15/24 at 10:50 A.M., the Administrator provided a policy titled Comprehensive Care Plans, dated 2023, that indicated The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During an interview on 7/15/24 at 12:10 P.M., the Regional Support Consultant indicated the facility did not have policy for following physician order but indicated physician orders should be followed as written. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 meal tray tested for food temperature. Findings include: On 7/10/24 at 12:09 P.M., a meal test tray was obtained on the 200 Unit Hall the following temperatures were obtained: chicken thigh- 126.5 degrees F (Fahrenheit) potato -125.5 degrees F cottage cheese 48.2 degrees F desert chocolate eclair pudding- 67.5 degrees F salad 53.6-degrees F During an interview on 7/8/24 at 11:21 A.M., Resident 15 indicated the food is cold. During an interview on 7/9/24 9:43 A.M., Resident 6 indicated the food is not always hot. The CNA's (Certified Nurse Aide) won't serve food right away. During an interview on 7/9/24 at 11:35 A.M., the Dietary Manager indicated the temperature for meats and vegetables should be greater than 165 degrees Fahrenheit and cold items should be less than 41 degrees Fahrenheit. On 7/15/24 at 8:55 A.M., the Administrator provided a current, nondated policy Record of Food Temperatures. The policy indicated .hot foods will be held at 135 degrees Fahrenheit or greater and . cold food temperatures will be kept at or below 41 degrees Fahrenheit. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure safe storage of foods brought in externally for 1 of 1 residents reviewed for resident refrigerators. (Resident 8) Findings include: During an observation on 7/9/24 at 9:39 A.M., Resident 8's refridgerator had two blank temperature logs, dated June 2024 and July 2024, taped to the outside door of the refrigerator; no temperatures were recorded. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers. During an interview on 7/12/24 at 11:04 A.M., LPN 14 indicated each morning when staff do rounds to check on resident's, they record the temperature of resident room refrigerators on the paper on the outside of the refrigerator. On 7/12/24 at 12:45 P.M., the Regional Support Consultant provided a policy titled Resident Refrigerators, dated 2024, that indicated It is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. Dormitory-sized refrigerators are allowed in a resident's room under the following conditions: The refrigerator is inspected and deemed safe prior to use and upon routine inspections. The refrigerator maintains proper temperature.

Based on observation, interview, and record review, the facility failed to ensure that documentation was completed entirely or accurately for 2 of 3 residents reviewed for wounds and 1 of 5 residents reviewed for unnecessary medications. Duplicate medication order was entered, therapeutic leaves were not tracked, and documented skin assessments were not completed accurately. (Resident 15, Resident 8, and Resident 26) Findings include: 1. On 7/11/24 at 10:13 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but was not limited to, major depressive disorder. The most current Annual Minimum Data Set (MDS) Assessment, dated 6/3/24, indicated Resident 15 was cognitively intact, required supervision for eating, and received an antidepressant medication during the 7-day look back period. Current physician orders included, but were not limited to: Sertraline (an antidepressant medication) Oral Capsule 150 mg (milligrams) - Give 1 capsule by mouth at bedtime related major depressive disorder, dated 1/28/24. Sertraline 100 mg Tablet - Give 1 tablet by mouth at bedtime related to major depressive disorder. Give with 50mg to equal 150mg, dated 7/4/24. A medication administration note, dated 7/9/24 at 7:45 P.M., indicated the order dated 7/4/24 was a duplicate order, and the resident received one tablet of 100 mg sertraline and one tablet of 50 mg sertraline. A Medication Administration note, dated 7/10/24 at 7:51 P.M., indicated the order dated 7/4/24 was a duplicate order. The July MAR (Medication Administration Record) indicated the resident received medication from both orders on 7/7/24. On 7/12/24 at 9:25 A.M., the Regional Nurse provided a medication packet with Resident 15's name on it from the pharmacy that contained one 100 mg tablet of sertraline and one 50 mg tablet of sertraline. She indicated that the order was a transcription error and not a medication error. The orders were supposed to reflect that the resident was receiving a 100 mg tablet and a 50 mg tablet because that was how the pharmacy dispensed it. She indicated a nurse tried to fix the order by creating two orders, but made the order more confusing. She indicated she would correct the orders immediately. 48057 2. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers. During an observation on 7/10/24 at 12:25 P.M., LPN 8 entered the exit door code and assisted Resident 8 outside. LPN 8 assisted Resident 8 with lunch on the outside patio, then went back into the building while resident 8 remained outside. During an interview on 7/12/24 at 11:04 A.M., LPN 14 indicated Resident 8 takes LOA (leave of absence) with family/friends almost daily and staff have to enter a code to let Resident 8 outside and back into the building but do not sign the LOA book for Resident 8 because Resident 8 usually verbally lets the nurse know when he is leaving. The clinical record lacked documentation each time Resident 8 left or returned from the building during therapeutic leaves. During an interview on 7/15/24 at 3:04 P.M., the Regional Support Consultant indicated Resident 8 did not have an evaluation for therapeutic LOA (leave of absence) and did not have a physician's order to go LOA. On 7/15/24 at 8:53 A.M., the Administrator provided a policy titled Therapeutic Leave, dated 2024, that indicated The nurse will obtain an order from the practitioner specifying approval for therapeutic leave. The facility will document in the medical records the resident's leave of absence, any medications sent with the resident, and any education given to the resident and/or representative prior to the leave. If a resident has not returned from therapeutic leave as expected, the facility will attempt to contact the resident and resident representative and document attempts in the medical record. 3. On 7/11/24 at 12:39 P.M., Resident 26's clinical record was reviewed. Resident 26 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia and type 2 diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 26 was cognitively impaired and required moderate assistance from staff for toileting, bathing, and transfers. A weekly skin review (assessment) completed on 6/10/24 by RN 9 indicated Resident 26's skin was intact and no alterations. A weekly skin review (assessment) completed on 6/17/24 by RN 9 indicated the only skin alteration Resident 26 currently had was a laceration to the chin. A physician's order for Mupirocin external ointment 2 % (antibacterial ointment) Apply to top of right foot topically three times a day for Abrasion for seven (7) Days, dated 6/10/24 through 6/17/24, was marked administered by RN 9 on 6/10/24, 6/12/24, 6/13/24, and 6/14/24. During an interview on 7/11/24 at 2:15 P.M., RN 9 indicated she was unsure where wound on resident foot was, was unsure of what the treatment was, and would need to look at orders on computer. On 7/15/24 at 11:09 A.M., the Administrator provided a Documentation in Medical Record policy, dated 2024, that indicated Documentation shall be accurate, relevant, and complete . 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure multi-resident use glucometers were cleaned according to manufacture instructions for 1 of 1 random observations. (100 unit) Finding includes: On 7/10/24 at 12:06 P.M., Registered Nurse (RN) 3 was observed cleaning a glucometer after acquiring a blood sugar from a resident. She wiped the machine with a Micro-kill Bleach wipe for 2 seconds and placed it in the medicine cart. On 7/11/24 at 12:58 P.M., Qualified Medication Aide (QMA) 4 indicated that to clean a glucometer you wipe the machine for 30 seconds using a bleach wipe and then let it air dry. On 7/15/24 at 9:53 A.M., the Infection Preventionist indicated that to clean a glucometer you wrap it in a bleach wipe for 3 minutes and place it in a water cup or on a paper towel so it became clean. On 7/11/24 at 10:15 A.M., the Administrator provided an EvenCare blood glucose monitoring system user's guide, dated 2022, that indicated Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe meter dry or allow to air dry. On 7/11/24 at 12:58 P.M., a Micro-kill Bleach Wipes user instructions were reviewed. It indicated A 30 second contact time is required to kill the bacteria and viruses on the label . Allow surface to air dry . On 7/15/24 at 8:53 A.M., the Administrator provided a Glucometer Disinfection policy, dated 2024, that indicated The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use . Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to treat a urinary tract infection (UTI) for 2 of 3 residents reviewed for infections. Resident F resident's lab results weren't reviewed, follow up appointments with specialists weren't scheduled, and treatment related to the UTI found were not done in a timely manner which resulted in a hospitalization from [DATE] to 9/30/23. Resident C had a Urinary Tract Infection (UTI) that was not diagnosed , the resident was then hospitalized that resulted in a necessary surgery being postponed. (Resident F and Resident C) Findings include: 1. During an observation on 10/11/23 at 11:24 A.M., Resident F was observed sleeping in bed. On 10/10/23 at 12:39 P.M., Resident F's clinical record was reviewed. Diagnoses included, but were not limited to, renal insufficiency and neurogenic bladder. Resident F's most recent Quarterly Minimal Data Set (MDS) Assessment, dated 9/19/23 indicated the resident was cognitively intact and required an extensive assist of 1 person for toileting. Resident F's care plans included, but were not limited to, I have a history of chronic/ recurring urinary tract infections r/t [related to] esbl [Extended Spectrum Beta-Lactamase. Beta-lactamases are enzymes produced by bacteria that could make them resistant to some antibiotics] infection, dated 9/20/23. Resident F's Physician Orders included, but were not limited to: - UA [urine analysis] WITH C&S [culture and sensitivity] IF INDICATED one time only for DYSURIA related to PERSONAL HISTORY OF URINARY (TRACT) INFECTIONS, dated 9/11/23. - Contact Deaconess Clinic Urology in AM to inquire which atb [antibiotic] resident is to be placed on for atb resistant UTI et [and] clarify if Urologist wants staff to resume straight cath [catheter] BID [two times a day] order, dated 9/19/23. A urinalysis report, dated 9/12/23, indicated the urine sample was collected at the facility on 9/12/23 at 12:00 A.M., received by the lab at 9/12/23 at 3:52 P.M., results were reported from the lab to the facility on [DATE] at 6:28 P.M., and results were reviewed by the facility on 9/18/23 at 12:47 P.M. The results included the following: Protein: reference range- less than 30, result- 70 Blood: reference range- negative, result- small Leukocyte Esterase: reference range- negative, result- large Appearance: reference range- clear, result- turbid urine red blood cells: reference range- less than 3, result- 27 urine white blood cells: reference range- less than 5, result- greater than 100 bacteria: reference range- none, result- few squamous epithelial: reference range- less than 5, result- 8 A urine culture report, dated 9/12/23, indicated the urine speciman for culture was collected on 9/12/23 at 12:00 A.M., received by the lab at 9/12/23 at 3:52 P.M., the result was reported from the lab to the facility on [DATE] at 7:04 A.M., and was reviewed by the facility on 9/18/23 at 1:01 P.M. The results included the following: Greater than 100,000 Escherichia Coli, ESBL producing organism detected. Resident F's progress notes from September 2023 included, but were not limited to: 9/11/23 at 7:45 P.M. - daughter here this afternoon asking about in and out cath [catheter] resident [sic]. will pass on to following shift to see if we are able to get order for this. daughter states we were doing this prior to residents [sic] latest hospital admission. 9/12/23 at 1:08 A.M. - Urine specimen obtained via in and out cath. Prior to cath, resident states she toileted herself. Once laying in bed her abdomen was distended but not tender to touch. Once cath inserted, urine specimen obtained and bladder emptied. 1,000cc [mililiters] of malodorous,cloudy yellow urine obtained. At the end of the stream urine became thick and white. Res [resident] tolerated procedure well. Denies burning with urination. Fluids encouraged. 9/13/23 at 1:42 P.M. - Received call from residents [sic] daughter [name of person] stating that she had gotten notification on my chart that residents [sic] US [sic] had came back positive for a UTI. Call placed to DR [name of doctor] office, md [doctor of medicine] aware and stated that they were waiting for the culture to culture out due to her allergies and that they would then start her on something. Notified res daughter and she stated okay 9/19/23 at 6:18 P.M. - . Staff to follow up with urologist in AM to determine which atb [antibiotic] is appropriate to treat atb resistant UTI et [and] to clarify if staff to resume [sic] straight catheterization BID [twice daily]. Fluids ecouraged [sic] et within easy reach. Meticulous peri-care provided, contact precautions being observed. Will continue to monitor. 9/19/23 at 9:07 P.M. - ESBL producing organism detected in urine, resident to be placed on contact isolation. Bedside commode obtained et placed in room for resident's use only. Staff observing all necessary measures. 9/20/23 at 12:40 A.M. - Referral sent to [name of hospital] Infectious disease at this time. 9/22/23 at 12:00 A.M. - Admin [administrator] states that patient has been having increased behaviors. She recently returned from a stay at an inpatient psych [psychology] hospital. Last week she was able to have a conversation; however, this week she is chanting, crying and yelling. Staff states she has not slept for 3 days. Staff states she has a UTI. Results were sent to infectious disease and facility has been waiting numerous days for orders as to which antibiotic she is to take. DON [Director of Nursing] was notified that no orders had been received for antibiotics for treatment of UTI. 9/22/23 at 7:34 P.M. - daughter called unit at 1715 [5:15 P.M.] and stated she wanted her mother sent to ER [emergency room ] to be checked since she has a UTI and has not been placed on antibiotic yet. Resident F was hospitalized from 9/22/23 through 9/30/23. Hospital notes included, but were not limited to: - . Patient is hysterically crying during exam and is focused on that she has been sitting in feces and urine. Patient was sent from nursing home for altered mental status but unable to obtain further clarification from their facility as they are not picking up their phone . patient was admitted to Internal Medicine service for further management of acute kidney injury, metabolic encephalopathy . recent urine culture, with ESBL. Started on ertapenem [name of antibiotic] . A confidential correspondence indicated that Resident F had a positive urine culture and the results were known for 8 days and nothing was done about it. During an interview on 10/11/23 at 1:01 P.M., Registered Nurse (RN) 5 indicated the facility failed to receive an order from the doctor and infectious disease to treat Resident F and the resident's daughter requested to send her to the ER. During an interview on 10/12/23 at 8:31 A.M., Licensed Practical Nurse (LPN) 7 indicated she thought Resident F received antibiotics prior to being admitted to the hospital and that she was colonized. During an interview on 10/12/23 at 9:32 A.M., the DON indicated they try to do what they can to keep the resident in the facility. During an interview on 10/12/23 at 9:39 A.M., Licensed Practical Nurse 9 indicated Resident F did not have a UTI care plan at the time of her UTI, but he would have expected her to have one prior to her hospital stay. 38770 2. On 10/10/23 at 9:26 A.M., Licensed Practical Nurse (LPN) 3 indicated Resident C had a catheter and a current UTI. On 10/10/23 at 10:44 A.M., Resident C's clinical record was reviewed. Diagnosis included, but were not limited to, sepsis, neuromuscular dysfunction of bladder, disorder of kidney and ureter, and infrarenal abdominal aortic aneurysm. The most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated no cognitive impairment. Resident C required extensive assistance with bed mobility, transfers, and toileting, and had an indwelling urinary catheter. Current physician orders included, but were not limited to, the following: Ertapenem Sodium (an antibiotic) Solution Reconstituted 1 GM (gram) intravenously every 24 hours for infection for 30 Days from 9/22/23 through 10/22/23. A current risk for infection related to catheter use care plan was dated 11/22/22. A current history of chronic/recurring urinary tract infections related to suprapubic catheter care plan, dated 8/14/23, included, but were not limited to, the following interventions: Observe and report signs and symptoms of UTI: changes in color, odor or consistency of urine, dysuria, frequency, fever, pain (dated 8/14/23). Progress notes included, but were not limited to, the following: 9/3/23 at 7:43 P.M. Resident C was reaching for an item and fell . 9/5/23 at 11:00 P.M. [MD] reviewed and addressed labs prior to 9/4/23 visit Diagnostic result review of the following labs: antibody screen, CBC (complete blood count) auto differential, basic metabolic profile, urine culture, urine 24 hour creatinine, lipid profile, liver profile, hemoglobin a1c, urinalysis with microscopic, culture if indicated, EKG with interpretation, ALT, AST, creatinine/GFR, free T4, TSH. The progress notes lacked information as to when the labs had been done. 9/6/23 at 10:59 A.M. This writer phoned [family member], listed contact, to insure he was aware that [Resident C] slid out of her wheelchair and was not injured 9/7/23 at 11:01 P.M. eMAR - Medication Administration Note Change foley catheter drainage bag weekly and PRN [as needed] changed due to bag leaking 9/11/23 at 4:30 P.M. covid tested and negative results 9/11/23 at 7:59 P.M. resident came in approx [4PM] from smoke break and had large emesis [vomit] in room . 9/11/23 at 11:00 P.M. written by the Nurse Practitioner (NP) Notified by nursing vomiting x2 nights unable to keep down prn phenergan [an antiemetic medication] or any meds i.e. bp [blood pressure], cool and clammy covid neg, 176/107, 90-99, 80% RA [room air] 88% on 2L [liters] 97.8, states not feeling well has not been eating well isdiabetic [sic] 483 did eat dinner, lethargic but easy to wake lungs diminished orders for IM [intramuscular] phenergan 25mg [milligrams]/ml [milliliter] . IM . PRN QID [four times a day] . supplemental O2, CXR [chest xray] and labs . IM phenergan effective 88-90% on 2L 98/52, 105 hx [history] COPD 9/12/23 at 2:06 P.M. COVID 19 Test Result: Negative 9/12/23 at 7:55 P.M. CNA notified this nurse of resident having emesis in her bedroom while sitting up in w/c watching tv. Upon entering, resident noted to be diaphoretic and lethargic. Does wake up when name called. Mumbling words. Blood glucose 483 VS: 176/107 p94 T97.8 forehead infrared, resp 18 SaO2 80% on room air. Per nursing measure, supplemental oxygen started via concentrator however was not effective. Once liquid oxygen per portable tank administered SaO2 increased to 90% on 2L/NC [liters per nasal canula]. Staff instructed to lay resident down in bed after cleaning her up and elevate HOB [head of bed] to prevent aspiration . No cough or SOB [shortness of breath] noted at rest. Res [resident] weak. On call NP phoned and notified of assessment findings. New orders rec'd [received]. Will call back to update on status once IM Phenergan administered. If effective will administer routine PO [by mouth] Clonidine [blood pressure medication] for HTN [hypertension] 9/12/23 at 11:39 P.M. Res tested again for covid and test results were negative. No further emesis. Tolerated IM injection well. Sleeping. NP phoned and updated on resident's current vitals and assessment findings. No new orders at this time 9/13/23 at 5:25 A.M. Res currently laying in bed with HOB elevated. SaO2 91% on 2L/NC from portable liquid oxygen tank. Resp 18. Skin warm and dry. BP 163/91 pulse 107 T98.2. Did have a cough during assessment. No sputum produced. Denies feeling SOB. Will continue to monitor 9/13/23 at 1:41 P.M. Staff called this nurse to residents room stating that res was not acting like her self. When I entered the room res was noted to be leaning over in her chair to the left and hard to arouse. When asked what was wrong res stated that she just didn't [sic] feel well and that she thought that she needed to go to the hospital. Res BP was noted to be low, 60s/30s with her pulse low and thready. Res foley cath is patent and draining yellow urine, small amount of sediment noted in the bag. MD updated of res change in condition and stating that she needed to go to the hospital, new order was obtained to send her to [hospital] ER [emergency room ] for eval and treatment. [Transportation service] called for transport and report called to [hospital] ER . 9/13/23 at 7:50 P.M. Resident admitted to the hospital with acute kidney injury, sepsis, hypotension, and complicated urinary tract infection. 9/14/23 at 12:17 P.M. Resident returned from the hospital. Transferred to personal W/C [wheelchair]with extensive assistance x2 staff members. VSS [vital signs stable] . BP 124/67; HR [heart rate] 81; T [temperature] 97.5; RR [respiratory rate] 18; O2 SAT [oxygen saturation] 93% RA. midline intact to LUE [left upper extremity] and flushes well with no resistance. Resident will continue IV ATB [antibiotic] r/t [related to] urinary sepsis w/e-coli bacteria. 9/22/23 at 7:30 P.M. spoke with [representative] at [surgery center] today and she states surgery for September 28 is cancelled [sic] until she is finished with antibiotic for UTI. when antibiotic is finished on October 22 we are to get medical clearance from [medical director] and then surgery will be [sic] rescheduled . 9/26/23 at 11:00 P.M. Patient is on IV antibiotics for complicated UTI. She was recently hospitalized for hypotension, AKI [acute kidney injury], and sepsis. She was seen by infectious disease and has IV Invanz [an antibiotic] daily until 9/26/23 . through a PICC [peripherally inserted central catheter] line. She is to follow up with infectious disease NP 1-2 weeks from now. Shealso [sic] has appointment with urology, [urologist name] on 10/26/23. She has a 5.6cm [centimeter] infrarenal AAA [abdominal aortic aneurysm], but will not receive intervention for that until her urinary infection is cleared. Patient reports being tired all the time for about the last 3 months . 10/6/23 at 9:43 A.M. eMAR - Medication Administration Note Resident refused, stating I don't feel well. 10/6/23 at 8:31 P.M. resident has felt better today. yesterday was in bed all day due to feeling sick to stomach and having some diarrhea 10/9/23 at 12:00 A.M. During session resident presented as neutral with flat affect. Resident described she was not feeling well and nursing stated that her blood pressure was up. Resident described feeling weak her speech was slightly slurred and she had trouble staying awake . We will follow-up 10/10/23 at 12:00 P.M. resident has had increasing lethargy today. does not want to lay down for nap 10/10/23 at 4:01 P.M. has continued to be lethargic and is now slurring her words. desires to go out to hospital to be checked out. vitals stable. o2 97% on room air bp 102/83 hr 61 10/10/23 at 7:33 P.M. res sent to ER Blood pressure readings for Resident C included, but were not limited to, the following: 9/12/23 7:53 P.M. 176 / 107 9/12/23 9:15 P.M. 118 / 66 9/12/23 10:48 P.M. 99 / 53 9/12/23 11:38 P.M. 98 / 52 9/13/23 5:29 A.M. 163 / 91 9/13/23 9:26 A.M. 114 / 65 The Medication Administration Record (MAR) for 9/2023 indicated Resident C did not receive her blood pressure medication on the evening of 9/12/23 due to vomiting. Behavior monitoring from 7/31/23 through 10/12/23 indicated no behaviors were observed any day on any shift. Resident C's clinical record lacked a urinalysis or urine culture since 3/2023. Current hospital records as follows: New diagnosis of Hepatitis C, possible liver cirrhosis, kidney stone. The resident received emergency kidney dialysis, was identified as having a decompressed bladder around Foley catheter on admission and one kidney was atrophied. Labs obtained in the hospital on 9/13/23 included, but were not limited to, the following: A urine culture, dated 9/13/23, indicated escherichia coli (a bacteria) ESBL (extended spectrum beta-lactamase) producing organism detected. A blood culture, dated 9/13/23, indicated enterobacterales (a bacteria), escherichia coli, and ESBL were detected. A progress note from an infectious disease physician, dated 9/16/23 (during Resident C's hospitalization ), indicated a recommendation for Ertapenem for a total of 14 days, to end on 9/26/23.fd On 10/10/23 at 12:19 P.M., the Director of Nursing (DON) indicated Resident C had not had a urine culture done prior to the hospitalization on [DATE] possibly because she was colonized. At that time, the DON indicated she was unaware what bacteria Resident C was colonized with, and to find out could take a lot of digging. On 10/11/23 at 10:29 A.M., DON indicated Resident C's March 2023 labs were reviewed on 9/6/23 because something was not right with the resident, but could not find an exact reason for the review in the resident's chart. She indicated Resident C began to have some odd behaviors on 8/24/23. She indicated on that date, she had come back from LOA (leave of absence) with behaviors that were different for her that had continued until the hospitalization on [DATE]. The DON also indicated she was still unsure what the resident was colonized with, as she may have gotten her mixed up with another resident, and Resident C may not have been the one that was colonized. She indicated when a resident was colonized, the doctor would have the staff go off of symptoms to check for a UTI, then do a urinalysis and culture if indicated. She further indicated Resident C was supposed to have AAA surgery on 8/28/23, but it was postponed due to a yeast infection she had at that time, then postponed again due to being on IV antibiotics for 30 days. She indicated Resident C's AAA was originally scanned on 3/10/23, then again on 3/17/23 and 7/22/23 that showed an increase in size. She then indicated when a resident came back from the hospital, all labs and orders were reviewed by either herself or LPN 3. She indicated she was unaware of the discrepancy between the infectious disease physician order and the admitting order for the IV antibiotic, and if she had been aware, she would have questioned it to verify what the order should have been. On 10/11/23 at 1:18 P.M., the DON indicated she had called the Medical Director and he told her he had changed the original order for the 14 day antibiotic to a 30 day because he knows her better than infectious disease and wanted her to be on it for a longer period of time. On 10/12/23 at 9:01 A.M., LPN 7 indicated when Resident C had been sent to the hospital on 9/13/23, she was working that day. She indicated the night shift nurse for the previous night had notified her that morning that Resident C's blood pressure had been high and her cognition was off. She indicated she had been aware that Resident C had a history of frequent UTIs and that a symptom she had displayed in the past was weakness. She indicated she had noticed a recent shift with Resident C that she had previously been energetic and happy, and recently she had been weak and not as happy. On 10/12/23 at 8:45 A.M., Certified Nurse Aide (CNA) 21 indicated Resident C would have symptoms of deliriousness and weakness with UTIs, and had been sick for about a month prior to her hospitalization on [DATE]. CNA 21 indicated she was unaware of any precautions for Resident C's aneurysm, other than to be mindful of the area when assisting to transfer and positioning in the bed. On 10/12/23 at 10:40 A.M., a current Behavioral Health Services policy, dated 1/1/23, was provided and indicated Assess and develop a person-centered care plan for concerns identified in the resident's assessment . Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record . On 10/12/23 at 10:40 P.M., a current Comprehensive Care Plans policy, dated 1/1/23, was provided and indicated The comprehensive care plan will describe, at a minimum, the following . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 10/12/23 at 10:40 A.M., the Regional Consultant provided a current Notification of Changes policy, revised 1/1/23, that indicated .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification .significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-Threatening conditions, or b. clinical complications .circumstances that require a need to alter treatment. This may include: .ii. acute condition. iii. exacerbation of a chronic condition . A nursing assessment policy was requested and not provided. This Federal tag relates to Complaint IN00417333 and Complaint IN00418540. 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a physician's order regarding intermittent catheterization was followed; failed to thoroughly assess a resident's complaints of discomfort, and failed to notify the physician of a resident's complaints, resulting in hospitalization [MEDICAL CONDITION] and a urinary tract infection [MEDICAL CONDITION], for 1 of 3 residents reviewed with a history of UTIs. (Resident B) Finding includes: On 2/10/20 at 11:00 [NAME]M., the Director of Education indicated Resident B had recently been treated for [REDACTED]. The clinical record of Resident B was reviewed on 2/10/20 at 11:30 [NAME]M. [DIAGNOSES REDACTED]. A Physician's order, initially dated 9/10/19 and on the (MONTH) 2020 orders, indicated: Straight Cath (catheterize) every 4 hours as needed for [MEDICAL CONDITION] may obtain 800 cc urine max, then repeat in 30 min (minutes) if indicated. A quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident B had a good short-term and long-term memory, required extensive assistance of two or more staff for toileting, was always incontinent of bladder, and required intermittent catheterization (placing a catheter in the bladder to drain the urine intermittently, but not leaving it in place). Nurses Notes included, but were not limited to, the following notations: 12/4/19 at 6:59 P.M.: Resident required to be straight cath'd (sic) at this time, tol (tolerated) well, 800 cc clear yellow urine out. 12/19/19 at 7:30 P.M.: Resident requested to be straight cath'd at this time, 800 cc clear yellow urine out, tol well. 12/28/19 at 3:30 P.M.: Resident requested to have straight cath at this time. 700 cc clear yellow urine out, tol well, reported relief. 12/30/19 at 12:57 P.M.: Psychosocial Note .Resident is alert and oriented. Resident is able to express his wants in (sic) needs .Resident has no current behavior problems 12/30/19 at 11:18 P.M.: .Resident requested to be straight cath'd, did get 800 cc out full stream. 1/4/20 at 6:16 P.M.: Res (resident) requested in/out cath this evening, nurse was able to drain 400 mL (milliliters) and flow diminished. Res tol well stated he did not feel empty. Nurse palpate (sic) abdomen soft and non tender. Explained to res he had been wet prior to lunch and nurse would have to wait 4 hours to recath. Res upset with nurse and requested CNA have Noc (night) nurse attempt next. 1/4/20 at 7:35 P.M.: Received phone call from (ambulance service)/911 that resident had made personal phone call to 911 and requested to be taken to the hospital. (Ambulance service) stated that ambulance should be at the facility at this time. This nurse grabbed appropriate papers for resident and went to the residents (sic) room with ambulance crew. 1/4/20 at 7:50 P.M.: Resident with reddened face and tympanic (per ear) fever of 99.7, pulse of 141, resp (respirations) 20. Resident left facility A Care Plan regarding the resident's bladder incontinence and/or the need for intermittent catheterization was not found in the clinical record. Vital signs, including temperature, pulse, or blood pressure was not documented in the clinical record from 12/29/19 until the temperature of 99.7 documented as the resident was preparing to leave for the hospital. An ambulance report, dated 1/4/20, indicated: At Pt (patient) side: 19:47 (7:47 P.M.) .Narrative: Responded to SNF (skilled nursing facility) for an emergency call. Upon arrival staff met crew at the door, stated patient called for himself, he wants them to cath him and he is having abdominal pain. Staff state 'We're only sending him because he wants to go.' Patient laying on bed conscious and alert states 'I need to be cathed.' Staff state that the patient was cathed between 1630-1730 (4:30 P.M.-5:30 P.M.), they had a positive return of urine, and they took the catheter out when 'it stopped dripping.' Staff was unable to state urine color, output, and clarity .Upon initial assessment patient's skin flush, hot and diaphoretic .Patient complained of sharp abdominal pain and 'kidney' pain rated 10/10. Patient's heart rate elevated. When staff at SNF was asked if a temperature was checked they stated, 'No, we're out of probes so we haven't been taking them.' Staff did have a temporal thermometer that they used at the request of EMS (emergency medical service) crew. Temperature 99.7 temporal. During transport patient stated ' I need to be cathed' repeatedly .Primary Impression:[MEDICAL CONDITION], Secondary Impression: Pain-Abdominal An emergency room note, dated 1/4/20 at 8:41 P.M., indicated, Chief complaint: abdominal pain, Temp: 102.1, Heart Rate: 143 .Presents to the ED (emergency department) complaining of abdominal pain. Patient states he has had abdominal pain for 'a couple days.' Patient states that the last time he emptied his bladder was 'a couple days ago.' Patient lives at (name of facility). Nurse states that the patient was incontinent at noon and at 1600 (4:00 P.M.) they cathed the patient and obtained 400 cc of urine. Before the initial evaluation, ED staff was able to obtain 999 cc of urine .ED staff states that the patient called 911 himself .Physical Exam: Abdomen: Soft, diffusely tender .Alert and Oriented x 4 .Good eye contact. Good insight, Alert .ED Diagnosis .Abdominal pain, acute, Acute [MEDICAL CONDITION], UTI (urinary tract infection),[MEDICAL CONDITION] On 2/10/20 at 11:50 [NAME]M., Resident B was interviewed. He indicated he had been in the hospital for a UTI. He had told LPN 1 that he needed to be catheterized again, because not enough urine had been drained from his bladder. He indicated, If she would have just listened to me, I wouldn't have had to call 911. He indicated the hospital drained 990 cc from his bladder. On 2/10/20 at 3:40 P.M., LPN 1 was interviewed. She indicated she catheterized Resident B on 1/4/20, and did inform him he would have to wait for 4 more hours until he could be catheterized again. LPN 1 indicated she interpreted the physician's order that if she got 800 cc urine returned, then she could catheterize him again in 30 minutes. Since she didn't obtain 800 cc, she could not repeat the catheterization. LPN 1 did not phone the physician to report the resident's complaints. She indicated Resident B had called 911 as she was leaving. On 2/11/20 at 9:05 [NAME]M., during an interview with the Director of Nursing (DON), she indicated she had reviewed Resident B's record, and had spoken to LPN 1. The DON indicated LPN 1 told her that she just followed the doctor's orders. On 2/11/20 at 11:55 [NAME]M., the Administrator provided the current facility policy, Notification of Change in Resident Health Status, dated 6/24/18. The policy included: The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is .Acute illness or a significant change in the resident's physical, mental, or psychosocial status .A need to alter treatment significantly This Federal tag relates to Complaint IN 010. 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention and interventions; failed to implement the wound care physician orders [REDACTED]. Findings include: 1. The closed clinical record of Resident D was reviewed on 8/7/19 at 10:40 [NAME]M. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission, Clinical Health Status assessment, dated 5/24/19 and untimed, indicated, Alert, Short-Term Memory: Memory OK, Memory Problem, Long-Term Memory: Memory OK, Memory Problem .Can resident ambulate independently? No. Can the resident transfer independently? No . Continent of bladder. Weakness Right Side, Left Side . The assessment indicated the resident had amputations of 2 toes, and a surgical wound/graft site on the left heel. The assessment did not indicate any areas of skin impairment on the buttocks. A Braden Scale for Predicting Pressure Sore Risk, dated 5/24/19, indicated: Sensory Perception: No Impairment. Moisture: Rarely Moist. Activity: Chairfast. Mobility: Slightly Limited. Nutrition: Probably Inadequate. Friction and Shear: Potential Problem. The resident's total score was documented as 14, which indicated the resident was not at risk for pressure ulcers. Nursing Progress Notes included the following notations: 5/24/19 at 12:15 P.M.: Arrived via (ambulance service) in w/c (wheelchair) following stay at acute care hospital secondary [MEDICAL CONDITION] r/t (related to) a chronic non healing diabetic left foot ulcer and a fall .He requires inpatient skilled therapy services to improve on his overall ADL (activities of daily living) independence, strength, activity tolerance .all of which are significantly below his prior baseline .He requires one to two assist with his ADL's at this time 5/25/19 at 5:12 [NAME]M.: .incontinent of B&B (bowels and bladder) assist x 1 with adl care .unable to hold self up in sitting position without assist An Occupational Therapy Plan of Care, dated 5/25/19, included: .the Patient reports the need for more assistance to complete Basic self care, toileting, bed mobility .Due to Cognitive impairments, decreased BUE (bilateral upper extremity) strength, activity tolerance .this patient will require skilled OT (occupational therapy) .Initial Assessment: Shower/Bathe Self, Dependent and/or needs assist of 2, Toilet Hygiene: Substantial/Max (maximum) Assist .Moderate Cognitive Impairment, Mobility, Roll Both Directions: Partial/Mod (moderate) Assist Nursing Progress Notes continued: 5/26/19 at 3:53 [NAME]M.: .mild memory deficit .assist x 1 with incontinent care .incontinent several times d/t (due to) forgetting or spillages .noted deficit with attempting to sit up in bed 5/27/19 at 7:12 [NAME]M.: Resident alert self (sic) .incont (incontinent) of B&B at noc (night) assist x 1 with adl care 5/28/19 at 4:26 P.M.: Resident noted to have slight redness in butt crack. Notified MD, received order for skin protectant PRN (as needed) once a shift for redness. Notified resident. 5/30/19 at 6:33 [NAME]M.: A+D Prevent Ointment Apply (applied) to buttocks topically for redness A Weekly Skin Review, dated 5/31/19, indicated, .resident has stage two area on coccyx being treated with T&R (turn and reposition) Q (every) 2H (two hours), medi-honey and dry dressing A Wound Evaluation, dated 5/31/19 and signed 6/2/19, indicated, Units of measure: centimeters. Site Coccyx, Type Pressure, Length 1.1 Width 1.7 Depth >0.1 Stage II .When was the wound identified? 05/31/2019. Wound Type: Pressure Ulcer (in-house acquired) .Exudate (drainage) None ., Wound Bed: [DIAGNOSES REDACTED] (redness) Painful .Current Treatment: cleanse with NS (normal saline), pat dry; apply Medi-honey to wound bed; apply dry dressing; change daily A wound physician's Wound Evaluation & Management Summary, dated 6/3/19, indicated, . has a stage 2 pressure wound coccyx for at least 7 days duration. There is moderate serous (clear liquid) exudate .Focused Wound Exam: Etiology: Pressure .Wound Size (L x W x D) 2 x 2 x 0.1 cm .Dressing treatment plan: [REDACTED]. Foam silicone bdr (border) & faced (sic) apply three times per week for 30 days. Nursing Progress Notes continued: 6/5/19 at 2:19 P.M.: IDT (interdisciplinary team) review of resident medical overall health status. Upon review it was noted on 5/31/19, during incontinent care, the staff noted an open area to residents (sic) coccyx. Staff notified the nurse. The nurse completed assessment and wound evaluation, contacted MD, new orders received .This writer assessed residents skin and determined open area is related to pressure. Resident has had a decline in condition since admission with mobility and ADL care The Treatment Administration Record (TAR), dated (MONTH) 2019, indicated the resident continued to receive Medi-honey to the pressure ulcer until (MONTH) 6, 2019, and did not receive the treatment ordered by the wound physician on (MONTH) 3, 2019. A Wound Evaluation, signed 6/6/19, indicated, Length (in cm) 2, Width (in cm) 2, Depth (in cm) 0.1 Staging II, Exudate: Color/Type: Serous .Amount: Moderate .Tender to touch .Current Treatment: Cleanse open area on coccyx with NS, apply calcium alginate cover with foam border dressing, change every other day A wound physician's Wound Evaluation & Management Summary, dated 6/10/19, included: .He has an unstageable DTI (deep tissue injury) coccyx for at least 14 days duration. There is moderate serous exudate .Focused Wound Exam: Wound Size: 6 x 4 x 0.1 cm .Thick adherent devitalized necrotic (black, dead) tissue: 80%, Slough: 20%, Wound Progress: Deteriorated .Recommendations: Off-load wound; Reposition per facility protocol, Low air loss mattress .Limit sitting to 30 minutes Nursing Progress Notes continued: 6/10/19 at 4:29 P.M.: IDT meting (sic) held regarding continued decline in overall medical condition and worsening of pressure area to coccyx/buttocks. He is seen weekly by the wound MD and was seen today with a new plan of care for treatment established. An air mattress is to be applied to his bed and he has been placed on a turning and repositioning at this time 6/12/19 at 2:42 P.M.: New orders received from (name of physician): zinc [MEDICATION NAME] .Vitamin C .and limit sitting x 30 minutes each siting (sic) time. Resident aware. 6/12/19 at 6:01 P.M.: (Resident D) has been unresponsive to tactile (touch) and verbal stimulus this after (sic) and is not currently alert enough for po (by mouth) nutrition. 6/14/19 at 11:00 [NAME]M.: (Director of Nursing) notified MD's office of resident's rapid decline. MD suggested resident sent to ER for eval (evaluation) and treat 6/14/19 at 11:35 [NAME]M.: Resident left with (name of ambulance service) A Care Plan, dated 5/28/19, indicated, (Resident D) has a chronic non healing diabetic wound to his foot and has decreased strength and mobility putting him at risk for pressure related skin impairments with need for treatment and monitoring. The Interventions included: (MONTH) be seen by wound MD. Provide thorough skin care after incontinent episodes and apply barrier cream. Treatments as ordered. An additional Care Plan, dated 6/10/19, indicated, (Resident D) has a pressure area to his coccyx and buttocks requiring treatment and monitoring. The Interventions included: 6/10/2019 Air mattress for bed. 6/10/2019 Treatments as ordered. 6/10/2019 Turning and repositioning schedule q2h and prn. An emergency room note, dated 6/14/19 at 2:35 P.M., indicated, Chief Complaint: Patient presents with Wound Check buttocks .presents with a sacral decubitus .He has had purulent (pus-filled) drainage from his wound .Patient has a deep ulcer over the sacral region with purulent foul-smelling drainage and surrounding [DIAGNOSES REDACTED] .Final Impression: Pressure injury of skin of buttock A hospital History and Physical, dated 6/14/19 at 2:37 P.M., indicated, .presents from NH (nursing home) with sacral decubitus ulcer. This has been present since (MONTH) and has been worsening over the past week .His brother states he has not been turned regularly. The decubitus ulcer has been worsening and the pain has become more severe .ED (emergency department) eval revealed Temp 101.5 .Assessment/Plan:[MEDICAL CONDITION], secondary to decubitus ulcer infection A hospital Wound Assessment, dated 6/15/19, indicated, Pt (patient) has severe sacral wound that he was admitted with, looks to be tunneling .Able to answer some questions, but falling back asleep easily .Per chart review, during last hospital stay patient had red, blanchable coccyx which was last assessed on 5/24/19 prior to discharge. Spoke with (name of nurse) that admitted resident yesterday. Reports significant other was here yesterday. States patient .has gone downhill since and has also not been turned regularly .Wound # 1 Unstageable pressure injury .Location: Coccyx Dimensions: 8 x 7 x 2.8 cm. Wound Bed: 100% necrotic (black, dead) tissue, palpable coccyx bone .Drainage: malodorous, yellow .Pain: yes On 8/8/19 at 10:15 [NAME]M., during an interview with the interim Director of Nurses (DON) and Administrator, the DON indicated that when Resident D was admitted to the facility, the resident was continent of bowels and bladder, was alert, and was able to transfer and move around himself. The DON indicated the resident's Braden scale indicated the resident was not at risk for pressure ulcers. The DON indicated the resident was independent and then declined. The DON indicated the resident got a small area which deteriorated quickly. On 8/8/19 at 3:35 P.M., the Administrator indicated they could not find a Care Plan which was initiated on admission to prevent pressure ulcers. The MDS (Minimum Data Set) Coordinator thought the Care Plan may be in her office. At that time, the DON indicated the reason the resident was not started on the wound care treatment on 6/3/19, was that the wound physician's computer system was down. She made rounds with the wound physician, she did not write down the recommendations for wound treatment, but waited until the office emailed the notes to the facility. The resident did receive the recommended treatment on 6/7/19 and 6/9/19. On 8/8/19 at 3:55 P.M., the MDS Coordinator provided a Resident Centered Baseline Care Plan for Resident D, dated 5/24/19. The MDS Coordinator indicated it was found in her office, but was not the one signed by the resident. The Care Plan included: Problem/Need/Concern .Risk for Skin Issues. The Interventions included: Perform preventative skin care, Tx (treatment) as ordered. T&R frequently. 2. On 8/7/19 at 9:20 [NAME]M., during the initial tour, the interim DON indicated Resident B had a pressure ulcer on the left outer ankle. The clinical record of Resident B was reviewed on 8/8/19 at 9:10 [NAME]M. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 2/28/19, indicated Resident B required extensive assistance of two plus staff for bed mobility, transfer, and dressing, and did not ambulate. The resident required total dependence of one person for bathing and did not have any pressure ulcers. A physician's orders [REDACTED]. A Care Plan, dated 4/14/17 and updated on 3/15/19, indicated, Pressure ulcer actual or at risk due to: Assistance required in bed mobility The Interventions included: Conduct weekly skin inspection - update MD (with) any abnormal findings. Enc/cue (encourage/cue) and assist (with) turning and repositioning freq (frequently) and prn Documentation indicated the resident had an orthopedic appointment on 5/1/19. A Wound Evaluation Flow Sheet, dated 5/1/19, indicated: Left ankle (outer), Pressure, Length 2 (cm), Width 2.2 (cm), Stage Unstageable. When was the wound identified? 05/01/2019. Pressure Ulcer (In-house acquired) Exudate: Serous, thin watery, Moderate .100% Necrotic The most recent Wound Evaluation Flow Sheet, dated 6/11/19, indicated: Length (in cm) 2, Width (cm) 1.7, Depth (in cm) 0.2 .Exudate: Serous, Thick, tenacious, Moderate, 70% Granulation, 30% Slough On 8/8/19 at 9:35 [NAME]M., a wound assessment was requested. LPN 2 indicated she had clarified the physician's orders [REDACTED]. The resident had a pressure ulcer on the left outer ankle. The wound bed had yellow tissue present. A scant amount of drainage was observed on the old dressing. No inflammation was observed. LPN 2 indicated the wound measurements and assessments should be in the computerized record, and she was unsure where the wound physician's documentation was. On 8/8/19 at 10:10 [NAME]M., during an interview with the interim DON, she indicated the wound physician's documentation was kept in her office. There was probably not more recent pressure ulcer documentation in the clinical record than 6/11/19. She toured with the wound physician, and so utilized the wound physician's measurements and notes. She was informed to keep the pressure ulcer documentation in her office, but that she would start keeping it in the resident's clinical record. At that time, the DON provided the most recent wound physician's documentation, dated 8/5/19. The documentation included: Stage 3 Pressure Wound of the Left Ankle. Etiology: Pressure, Stage 3, Wound Size (L x W x D): 0.7 x 0.5 x 0.1 cm, Exudate: Moderate Serous .Collagen sheet apply once daily for 9 days. Gauze island (dressing) apply once daily for 9 days On 8/8/19 at 2:45 P.M., during an interview with the interim DON, she indicated she thought staff had been removing the resident's leg brace twice daily, and that documentation would be on the Treatment Administration Record (TAR). The skin was difficult to evaluate due to the resident's skin color and texture. During a review of the resident's TAR, dated (MONTH) and (MONTH) 2019, there was no documentation that staff were removing the resident's left leg brace to assess the skin. On 8/8/19 at 3:05 P.M., during an interview with the interim DON, she indicated there was a physician's orders [REDACTED]. She checked the instructions at that time, and they indicated the brace should have been removed three times a day and she was unsure if nursing staff were aware of that. 3. On 8/7/19 at 9:20 [NAME]M., during the initial tour, the interim DON indicated Resident C had a deep tissue injury pressure ulcer on the right ankle. On 8/8/19 at 11:00 [NAME]M., a wound assessment was requested. Resident C was lying on an air mattress. A dressing was observed on the right heel. RN 2 indicated the resident returned from the hospital with a blackened area on the heel. A small open area was observed on the heel, with a scant amount of drainage. The clinical record of Resident C was reviewed on 8/8/19 at 11:15 [NAME]M. [DIAGNOSES REDACTED]. A Wound Evaluation Flow Sheet, dated 4/14/19, indicated: Right heel, Blister, Length 9 (cm), Width 8 (cm), Depth 0 .Blister, not pressure wound The most recent Wound Evaluation Flow Sheet was dated 6/11/19. The sheet indicated: Length (in cm) 6, Width (in cm) 2, Depth (in cm) 0.2. Staging: Suspected Deep Tissue Injury A Care Plan, initially dated 12/21/17 and updated on 4/18/19, indicated: (Resident C) is at risk for pressure related skin impairments d/t (due to) her hx (history) of pressure areas, impaired mobility, weakness, requiring assistance from staff for her ADLs. The Interventions included: Conduct weekly skin inspection. Skin assessment to be completed per (name of facility) policy On 8/8/19 at 10:10 [NAME]M., the DON provided the wound physician's documentation. The DON indicated the documentation was kept in her office. The DON indicated she had not updated the wound flowsheets since 6/11/19. The most recent wound physician's documentation, dated 8/5/19, indicated: Stage 3 Pressure Wound of the Right Heel, Etiology Pressure, Wound Size (L x W x D) 0.4 x 0.4 x Not Measurable (cm), Slough 50%, Granulation tissue: 50% According to the National Pressure Ulcer Advisory Panel staging system, (YEAR): Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple of maroon discoloration; these may indicate deep pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible nor are deeper tissues. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss. Full thickness loss of skin, in which adipose tissue is visible in the ulcer, meets the definition of a Stage 3 pressure injury. Granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this becomes an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss occurs with exposed or directly palpable fascia, muscle tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. The depth of the injury varies by anatomical location. If slough or eschar obscures the extent of tissue loss, an injury such as this would be described as an Unstageable Pressure Injury. Deep Tissue Pressure Injury: persistent non-blanchable deep red, maroon or purple discoloration. This type of injury may involve either intact or non-intact skin, presenting with a localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. This type of injury involves full-thickness skin and tissue loss. The extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If the slough or eschar is removed from the wound, a stage 3 or 4 pressure injury will be revealed. On 8/8/19 at 1:50 P.M., the Administrator provided the current facility policy, Skin Integrity Guideline, dated 1/28/19. The policy included: Purpose: To provide a comprehensive approach for monitoring skin conditions. To decrease pressure ulcer, pressure injury, and/or wound formation by identifying those patients/residents who are risk, and implementing appropriate interventions. To promote healing wounds of any etiology, whether admitted or acquired .The facility develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings .The interdisciplinary plan of care will address problems, goals, and interventions directed toward prevention of pressure ulcers .Patients/Residents will be observed by the CNA daily for reddened/opened areas, [MEDICAL CONDITION] (swelling) of feet or sacrum. Reposition every two hours .Licensed nurse to document weekly on identified wounds using the 'Wound Evaluation Flow Sheet' .Care plan is to be implemented, evaluated and revised based on the needs of the resident This Federal tag relates to Complaint IN 328. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident's knee immobilizer was removed for thorough skin assessments, resulting in an unstageable pressure ulcer, and then failed to ensure the physician was notified of changes in the pressure ulcer, ultimately resulting in hospitalization , for 1 of 3 residents reviewed with pressure ulcers, in a sample of 4. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 11/14/18 at 11:30 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital physician's discharge order, dated 7/30/18, indicated: NWB (no weight bearing) LLE (left lower extremity), continue in knee immobilizer on LLE The orders did not specify when to remove the immobilizer for skin assessments. A nursing admission assessment, dated 7/30/18, indicated the resident had no skin impairment to her left lower calf area. An admission Minimum Data Set (MDS) assessment, dated 8/6/18, indicated Resident B had impaired cognition, and required extensive assistance of two+ staff for bed mobility and transfer. A Care Plan, initially dated 8/10/18, indicated, Pressure ulcer actual or at risk due to: Assistance required in bed mobility, in bed most of time r/t (related to) physical condition and skin condition, limited mobility The Interventions included: Conduct weekly skin inspection. An additional Care Plan, initially dated 8/10/18 and revised at an unknown date, indicated, Altered skin integrity non pressure related to: Surgical wound on admission to left knee - infection present - wound vac as ordered .potential for adr (adverse reactions) r/t abx (antibiotics) knee immobilizer. The Interventions included: Conduct weekly skin inspection and inspection (with) dressing changes as ordered .Treatments as ordered - wound vac as ordered - knee immobilizer as ordered Nursing Progress Notes included the following notations: 10/6/18 at 11:31 A.M.: Resident alert with increased confusion .Wound vac to left knee, patent settings accurate, immobilizer in place. Drsgs (dressings) to be changed as ordered 10/8/18 at 8:22 A.M.: Upon assessment today, noted a new unstageable pressure ulcer to L (left) calf from knee immobilizer, area measures 3.5 x 3 x 0.1 (centimeters), area is black stable eschar, notified (name of physician's office) requested order to remove immobilizer while in bed .cleansed area with NS (normal saline) and applied skin prep/foam dressing A Wound Evaluation flow sheet, dated 10/8/18, indicated: Left lower leg (rear), Pressure, Length 3.5, Width 3, Depth 0.1, Stage Unstageable. When was the wound identified? 10/8/2018. Wound Type: Pressure Ulcer (In-house acquired) .Exudate (drainage) None, Necrotic (dead tissue) 100% .Current treatment: skin prep/foam dressing The flow sheet indicated: Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, brown or brown) .and/or eschar (tan, brown or black) in the wound bed. Nursing Progress Notes continued: 10/8/18 at 4:30 P.M.: (Name of physician) office returned call and states to ask therapy to pad immobilizer more at this time. Documentation that therapy added additional padding to the immobilizer was not found in the clinical record. A physician's orders [REDACTED]. An additional physician's orders [REDACTED]. A Wound Evaluation flow sheet, dated 10/15/18, indicated: Left lower leg (rear), Length (in cm, centimeters) 7.8, Width 2.4, Depth 0.1, Unstageable, Exudate Serosanguineous (slightly bloody), Thin, watery, Amount scant, Painful, Necrotic 100%, Current Treatment: skin prep/foam dressing .area black, with scant serosanguineous drainage noted .wound recommend to continue current order Documentation that the physician was notified of the increase in size of the pressure ulcer, and the new drainage, was not found. A Surgeon's note, dated 10/16/18, did not indicate the physician observed the pressure ulcer on the resident's left calf. A Nurses Note, dated 10/22/18 at 11:12 A.M., indicated, Upon assessment of L leg noted dressing to lateral wound to be saturated with serous (clear) drainage and a small amount of purulence (yellowish pus) noted. Leg noted to warm, swollen, and red, also noted resident to have dry cough, contacted (name of Physician's) office and requested order for CBC and Chest X-ray, MD states ok, called (name of surgeon's) office and made aware as well A Wound Evaluation flow sheet, dated 10/22/18, indicated: Left lower leg (rear), Length 7.8, Width 1.8, Depth 0.1, Unstageable, Exudate: Serosanguineous, thin,watery, scant, Necrotic 75%, Current Treatment: skin prep/foam dressing .Assessed resident's unstageable to L calf, wound bed noted to be covered 75% with black necrotic tissue .Performed treatment per current order, resident tolerated fairly well, resident co (complains of) pain with any movement .nurse will plan to continue to monitor at this time A surgeon's note, dated 10/31/18, indicated, New wound 8 cm in length over fibula with scab tissue .Treatment .The brace is hurting more than helping so will discontinue this The resident was transferred to the hospital on [DATE]. An emergency room note, dated 11/2/18, indicated, .Also patient has a deep ulcerated wound on the posterior left calf with the outline of the wound as a has (sic) an elongated oval shape according to the daughter when patient had surgery for [REDACTED].she was on a knee immobilizer in that the leg splint was kept on for a long time On 11/16/18 at 9:20 A.M., RN 1 was interviewed. RN 1 indicated he was the Wound Care nurse who was involved with Resident B's treatment. The resident was admitted with an immobilizer over her left knee and leg, and kept in place with straps going around her leg. RN 1 indicated the facility did not have orders to remove the immobilizer. The resident had an unstageable pressure area that was observed on (MONTH) 8, and was caused by the immobilizer. He indicated he knew therapy did put extra padding on the immobilizer. He didn't notify the physician of the increase in size of the area on 10/15, because the resident was going to the physician on 10/16. He indicated he did not know if the physician observed the pressure ulcer at that time. RN 1 indicated he accompanied the resident to the physician's office on 10/31, and the physician did order for the immobilizer to be discontinued. On 11/16/18 at 10:15 A.M., the Director of Nursing (DON) was interviewed. The DON indicated that although the facility did not have an order to remove the immobilizer prior to 10/8/18, the immobilizer would be loosened over the knee during dressing changes. The DON acknowledged that the immobilizer was not removed prior to 10/8/18, and would be wrapped and bagged during showers, so a complete skin assessment could not be completed. On 11/16/18 at 1:30 P.M., the DON provided the current facility policy, Skin Integrity Guideline, reviewed 3/1/18. The policy included: Purpose: To decrease pressure ulcer, pressure injury, and/or wound formation by identifying those patients/residents who are at risk, and implementing appropriate interventions. To promote healing of wounds of any etiology .Patients/Residents will be observed by the CNA daily for reddened/opened areas .Licensed nurse will be responsible for performing a skin evaluation/observation weekly . This Federal tag relates to Complaint IN 727. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident was weighed on admission; failed to notify the physician of weight losses; and failed to monitor fluid intake in a resident with a decreased intake and thickened liquids, resulting in hospitalization with [DIAGNOSES REDACTED]. ( Resident B) Findings include: The closed clinical record of Resident B was reviewed on 12/18/17 at 10:10 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 9/21/17 at 5:00 P.M., indicated Resident B was non-verbal, and was able to understand others. The Nutritional Risk section of the assessment was left blank. The admission weight was left blank. An admission Minimum Data Set (MDS) assessment, dated 9/28/17, indicated Resident B had a short term and long term memory problem, and was severely impaired in cognitive skills for daily decision making. Behavior assessment 1 (occurred 1-3 days in the previous 7 days) was Physical 1, Verbal 1, Other 1 and 1 rejection of care. The resident required extensive assistance of one staff for eating. There was no weight documented. The first recorded weight, dated 10/4/17, was 146 lbs (pounds). A Nurses Note, dated 10/4/17 at 3:54 P.M., indicated, Order changed to puree, she got chocked (sic) on a cookie yesterday and we are changing diet so res (resident) can swallow easier. A Nutrition Assessment, dated 9/28/17 and locked 10/5/17, indicated Resident B's current body weight was 146#. The assessment indicated she required approximately 1991 calories daily, and required approximately 1991 cc fluid daily. The assessment indicated, Admit (with) dx (diagnosis) of dislocation L (left) humerus (shoulder) .dysphagia. Diet pureed; consuming 77% of meals. Fed per staff. Recent swallowing episode leading to downgrade of diet to puree .Nutrition Interventions: Diet per MD, Meds per MD, Monitor weight, Monitor intake A Nursing Progress Note, dated 10/13/17 at 11:14 A.M., indicated, Resident followed due to new admission, weight is 146# on 10-04-2017, no weight this week due to unable to obtain due to behavior, diet is pureed, intake 84%, will continue to monitor The resident's weight on 10/18/17 was 153#. Nursing Progress Notes continued: 10/26/17 at 10:55 A.M.: .weight is 148#, weight loss of 5# in 1 week, diet is pureed, intake 92%, will continue to monitor Documentation that the physician was notified of the weight loss was not found in the clinical record. Nursing Progress Notes continued: 11/2/17 at 12:21 P.M.: .weight is 148#, no change x 1 week, diet is pureed, fluids changed to NTL (nectar thickened liquids) with thin water on 10/31/17, intake 80% will continue to monitor 11/6/17 at 2:42 P.M.: Resident with productive cough; light yellow per therapy .Ordered chest xray stat 11/7/17 at 10:16 A.M.: Resident unable to swallow medications/or eat - currently NPO (nothing by mouth). ST (speech therapy) evaluated .(POA) request send to ER for evaluation/treatment The resident returned to the facility on [DATE] at 6:54 P.M. with no new orders. Nurses Notes continued: 11/9/17 at 10:45 A.M.: .Weight is 140#, down 8# x 1 week, diet is pureed .recommend (sic) two cal 90 cc TID (three times daily) will continue to monitor Documentation that the physician was notified of the weight loss was not found in the clinical record. Nurses Notes continued: 11/16/17 at 10:22 A.M.: .weight is 141#, up 1# x 1 week .will continue to monitor 11/21/17 at 12:05 P.M.: Resident having problems swallowing. Speech therapy aware .Is still having loose stools. Is on all liquid diet for next day .will continue to monitor. 11/22/17 at 2:57 P.M.: Notified (physician) of refusal of supplements, will review in NAR (nutrition at risk) 11/24/17 at 7:37 A.M.: .noted more lethargic compared to baseline .appetite & hydration have been decreased compared to baseline, total care with feedings 11/24/17 at 3:50 P.M.: Pt (patient) has increased congestion, refusing to eat, and afebrile .New order for (lab work) and chest x ray 11/25/17 at 2:11 A.M.: Resident has had a decrease in level of functioning .having difficulty swallowing .chest x-ray came back clear .will continue to monitor. 11/27/17 at 8:27 A.M.: (Name of POA) returned call regarding refusing supplements. ST (speech therapy) recommendation for [MEDICATION NAME] swallow, but resident may be uncooperative with instructions. POA .agreeable for placement of a feeding tube. Will update (physician). 11/28/17 at 1:50 P.M.: (Name of physician's nurse) will contact (surgeon) to set up an appt (appointment) for feeding tube. Awaiting reply. 11/28/17 at 2:16 P.M.: .Having to remind resident to swallow with medication administration. Ate a little breakfast and slept through lunch 11/29/17 at 6:30 A.M.: Resident did not swallow medication. This nurse attempted to swab mouth clean, resident a little resistive to clean her mouth. 11/29/17 at 7:27 A.M.: .Respirations became very raspy .Suctioned the resident .called 911 .resident sent to ER per ambulance A hospital history and physical, dated 11/29/17 at 9:53 A.M., indicated, .Recent concern for possible aspiration and poor oral intake on puree diet with nectar thick liquids .Lab work on admission showed a sodium of 160 (normal 136-145), BUN/Creatinine was 42/1.9 (normal 8-23/.4-1.1) .Assessment/Plan:[MEDICAL CONDITION] - Likely 2nd to aspiration pneumonia. Chest x-ray negative but could be dehydrated. [MEDICAL CONDITION] (elevated sodium level) Likely 2nd to extreme volume depletion. Acute kidney injury Likely 2nd to volume loss On 12/19/17 at 2:40 P.M., the Administrator indicated there was no intake and output monitoring for Resident B. The DON indicated at that time that the facility would only do intake and output monitoring if a resident was on restricted fluids, or if a resident had a catheter. On 12/20/17 at 2:05 P.M., the Dietary Manager (DM) was interviewed. She indicated Resident B was weighed weekly at first because she was a new admission, and then was weighed because her weights were fluctuating. She indicated, We monitor food consumption in our NAR meetings. She indicated they did not monitor fluid consumption. On 12/20/17 at 2:10 P.M., the DM provided the current facility policy Hydration, dated 12/17/15. The policy included: The dietician calculates daily fluid requirements for all patients annually or with changes in condition. The following are risk factors for dehydration: Coma/decreased sensorium, Fluid loss and increased fluid needs (e.g. diarrhea .), Functional impairments making it difficult to drink, reach for fluids or communicate fluid needs (e.g. [MEDICAL CONDITION] (difficulty communicating), thickened liquids) .Refusal of fluids This Federal tag relates to Complaint IN 103. 3.1-46(a)(1) 3.1-46(b)

Based on observation, interview, and record review, the facility failed to manage resident behaviors, resulting in residents wandering into other resident rooms uninvited, and 1 resident punching another resident in the face (Resident B), causing swelling, bruising, and fear, for 3 of 4 residents reviewed for wandering, in a sample of 7. (Residents A, C, E, F, G) Findings include: 1. On 10/17/16 at 9:50 A.M., the Administrator provided an Indiana State Department of Health reportable incident. The document included: Date of Alleged Event: 10/03/2016, Residents Involved: (Resident B) .(Resident A) .(Resident A) entered (Resident B's) room at approximately 11:25 pm, staff heard sensor alarm at door threshold and responded immediately. Upon entering room, (Resident A) was witnessed to be hitting (Resident B). (CNA # 1) separated the residents when nurse entered. Both staff assisted (Resident A) out of the room .(Resident B) and (Resident A) were sent to the hospital for evaluation and treatment. (Resident B) returned to facility at approximately 2:45 am with a [DIAGNOSES REDACTED].Type of injury .bruising to cheek area .(Resident A) was sent to the ER for psych evaluation and treatment The clinical record of Resident A was reviewed on 10/17/16 at 11:30 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Progress Notes included the following notations: 9/28/16 at 8:16 P.M.: Res (resident) arrived at facility .He is alert & disoriented x 3. Ambulating through halls. Wandering into other resident's room. Attempted redirection unsuccessful. Flat affect & speech is clear but does not make much sense .Will cont (continue) to monitor 9/29/16 at 7:08 A.M.: Resident up ad lib ambulating all over unit attempting to open exit doors .unable to redirect going in & out of other residents (sic) rooms taking belongings from them moving to other rooms, when attempted to redirect resident becomes aggressive talks about fighting 'everyone' unable to get resident to take HS (bedtime) meds .resident ambulated to another resident and sat meds on their table and walked out 9/30/16 at 3:53 A.M.: Resident sleeping at beginning of shift awoke and was up ad lib ambulating all over unit in & out of other residents rooms getting into beds attempting to open exit doors .redirected numerous times 10/2/16 at 1:30 P.M.: Resident has been going into other resident's room. Attempts at redirecting out of rooms has been ineffective. When get (sic) resident out of wrong room he has been combative with staff. Redirected to his room and he stayed for a few minutes then was up wandering again. He continues to go into others rooms and is taking thinks off their tables like glasses. When trying to get them back he becomes very agitated .got into verbal altercation with roommate, he had his roommates shoes on and he wanted the back .resident is not easy to redirect. 10/2/16 at 2:24 P.M.: .Resident has been going in other resident's rooms and when trying to redirect him he is being combative with staff. New med order to start 10/3/16 at 4:47 A.M.: Resident was sleeping at the beginning of this shift, awoke and was up ad lib ambulating in & out of other residents rooms, getting into beds attempting to open exit doors .Resident was redirected numerous times 10/3/16 at 2:09 P.M.: Alert with confusion. Continues to wander into other resident's rooms. No angry outbursts noted today .Will continue to monitor. 10/4/16 at 12:23 A.M.: Resident had taken all HS (bedtime) meds & was resting quietly in his bed since that time approximately 21:30 (9:30 P.M.). Resident awoke & ambulated from his room at approximately 23:45 (11:45 P.M.) down hallway while staff in hallway watching him, into room (number) staff in hallway at time and followed right behind resident into room to tell him it wasn't his room & he had to leave room, entered room and resident was already at bed (number) and punching female resident with closed fist in face/head staff x 2 pulled resident away from residents (sic) bed and out of room resident swinging hitting & kicking staff the whole time .attempted to re-enter room numerous times .he kept trying to hit push & kick staff, mumbling incoherently unable to understand what resident was saying other than curse words & 'I'm going to kill you all' over & over while swinging & kicking at staff .resident transported to (hospital) ER A Care Plan, dated 10/3/16, indicated, My safety is at risk and there is a potential for abuse due to: Decreased cognitive ability, inability to communicate, wandering. The Interventions, all dated 10/3/16, included: Please re-direct me when I wander into other rooms or areas that are unsafe for me. There was not a care plan regarding wandering prior to 10/3/16. An additional Care Plan, dated 10/3/16, indicated, I sometimes have behaviors which included bumping into other people, hitting during care, kicking, screaming, shouting, spitting. The Interventions included: Attempt interventions before my behaviors begin. Offer me something I like as a diversion. Individualized interventions were not documented. On 10/17/16 at 1:40 P.M., CNA # 1 was interviewed. CNA # 1 indicated she was working the night of 10/3/16. CNA # 1 indicated Resident A had been pacing up and down the hallway, trying to go into other rooms. We finally got him to lay down in bed. CNA # 1 indicated she was standing at the linen closet in the hallway, when she heard Resident B's alarm sounding. She indicated when she went to the resident's room, she saw Resident A bending over Resident B's bed, punching her with his fist. She indicated she pulled the resident off of Resident B. CNA # 1 indicated Resident A was punching Resident B on her face and head, and was hitting her pretty hard. She indicated she guessed the nurse heard me yelling, and she came in and helped me pull him off of her. CNA # 1 indicated she never even saw him walk by me or go into the room. CNA # 1 indicated that was the 2nd time that the resident had entered the room that evening. On 10/17/16 at 3:15 P.M., LPN # 1 was interviewed. LPN # 1 indicated she was working the night of 10/3/16. She indicated Resident A had taken his bedtime medication. She indicated she and CNA # 1 were standing at the medication cart by the nurses station, and heard Resident B's alarm sound. She indicated CNA # 1 entered the room, and she heard her yell, and came into the room. She indicated Resident A was still punching (Resident B). She indicated Resident A was always going in and out of others rooms. LPN # 1 indicated Resident B had a motion detector alarm on her doorway, and a sensor alarm on a mat on the floor. LPN # 1 indicated she did not think Resident A was targeting Resident B in particular. She indicated Resident A had been in just about every other room. On 10/18/16 at 8:50 A.M., during an interview with the Administrator, she indicated Resident A had been readmitted to the facility on [DATE], and that the hospital had adjusted his medications. She indicated she kept the resident 1:1 during the night to see how he would do, and that he did well. The Administrator indicated Resident A had not been aggressive prior to the incident with Resident B. On 10/18/16 at 10:10 A.M., during an interview with the Administrator, she indicated therapy staff had evaluated Resident A for different behaviors, and then would come up with different interventions. The Administrator indicated the evaluation was kept in the therapy department, and therapy staff did not have time to fully implement any interventions regarding wandering. The clinical record of Resident B was reviewed on 10/17/16 at 1:10 P.M. The most recent Social Services Progress Note, dated 10/6/16 at 11:14 A.M., indicated: Late Entry . interviewed resident on this date, (Resident B) was in good spirits .no signs/symptoms of distress or discomfort On 10/18/16 at 2:35 P.M., Resident B was interviewed. Resident B requested Staff # 4 to be present in the room during the interview. Resident B indicated she was watching TV, and Resident A came in and started punching me in the face. She indicated he probably punched her 4 times in the cheek/jaw area. She indicated it scared her, and she feared for her life. Resident B indicated she was very fearful that Resident A had been readmitted to the facility. Staff # 4 indicated at that time that Resident B's jaw area had been swollen and Resident B complained of pain. Staff # 4 indicated, She was pretty upset. Staff # 4 indicated the resident had been also upset that day because of Resident A being readmitted to the facility the previous night. 2. On 10/17/16 at 9:20 A.M., during the initial tour, the MDS Coordinator indicated Resident C had behaviors of wandering. She indicated the resident needed constant redirection. Resident C was observed ambulating in the hallway, and entered a resident room. No staff was with the resident. The clinical record of Resident C was reviewed on 10/17/16 at 1:40 P.M. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. Nurses Notes included the following notations: 10/5/16 at 1:33 P.M.: .admitted this date .resident wanders unit and must be redirected per staff. Resident can communicate, but had non-sensical (sic) answers to questions given to him 10/5/16 at 5:55 P.M.: Resident arrived around 12:05 pm this afternoon, has since been pacing the floor non stop going into other resident's room, redirected with success at times .Attempts to take food and fluids off others trays, the tray cart, and out of residents rooms 10/6/16 at 1:41 P.M.: Resident has paced halls since start of shift. Continues to go into other resident's rooms and take their water from bedside, able to redirect out of areas then comes right back within a few minutes 10/7/16 at 1:57 P.M.: Res (resident) walking length of hallway this entire shift. Wanders into other resident's rooms but redirects w/o (without) difficulty to come out 10/8/16 at 6:49 A.M.: Resident slept last noc (night) approx. 6 hours. Wanders up et (and) down halls et in et out of other residents room .Difficult to redirect at times .Will monitor. 10/8/16 at 12:46 P.M.: Res conts to pace halls & wander into other resident's rooms .Attempts to get food & drink off other res's trays during meal times. Difficult to redirect at times. Remains with flat affect & confusion 10/12/16 at 6:56 P.M.: Res wandering halls entire shift. Attempting to put various objects in his mouth, including an artificial plant 10/15/16 at 6:28 A.M.: .Continues to attempt to push male peer in his w/c (wheelchair) et said resident not wanting assist A care plan regarding wandering or other behaviors was not found in the clinical record. On 10/17/16 at 3:00 P.M., during an interview with Staff # 3, the staff member indicated, You cannot redirect (Resident C). He goes in and out of others rooms constantly. I don't think he belongs here. On 10/17/16 at 3:30 P.M., during an interview with the Administrator, she indicated she found a care plan regarding wandering. She provided a care plan, dated 10/17/16, which indicated, Activity Focus: I have a poor response to others and the environment in that I have a constant need to move, collect and am not aware of my surroundings. I 'm constantly wandering and pacing up and down the halls. The Administrator was informed the care plan was just written on that date, and had not been in the clinical record. She indicated, We have 14 days to develop care plans. The Administrator indicated, Residents are going to wander. 3. On 10/17/16 at 9:20 A.M., during the initial tour, the MDS Coordinator did not indicate that Resident E had any behaviors which were being monitored. On 10/17/16 at 3:00 P.M., during an interview with Staff # 3, she indicated, You cannot redirect (Resident E). He's in and out of everyone's rooms. On 10/18/16 at 9:25 A.M., Resident E was observed ambulating in the hallway. He was observed to enter a resident room, in which 3 female residents lived. None of the residents were in the room. Resident E entered the room, looked around, and exited. No staff members were present. The clinical record of Resident E was reviewed on 10/18/16 at 9:45 A.M. [DIAGNOSES REDACTED]. Nurses Notes included the following notations: 10/13/16 at 8:50 P.M.: Res arrived at facility .alert to staff .Up ad lib ambulating throughout hallways 10/13/16 at 10:30 P.M.: Resident ambulating up hallway .Directed him to the dining area and he sat for about three minutes before getting up to ambulate down the hall again 10/16/16 at 9:55 A.M.: Resident wandering up and down the hallway went into the doorway of another resident's room and stated 'I'm going to kill you' .Initiated 15 min checks. A care plan regarding managing the resident's wandering behaviors was not found in the clinical record. 4. On 10/17/16 at 9:50 A.M., the Administrator provided a list of residents, highlighting those residents considered interviewable. Resident G was highlighted as interviewable. On 10/18/16 at 9:20 A.M., during an interview with Resident G, he indicated he kept his doors closed. He indicated the residents who wander don't open the doors. Resident G indicated, If I kept the door open, they would come in. 5. On 10/17/16 at 9:50 A.M., the Administrator provided a list of residents, highlighting those residents considered interviewable. Resident F was highlighted as interviewable. On 10/18/16 at 9:35 A.M., during an interview with Resident F, he indicated there are 2 male residents who wander into his room uninvited. He indicated he just yells at them to get out. He indicated he was not scared, but he did not like it. He indicated, Now they are keeping the door closed and you can't see nothing out in the halls. 6. During a confidential interview with Staff # 5, the staff member indicated it was very difficult at times to monitor the residents who wander. The staff member indicated, Sometimes we will have 3 residents pacing and it's too much. I worry about that. On 10/18/16 at 8:50 A.M., during an interview with the Administrator, she indicated once again that All residents will wander. She indicated that she has staff interview alert and oriented residents, and no residents had indicated they were fearful if a resident entered their room uninvited. On 10/18/16 at 9:10 A.M., during an interview with the Social Services Director (SSD), he indicated he became aware of resident behaviors by talking to the nurses and CNAs. He indicated, They tell me, or I read the notes sometimes. He indicated he did not keep any behavior logs, which would track behaviors. The SSD indicated he would utilize stop signs or motion detectors to manage behaviors. The SSD indicated he also would speak to residents, and inform them that the residents who wander into their rooms did not mean any harm, and they were fine with it. He indicated he did not use specific behavior plans, but would care plan the behavior. On 10/18/16 at 11:00 A.M., the Administrator provided the current facility policy Behavior Management Guideline, dated 3/30/16. The policy included: Guideline Statement: To develop behavior plans and medication regimens, when appropriate, to optimize the functional abilities of patients/residents while monitoring for adverse side effects and improved behaviors .The Antecedent Behavior Monitoring Log is utilized for new patients/residents with behaviors and current patients/residents who exhibit new behaviors which negatively impact functioning or quality of life. The log is reviewed by the Behavior Committee members to identify patterns and causative or triggering events for the behavior(s) and effectiveness of interventions. Observe patient/resident and review for reversible cause .Non-pharmacological interventions implemented and assessed for effectiveness, PRIOR to considering initiation of any psychoactive medications .IPOC (Interdisciplinary Plan of Care) or care plan is developed for patients/residents exhibiting negative behavior .A monitoring system is established for targeted behaviors, interventions, and medication effectiveness and side effects This Federal tag relates to Complaint IN 749. 3.1-34(a)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent a confused resident from wandering into another resident's room, punching her in the face, resulting in facial bruising, swelling, and fear, for 1 of 4 residents reviewed for supervision, in a sample of 7. (Resident A and B) Findings include: 1. On 10/17/16 at 9:50 A.M., the Administrator provided an Indiana State Department of Health reportable incident. The document included: Date of Alleged Event: 10/03/2016, Residents Involved: (Resident B) .(Resident A) .(Resident A) entered (Resident B's) room at approximately 11:25 pm, staff heard sensor alarm at door threshold and responded immediately. Upon entering room, (Resident A) was witnessed to be hitting (Resident B). (CNA # 1) separated the residents when nurse entered. Both staff assisted (Resident A) out of the room .(Resident B) and (Resident A) were sent to the hospital for evaluation and treatment. (Resident B) returned to facility at approximately 2:45 am with a [DIAGNOSES REDACTED].Type of injury .bruising to cheek area .(Resident A) was sent to the ER for psych evaluation and treatment The clinical record of Resident A was reviewed on 10/17/16 at 11:30 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Progress Notes included the following notations: 9/28/16 at 8:16 P.M.: Res (resident) arrived at facility .He is alert & disoriented x 3. Ambulating through halls. Wandering into other resident's room. Attempted redirection unsuccessful. Flat affect & speech is clear but does not make much sense .Will cont (continue) to monitor 9/29/16 at 7:08 A.M.: Resident up ad lib ambulating all over unit attempting to open exit doors .unable to redirect going in & out of other residents (sic) rooms taking belongings from them moving to other rooms, when attempted to redirect resident becomes aggressive talks about fighting 'everyone' unable to get resident to take HS (bedtime) meds .resident ambulated to another resident and sat meds on their table and walked out 9/30/16 at 3:53 A.M.: Resident sleeping at beginning of shift awoke and was up ad lib ambulating all over unit in & out of other residents rooms getting into beds attempting to open exit doors .redirected numerous times 10/2/16 at 1:30 P.M.: Resident has been going into other resident's room. Attempts at redirecting out of rooms has been ineffective. When get (sic) resident out of wrong room he has been combative with staff. Redirected to his room and he stayed for a few minutes then was up wandering again. He continues to go into others rooms and is taking thinks off their tables like glasses. When trying to get them back he becomes very agitated .got into verbal altercation with roommate, he had his roommates shoes on and he wanted the back .resident is not easy to redirect. 10/2/16 at 2:24 P.M.: .Resident has been going in other resident's rooms and when trying to redirect him he is being combative with staff. New med order to start 10/3/16 at 4:47 A.M.: Resident was sleeping at the beginning of this shift, awoke and was up ad lib ambulating in & out of other residents rooms, getting into beds attempting to open exit doors .Resident was redirected numerous times 10/3/16 at 2:09 P.M.: Alert with confusion. Continues to wander into other resident's rooms. No angry outbursts noted today .Will continue to monitor. 10/4/16 at 12:23 A.M.: Resident had taken all HS (bedtime) meds & was resting quietly in his bed since that time approximately 21:30 (9:30 P.M.). Resident awoke & ambulated from his room at approximately 23:45 (11:45 P.M.) down hallway while staff in hallway watching him, into room (number) staff in hallway at time and followed right behind resident into room to tell him it wasn't his room & he had to leave room, entered room and resident was already at bed (number) and punching female resident with closed fist in face/head staff x 2 pulled resident away from residents (sic) bed and out of room resident swinging hitting & kicking staff the whole time .attempted to re-enter room numerous times .he kept trying to hit push & kick staff, mumbling incoherently unable to understand what resident was saying other than curse words & 'I'm going to kill you all' over & over while swinging & kicking at staff .resident transported to (hospital) ER A Care Plan, dated 10/3/16, indicated, My safety is at risk and there is a potential for abuse due to: Decreased cognitive ability, inability to communicate, wandering. The Interventions, all dated 10/3/16, included: Please re-direct me when I wander into other rooms or areas that are unsafe for me. There was not a care plan regarding wandering prior to 10/3/16. An additional Care Plan, dated 10/3/16, indicated, I sometimes have behaviors which included bumping into other people, hitting during care, kicking, screaming, shouting, spitting. The Interventions included: Attempt interventions before my behaviors begin. Offer me something I like as a diversion. Individualized interventions were not documented. On 10/17/16 at 1:40 P.M., CNA # 1 was interviewed. CNA # 1 indicated she was working the night of 10/3/16. CNA # 1 indicated Resident A had been pacing up and down the hallway, trying to go into other rooms. We finally got him to lay down in bed. CNA # 1 indicated she was standing at the linen closet in the hallway, when she heard Resident B's alarm sounding. She indicated when she went to the resident's room, she saw Resident A bending over Resident B's bed, punching her with his fist. She indicated she pulled the resident off of Resident B. CNA # 1 indicated Resident A was punching Resident B on her face and head, and was hitting her pretty hard. She indicated she guessed the nurse heard me yelling, and she came in and helped me pull him off of her. CNA # 1 indicated she never even saw him walk by me or go into the room. CNA # 1 indicated that was the 2nd time that the resident had entered the room that evening. On 10/17/16 at 3:15 P.M., LPN # 1 was interviewed. LPN # 1 indicated she was working the night of 10/3/16. She indicated Resident A had taken his bedtime medication. She indicated she and CNA # 1 were standing at the medication cart by the nurses station, and heard Resident B's alarm sound. She indicated CNA # 1 entered the room, and she heard her yell, and came into the room. She indicated Resident A was still punching (Resident B). She indicated Resident A was always going in and out of others rooms. LPN # 1 indicated Resident B had a motion detector alarm on her doorway, and a sensor alarm on a mat on the floor. LPN # 1 indicated she did not think Resident A was targeting Resident B in particular. She indicated Resident A had been in just about every other room. On 10/18/16 at 10:10 A.M., during an interview with the Administrator, she indicated therapy staff had evaluated Resident A for different behaviors, and then would come up with different interventions. The Administrator indicated the evaluation was kept in the therapy department, and therapy staff did not have time to fully implement any interventions regarding wandering. 2. The clinical record of Resident B was reviewed on 10/17/16 at 1:10 P.M. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 9/21/16, indicated Resident B scored a 14 out of 15 for cognition, with 15 indicating no memory impairment, and required extensive assistance of two+ staff for transfer, dressing, and hygiene/bathing. The resident did not ambulate. A hospital emergency room note, dated 10/4/16 at 1:42 A.M., indicated, .This patient comes emergency department (sic) for evaluation of being punched in the face by another resident of a nursing home. Complaining of some pain in her right cheek .Patient is at baseline a quadriplegic .Medical Decision Making .Evaluate for acute traumatic injuries to the head and neck .ED Course: .Will be treated for [REDACTED]. Tylenol or Advil as needed A Nurses Note, dated 10/4/16 at 10:22 A.M., indicated, IDT (interdisciplinary team) Notes .(Resident A) entered room, staff responded to sounding sensory alarm at door threshold, CNA intervened immediately, nurse and CNA removed resident .resident was alert and sent to ER for evaluation and treat .returned with DX (diagnosis) of bruising On 10/18/16 at 2:35 P.M., Resident B was interviewed. Resident B requested Staff # 4 to be present in the room during the interview. Resident B indicated she was watching TV, and Resident A came in and started punching me in the face. She indicated he probably punched her 4 times in the cheek/jaw area. She indicated it scared her, and she feared for her life. Resident B indicated she was very fearful that Resident A had been readmitted to the facility. Staff # 4 indicated at that time that Resident B's jaw area had been swollen and Resident B complained of pain. Staff # 4 indicated, She was pretty upset. Staff # 4 indicated the resident had been also upset that day because of Resident A being readmitted to the facility the previous night. This Federal tag relates to Complaint IN 749. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a resident's declining condition of severe bruising and blisters and continued onset of signs and symptoms and lack of obtaining a urinalysis resulting in a hospitalization of a resident for 2 of 26 residents reviewed during Stage 2 of the survey. This deficient practice resulted in Resident G hospitalization and subsequent amputation. (Resident G, Resident I). Findings include: 1. On 4/26/16 at 9:19 a.m., Resident G was observed lying in bed. Resident G was observed to have had a right lower extremity amputation. On 4/26/16 at 10:51 a.m., Resident G's clinical record was reviewed. Resident G's [DIAGNOSES REDACTED]. The Progress Notes included, but were not limited to: 12/25/15 at 6:37 p.m., Resident's right foot noted to be swollen and bruised. Notified MD (Medical Doctor). Received order to obtain two view x-ray STAT (immediately). 12/25/15 at 7:23 p.m., Received results back from (Name of Radiological Service). Called MD. New orders for [MEDICATION NAME] (an antibiotic medication) 100 mg (milligrams), two times a day, for one week and a CBC (complete blood count) in the morning. (Written by a RN #1) 12/25/15 at 8:00 p.m., Assessed resident's right foot at this time. Right foot noted to have purple/black bruising covering entire top, sides, bottom, heel, and toes of right foot. Resident noted to have three extremely large bloody, fluid filled blisters on inner right foot, outer right foot, and outer right heel. Foot is cold to touch. Left foot is warm to touch. While lifting resident's right leg, resident is moaning loudly. Asked resident how she injured her foot, resident is non responsive, only looking at this nurse. Resident is noted to have head tilted back on pillow slightly and leaving mouth open. Resident's skin is warm and dry to touch. Color pale, with slight yellow cast. Resident raised to sitting position in bed and evening medications taken without difficulty. Fluids taken without difficulty. Pain medications given at this time per orders. VS (vital signs): blood pressure 104/63, pulse 97, respirations 22, Temperature 98.8, oxygen saturation 97% on room air. (Written by LPN #4) 12/25/15 at 8:25 p.m., (Name of LPN Supervisor) called for results of resident's right foot X-ray. Informed of results. (LPN Supervisor) Requested current measurements of blisters. Measurements obtained as follows. 1.) outer right foot 9.0 x 9.0 cm (centimeters) bloody, fluid filled blister surrounded by purple/black bruising. 2.) outer right heel 3.0 x 3.0 cm fluid filled blisters surrounded by purple/black bruising. 3.) inner right foot 11.0 x 6.5 cm bloody, fluid filled blister, surrounded by purple/black bruising. Unable to palpate a pedal pulse in right foot due to extent of blisters and palpating would cause rupture of blisters. Pedal pulse present and strong in left foot. Right toenail beds appear black. Unable to obtain capillary refill on right foot. Notified (Name of LPN), of measurements and current VS: blood pressure 106/66, pulse 94, respirations 20, temperature 98.7, oxygen saturation 97% on room air. Right foot elevated and heels floated at this time. (Name of LPN, Name of DON) notified of residents status, will continue to monitor. No other documentation was recorded until five hours later: 12/26/15 at 1:28 a.m., Entered resident's room to check status of right foot, when noted resident to be diaphoretic and hot to touch. VS taken at this time: blood pressure 95/61, pulse 96, respirations 40 rapid and shallow, Temperature 99.4, oxygen saturation 96% on room air. Assessment of right foot at this time. Bloody fluid filled blisters completely encompass foot with bruising and blister now extending up inside of the right ankle. Call placed to (Name of Physician) with status update. New order to send resident to emergency room for evaluation and treatment. 12/26/15 at 8:34 p.m., Called (Name of Hospital) for status update on resident. [DIAGNOSES REDACTED]. Resident had emergency [MEDICAL CONDITION] at 6:00 a.m. On 4/26/16 at 3:52 p.m., the DON indicated the physician had not been notified of the declining condition of the resident's foot because he had already been notified prior to the observation of black and purple bruising with fluid filled blisters. On 4/27/16 at 11:04 a.m., the DON provided the Notification of Change in Resident Health Status policy, dated 11/2014. The policy included, but was not limited to: The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: B) Acute illness or significant change in the resident's physical, mental, or psychosocial status 2. The clinical record of Resident I was reviewed on 4/19/16 at 3:30 p.m. Resident I had [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 2/12/16, indicated Resident I had a BIMS (Brief Interview for Mental Status) staff assessment which indicated Resident I had moderate cognitive impairment. The MDS assessment indicated Resident I was an extensive assist of two (2) persons for toileting with the resident being on a toileting program. The MDS assessment further indicated Resident I was always incontinent of bladder and bowel. A care plan, initiated 11/6/15, indicated Resident I had a potential for dehydration related to the need for nectar thickened liquids. Interventions included, but were not limited to, observe for signs of dehydration such as cracked lips, decreased urine output, dry mucous membranes, dry or poor skin turgor, dark concentrated urine, sunken eyes, increased confusion, or fever and report to the charge nurse or physician A progress note, dated 3/28/16 at 0318 (3:18 a.m.) indicated an unnamed CNA reported to the nurse Resident I exhibited a foul malodorous urine. The note indicated the physician was faxed for a follow-up urinalysis culture and sensitivity. A progress note, dated 3/28/16 at 1718 (5:18 p.m.) the facility received an order to collect a urinalysis culture and sensitivity. A progress note, dated 3/29/16 at 0633 (6:33 a.m.) indicated the facility had been unable to obtain the urine specimen after multiple attempts. The note indicated the facility may in and out catheterize Resident I to obtain the specimen. The note further indicated the on-coming shift would be notified to attempt to obtain the urine specimen. A progress note, dated 3/31/16 at 1837 (6:37 p.m.), indicated the urine specimen was not obtained after several attempts. A progress note, dated 3/31/16 at 2133 (9:33 p.m.), indicated the physician had given a new order for intravenous (IV) fluids of D5W ([MEDICATION NAME]/Water) with 0.45% NaCl (Sodium Chloride) and 20 mEq (millequivalents) KCl (Potassium Chloride) at 100 ml (milliliters) per hour for 2 bags. The note indicated the facility had attempted to establish a peripheral IV to both forearms by 2 different nurses without success. The physician was notified and an order was obtained to send Resident I to the hospital. A progress note, dated 4/1/16 at 0519 (5:19 a.m.), indicated the facility was notified Resident I had been admitted to the hospital with [REDACTED]. The clinical record lacked documentation the physician was notified the U/A C&S was not obtained. During an interview with LPN # 2 on 4/26/16 at 10:28 a.m., indicated if a resident was incontinent, the nurse should obtain a physician's orders [REDACTED]. This Federal tag relates to Complaint IN 380. 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to provide the necessary care and services, in that, a resident had a continued decline in the status of the residents right foot and leg for 1 of 26 residents reviewed during Stage 2 of the survey. This deficient practice resulted in Resident G requiring hospitalization and amputation. (Resident G) Findings include: On 4/26/16 at 9:19 a.m., Resident G was observed lying in bed. Resident G was observed to have had a right lower extremity amputation. On 4/26/16 at 10:51 a.m., Resident G's clinical record was reviewed. Resident G's [DIAGNOSES REDACTED]. The Progress Notes included, but were not limited to: 12/25/15 at 6:37 p.m., Resident's right foot noted to be swollen and bruised. Notified MD (Medical Doctor). Received order to obtain two view x-ray STAT. 12/25/15 at 7:23 p.m., Received results back from (Name of Radiological Service). Called MD. New orders for [MEDICATION NAME] (an antibiotic medication) 100 mg (milligrams), two times a day, for one week and a CBC (complete blood count) in the morning. (Written by RN #1) 12/25/15 at 8:00 p.m., (Written by LPN #4) Assessed resident's right foot at this time. Right foot noted to have purple/black bruising covering entire top, sides, bottom, heel, and toes of right foot. Resident noted to have three extremely large bloody, fluid filled blisters on inner right foot, outer right foot, and outer right heel. Foot is cold to touch. Left foot is warm to touch. While lifting resident's right leg, resident is moaning loudly. Asked resident how she injured her foot, resident is non responsive, only looking at this nurse. Resident is noted to have head tilted back on pillow slightly and leaving mouth open. Resident's skin is warm and dry to touch. Color pale, with slight yellow cast. Resident raised to sitting position in bed and evening medications taken without difficulty. Fluids taken without difficulty. Pain medications given at this time per orders. VS (vital signs): Blood pressure 104/63, Pulse 97, Respirations 22, Temperature 98.8, Oxygen Saturation 97% on room air. 12/25/15 at 8:25 p.m., (Name of LPN Supervisor) called for results of resident's right foot X-ray. Informed of results. (LPN Supervisor) Requested current measurements of blisters. Measurements obtained as follows. 1.) outer right foot 9.0 x 9.0 cm (centimeters) bloody, fluid filled blister surrounded by purple/black bruising. 2.) outer right heel 3.0 x 3.0 cm fluid filled blisters surrounded by purple/black bruising. 3.) inner right foot 11.0 x 6.5 cm bloody, fluid filled blister, surrounded by purple/black bruising. Unable to palpate a pedal pulse in right foot due to extent of blisters and palpating would cause rupture of blisters. Pedal pulse present and strong in left foot. Right toenail beds appear black. Unable to obtain capillary refill on right foot. Notified (Name of LPN), of measurements and current VS: blood pressure 106/66, Pulse 94, Respirations 20, Temperature 98.7, Oxygen Saturation 97% on room air. Right foot elevated and heels floated at this time. (Name of LPN, Name of DON) notified of residents status, will continue to monitor. (Written by a LPN #4) No other documentation was recorded until five hours later. 12/26/15 at 1:28 a.m., Entered resident's room to check status of right foot, when noted resident to be diaphoretic and hot to touch. VS taken at this time: Blood Pressure 95/61, Pulse 96, Respirations 40 rapid and shallow, Temperature 99.4, Oxygen Saturation 96% on room air. Assessment of right foot at this time. Bloody fluid filled blisters completely encompass foot with bruising and blister now extending up inside of the right ankle. Call placed to (Name of Physician) with status update. New order to send resident to emergency room for evaluation and treatment. 12/26/15 at 8:34 p.m., Called (Name of Hospital) for status update on resident. [DIAGNOSES REDACTED]. Resident had emergency [MEDICAL CONDITION] at 6:00 a.m. On 4/26/16 at 3:52 p.m., the DON indicated the physician had not been notified of the declining condition of the resident's foot because he had already been notified prior to the observation of black and purple bruising with fluid filled blisters. On 4/27/16 at 11:04 a.m., the DON provided the Notification of Change in Resident Health Status policy, dated 11/2014. The policy included, but was not limited to: The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: B) Acute illness or significant change in the resident's physical, mental, or psychosocial status An assessment policy was not available for review. This Federal tag relates to Complaint IN 380. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident was free from accidents for 1 of 3 residents reviewed for falls/accidents in a sample of 3 who met the criteria for falls/accidents, received supervision and assistance. Alarms, nonskid footwear, and hip protectors were not in place. This deficient practice resulted in a resident being transferred to the hospital and receiving sutures to the head. (Resident A) Findings include: The closed, clinical record for Resident A was reviewed on 4/21/16 at 1:28 p.m. Resident A had [DIAGNOSES REDACTED]. A significant change MDS (Minimum Data Set) assessment, dated 3/4/16, indicated Resident A had a BIMS (Brief Interview for Mental Status) assessment which indicated, through staff assessment, the resident was severely cognitively impaired. A falls care plan, initiated 3/17/15, included, but was not limited to, alarming floor mat (initiated 12/1/15), bed in low position (initiated 9/4/15), call light or personal items available and in easy reach (initiated 9/4/15), fall nonskid footwear (initiated 4/10/15), and hip protectors as tolerated (initiated 4/13/15). A Progress Note, dated 11/16/15 at 11:00 a.m., indicated the staff had heard a loud thump in the room next to the nurse's at 10:35 a.m. The note indicated upon investigation, Resident A was observed to be lying on the floor parallel to the bed. The note indicated the resident had a laceration and raised area on the right forehead. The note indicated the resident had 2 skin tears on the right elbow. The progress note lacked documentation that any interventions were in place when the resident fell . No assessment was noted for the resident after the fall. A new intervention of an alarming floor mat was added to the care plan after the fall. A Progress Note, dated 11/30/15 at 6:15 a.m., indicated Resident A was observed to ambulate out of his room, walk across the hall, and upon turning toward the nurse's station, the resident fell hitting his left hip and shoulder. The note indicated the resident did not hit his head. The note further indicated the physician and power of attorney had been notified. The note indicated a physician's orders [REDACTED]. No resident assessment was documented. A Verification of Investigation form, dated 11/30/15 at 0615 (6:15 a.m.), and obtained from the Administrator (Adm) on 4/27/16 at 11:55 a.m., indicated the resident had gripper socks on. No further interventions were listed prior to the fall. A Progress Note, dated 11/30/15 at 6:40 p.m., indicated Resident A was found in the floor at the bedside. The note indicated Resident A had a laceration to the lateral aspect of the right eye. Resident A was sent to the emergency room and had sutures placed. The note indicated the resident's neurological signs were WNL (within normal limits). No interventions were listed prior to the fall as being in place in the notes. A Verification of Investigation form, dated 11/30/15 at 1750 (5:50 p.m.), and obtained from the Administrator (Adm) on 4/27/16 at 11:55 a.m., indicated the resident had gripper socks on. No further interventions were listed as being in place prior to the fall and no new assessments were put into place after the fall. During an interview with the DON (Director of Nursing) on 4/27/16 at 9:50, the DON indicated interventions would be documented on the Treatment Administration Record (TAR). The DON indicated if the intervention was not in place during the accident, the charting should reflect it. The facility failed to provide a policy for falls/accident prevention. This Federal tag relates to Complaint IN 435. 3.1-45(a)(2)

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE SUPERVISION WAS PROVIDED TO PREVENT ACCIDENTS, RELATED TO A RESIDENT WITH A HISTORY OF FALLS AND AT RISK FOR FURTHER FALLS BEING LEFT UNSUPERVISED AFTER TRANSFER TO A BEDSIDE COMMODE. THE RESIDENT (#B) fell OFF THE BEDSIDE COMMODE AND SUSTAINED A C3 FRACTURE. THIS AFFECTED 1 OF 3 RESIDENTS REVIEWED FOR FALLS IN A SAMPLE OF 6. FINDINGS INCLUDE: 1. RESIDENT # B'S CLOSED RECORD WAS REVIEWED ON 10/26/10 AT 11:00 A.M. [DIAGNOSES REDACTED]. THE "CLINICAL HEALTH STATUS" assessment dated [DATE], INDICATED "RISK FOR FALLS" WITH A SCORE OF 15. A SCORE OF 10 OR ABOVE DEEMED THE RESIDENT AT RISK FOR FALLS. THE ASSESSMENT INDICATED THE RESIDENT HAD FALLEN IN THE PAST SIX MONTHS. THE ASSESSMENT INDICATED THE RESIDENT HAD LOWER EXTREMITY WEAKNESS AND PROBLEMS WITH BALANCE WHILE SITTING AND STANDING. THE ASSESSMENT INDICATED THE RESIDENT'S GAIT WAS UNSTEADY. THE RESIDENT'S CARE PLAN (DATED 9/27/10) TITLED, "AT RISK FOR FALLS RELATED TO USE OF MEDICATIONS, fell IN THE PAST 31 - 180 DAYS" WAS REVIEWED. THE GOAL WAS, "NO FALL RELATED INJURIES." THE INTERVENTIONS INCLUDED, "ASSESS FOR PAIN. BED IN LOW POSITION. CALL LIGHT OR PERSONAL ITEMS AVAILABLE AND IN EASY REACH OR PROVIDE REACHER. GRAB BAR. KEEP ENVIRONMENT WELL LIT AND FREE OF CLUTTER. OBSERVE FOR SIDE EFFECTS OF MEDICATIONS. ORIENTATION OF NEW ROOM ROOMMATE. TOILET SCHEDULE." THE NURSES' NOTES INCLUDED, BUT WERE NOT LIMITED TO, THE FOLLOWING: 10/6/10 AT 6:30 A.M. "REPORTED TO THIS WRITER THIS RESIDENT HAD FALL FROM COMMODE AND HAD HIT HER HEAD ON THE FLOOR. I WENT TO RESIDENT AND NOTED SHE WAS BLEEDING FROM FOREHEAD WITH A 1.5 TO 2 CM (CENTIMETER) LACERATION, RESIDENT WAS SITTING UP IN W/C (WHEELCHAIR) AT THAT TIME. CALL WAS PLACED TO (PHYSICIAN'S NAME) ANSWERING SERVICE TO INFORM OF RESIDENT'S NEED TO BE SEEN IN ER (emergency room ). DAUGHTER (NAME) NOTIFIED OF INCIDENT WITH REQUEST AS TO WHICH HOSPITAL SHE WANTED MOTHER SENT TO. (NAME OF HOSPITAL) (NAME OF AMBULANCE SERVICE) NOTIFIED TO WHEELED CART FOR TRANSPORT TO ER. ALL NEEDED PAPERWORK SENT WITH EMTs (EMERGENCY MEDICAL TECHNICIANS)." REVIEW OF AN INCIDENT REPORTED BY THE FACILITY ON 10/26/10 AT 10:00 A.M. INDICATED THE FOLLOWING: "NAME: (RESIDENT #B) DATE OF ALLEGED EVENT: 10/6/10 BRIEF DESCRIPTION OF INCIDENT: (RESIDENT #B) SUSTAINED FALL W/ (WITH) C3 (THIRD CERVICAL VERTEBRAE) FRACTURE. TYPE OF INJURY: C3 FRACTURE. IMMEDIATE ACTION TAKEN: RESIDENT TRIAGED - TAKEN TO HOSPITAL - CURRENTLY IN STABLE CONDITION. PREVENTIVE MEASURES TAKEN: RESIDENT SENT TO HOSPITAL." A "REPORT PATIENT ABUSE AND NEGLECT" DATED 10/6/10 WAS RECEIVED FROM THE ADMINISTRATOR ON 10/26/10, AND INCLUDED, BUT WAS NOT LIMITED TO, THE FOLLOWING: "(LPN #5) HELPED A CNA (#4) PUT (RESIDENT #B'S NAME) ON THE BEDSIDE COMMODE AND LEFT THE FACILITY WITHOUT INFORMING THE OTHER NURSE SHE WAS LEAVING AND TOOK THE KEYS TO THE MED (MEDICATION) CART. WHILE SHE WAS GONE, (RESIDENT #B'S NAME) fell OFF THE BEDSIDE COMMODE. HER ACTIONS PUT THE RESIDENTS AT RISK." THE FOLLOWING WRITTEN INTERVIEWS/STATEMENTS WERE RECEIVED FROM THE ADMINISTRATOR ON 10/27/10 AT 1:15 P.M.: DATE: 10/7/10 AT 7:50 A.M. "CALLED (CNA #4) FOR HER STATEMENT. WHO PUT (RESIDENT #B INITIALS) ON BEDSIDE COMMODE? (CNA #4 AND CNA #6). WAS SHE LEFT UNATTENDED: YES. IF SO, WHY WAS SHE LEFT UNATTENDED? (RESIDENT #B'S NAME) STATED, 'I NEED TO SIT AWHILE TO SEE IF I HAVE A BOWEL MOVEMENT.' SHE SAID SHE WASN'T READY TO GET OFF OF THE POT AND I HAD OTHER CALL LIGHTS TO ANSWER. ASKED (RESIDENT #B'S INITIALS) IF IT WAS OKAY THAT I LEAVE HER AND SHE SAID YES. WHEN DID CHARGE NURSE (LPN #5'S INITIALS) LEAVE THE FLOOR? 2 OR 3 MINUTES AFTER WE PUT HER ON THE BEDSIDE (COMMODE). DID (LPN #5'S NAME) LEAVE HER KEYS WITH YOU? NO. HOW LONG WAS (LPN #5'S INITIALS) GONE? 15 - 20 MIN (MINUTES). WHEN DID FALL HAPPEN? ALMOST IMMEDIATELY AFTER (LPN #5) LEFT." ON 10/27/10 AT 12:55 P.M. THE ADMINISTRATOR PRESENTED AN "EMPLOYEE MEMORANDUM" DATED 10/11/10. THE EMPLOYEE MEMORANDUM INDICATED LPN #5 WAS TERMINATED FROM EMPLOYMENT. 3.1-45(a)(2)