Every finding on record at Bridgewater Healthcare Center

Based on interview and record review, the facility failed to ensure a resident with a nasogastric tube was sent to the hospital for an evaluation in a timely manner as ordered by the physician for 1 of 3 residents reviewed for enteral feedings. (Resident B)Findings include: During an interview, on 6/10/26 at 12:52 p.m., Resident B's family member indicated Resident B was transferred to the emergency room, on 2/16/26, for a clogged nasogastric tube (a tube which passes through the nose and down through the nasopharynx and esophagus into the stomach). The length of time the nasogastric tube had been clogged was uncertain, but it may have become clogged as early as 2/13/26. The emergency room personnel were unable to unclog the nasogastric tube either and the facility removed the tube on 2/17/26. The clinical record for Resident B was reviewed on 6/10/26 at 10:45 a.m. The diagnoses included, but were not limited to, cirrhosis of the liver, ascites, acute kidney failure, anxiety, and chronic obstructive pulmonary disease.A nursing progress note, dated 2/14/26 at 5:57 a.m., indicated the resident's feeding pump was alarming. The resident had recently been turned and repositioned with the pump off to lower his head for incontinent care. When the feeding tube was reactivated, the feeding tube would not flush. The nurse was unable to administer the resident's medications or restart the feeding at that time. A nurse practitioner's note, dated 2/14/26 and e-signed at 5:03 p.m., indicated the call was for a clogged nasogastric tube. The resident depended on the nasogastric tube for his medications and feedings. He did not like the idea of going to the emergency room but after a discussion he was agreeable to go. The resident had temporal wasting (thinning or loss of the temporalis muscle and underlying fat at the temples) and cachexia (a metabolic condition linked to an underlying chronic illness) present. His nasogastric tube was still present in his nose. The nasogastric tube could not be replaced in the facility, so he needed to be sent to the emergency room for replacement. A nursing progress note, dated 2/14/26 at 3:08 p.m., indicated the nasogastric tube was not functioning.A nursing progress note, dated 2/14/26 at 6:11 p.m., indicated the resident's nasogastric tube was clogged and he was going out to the hospital for it to be replaced. A nursing progress note, dated 2/14/26 at 7:41 p.m., indicated the resident's nasogastric tube was clogged and he was going out to the hospital for it to be replaced. A nursing progress note, dated 2/14/26 at 9:18 p.m., indicated the resident's nasogastric tube was clogged and he was going out to the hospital for it to be replaced. A nursing progress note, dated 2/15/26 at 2:28 a.m., indicated the nurse had obtained in report the resident was waiting to be picked up to go to the emergency room for a clogged nasogastric tube. The on-call service indicated they were setting up the transportation. A call was made to the on-call service to check on the status of the transportation. The on-call service indicated the transportation was for the facility to arrange. Resident B's nasogastric tube continued to remain clogged. Since the transportation was not emergent, the nurse asked the on-call provider if transportation could be arranged the next morning and the provider indicated that was okay. A nursing progress note, dated 2/15/26 at 7:31 p.m., indicated Resident B's nasogastric tube was clogged with unsuccessful attempts to get it flushed. The nurse was told management was aware of the situation. The resident ate pureed foods by mouth and had no issues taking his medications by mouth.A nursing progress note, dated 2/16/26 at 6:16 a.m., indicated the resident's nasogastric tube was not patent. He was scheduled to have the tube replaced when transportation was arranged. A nurse practitioner's progress note, dated 2/16/26 at 10:00 a.m., indicated Resident B would be sent to the emergency room to get his nasogastric tube replaced. His spouse was aware the nasogastric tube was being replaced and indicated she would ask the hospital not to replace it as she wanted the nasogastric tube discontinued. A nursing progress note, dated 2/16/26 at 2:30 p.m., indicated the resident was transported to the hospital emergency room to have his nasogastric tube removed.A nursing progress note, dated 2/16/26 at 9:47 p.m., indicated the resident returned from the emergency room. His nasogastric tube was not unclogged, nor was it removed from his nose. A nurse practitioner's progress note, dated 2/17/26 at 1:00 a.m., indicated Resident B was seen in the hospital emergency room for an obstructed nasogastric feeding tube. The emergency room was unable to relieve the obstruction. He was sent back to the facility with directions to schedule an appointment with interventional radiology for replacement of the feeding tube. Resident B's wife requested the tube be removed and not replaced. She reported he had been eating more, and she felt he did not need the feeding tube anymore. The nursing staff reported Resident B had been eating all his meals. His weight remained steady. It was okay to remove the nasogastric feeding tube. A nursing progress note, dated 2/17/26 at 5:10 p.m., indicated the resident's nasogastric feeding tube was removed. Resident B was not sent to the emergency room to have his nasogastric tube assessed until 2/16/26, which was two (2) days after it had become clogged, and the nurse practitioner had indicated to send him to the emergency room.During an interview, on 6/10/26 at 10:59 a.m., the Director of Nursing indicated the nursing staff should have sent Resident B to the emergency room on 2/14/26, when the nurse practitioner had ordered him to go and have his clogged nasogastric feeding tube evaluated. A policy on following physicians' orders was not provided by the time of exit.This citation relates to Intake 3036639.410 IAC (Indiana Administrative Code) 3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure insulin was administered according to the physician's order or new orders were documented, daily weights were obtained according to the physician's order, and cardiac medications were held according to the physician's ordered parameters for 4 of 4 residents reviewed for quality of care. (Resident 21, 6, 13 and 117)Findings include: 1. During an interview, on 5/7/26 at 10:15 a.m., Resident 21 indicated her blood sugars readings were up and down. The clinical record for Resident 21 was reviewed on 5/11/26 at 10:58 a.m. The diagnoses included, but were not limited to, type 2 diabetes, peripheral vascular disease, and failure to thrive. A physician's order, dated 3/25/26, indicated to administer Humalog (a rapid acting insulin) according to the sliding scale and to contact the physician if the blood sugar results were over 400. The sliding scale coverage was written as follows: If the blood glucose reading was 151-200, administer 2 units If the blood glucose reading was 201-250, administer 4 units If the blood glucose reading was 251-300, administer 6 units If the blood glucose reading was 301-350, administer 8 units If the blood glucose reading was 351-400, administer 10 units A blood sugar reading, on 4/27/26 at 4:00 p.m., was documented as 470. The Medication Administration Record indicated 5 units of Humalog were administered. There were no notes on the Medication Administration Record, assessment tab, or in the progress notes to indicate the nurse had contacted the physician or received new orders for the insulin administration. During an interview, on 5/11/26 at 2:30 p.m., the Director of Nursing indicated the physician was notified and gave an order to administer an additional five (5) units of insulin. The nurse should have documented, in the progress note, she had contacted the physician and received an order to give five (5) additional units of insulin. 2. The clinical record for Resident 6 was reviewed on 5/13/26 at 8:56 a.m. The diagnoses included, but were not limited to, heart failure, hypertension, and chronic kidney disease (a condition in which the kidneys gradually lose function). A care plan, dated 8/2/22 and last revised on 12/11/23, indicated the resident had hypertension disease and to obtain and monitor labs/diagnostic studies as ordered and to report abnormal findings to the medical provider and resident's representative. A physician's order, dated 2/2/26, indicated to obtain a weight every day on the dayshift. The Medication Administration Record (MAR), Treatment Administration Record (TAR), vital sign documentation, physician notes, assessments, and nutrition at risk (NAR) notes were reviewed and indicated: On 2/7, 2/8, 2/9, 2/12, 2/13, 2/14, 2/19, 2/21, 2/22, and 2/28, the weights were marked NA. There was no corresponding weights, physician notification, or documentation explaining the missing weights. On 3/1, 3/7, 3/8, 3/13, 3/14, 3/16, 3/18, 3/19, and 3/26, there was no documentation found to indicate the weights were obtained and no physician notification related to the missed weights. On 4/27 and 4/29, the entries were blank. On 4/28, the entry was marked with an X and no explanation was noted. During an interview, on 5/13/26 at 9:26 a.m., the Director of Nursing (DON) indicated she did not know why the staff were charting NA and X for the weights in the MAR/TAR. Staff were supposed to obtain and chart the weights daily. 3. The clinical record for Resident 13 was reviewed on 5/11/26 at 11:00 a.m. The diagnoses included, but were not limited to, hypertension, anxiety disorder, and severe protein-calorie malnutrition. a. A physician's order, dated 1/8/26, indicated to obtain daily weights. The Medication Administration Record (MAR), Treatment Administration Record (TAR), vital sign documentation, physician notes, assessments, and nutrition at risk (NAR) notes were reviewed and indicated: On 4/2, 4/9, 4/10, 4/12, 4/21, 4/22, 4/24 and 4/30, the weights were marked NA. There was no corresponding weights, physician notification, or documentation explaining the missing weights. On 4/13, in the vital tab, the weight documented was crossed out and documented as a re-weight. The re-weight was not obtained until 4/14. On 5/2, 5/6 and 5/9, the weights were marked NA. There was no corresponding weights, physician notification, or documentation explaining the missing weights. During an interview, on 5/12/26 at 10:53 a.m., LPN 5 indicated the weights were marked NA to keep the MAR open for more opportunities to attempt to obtain the weight. During an interview, on 5/12/26 at 11:13 a.m., LPN 6 indicated when documenting on the MAR, NA meant not applicable and an X meant the task was not completed. b. A care plan, dated 10/6/20, indicated Resident 13 had the potential for unstable blood pressures due to hypertension and to administer an anti-hypertensive medication as ordered. A physician's order, dated 1/17/26, indicated to administer amlodipine (a medication used to treat high blood pressure) with instructions to hold the medication if the systolic blood pressure was less than 110. A physician's order, dated 1/7/26, indicated to administer hydralazine (a medication used to treat high blood pressure), three (3) times a day with instructions to hold the medication if the systolic blood pressure was less than 110. A physician's order, dated 1/7/26, indicated to administer losartan potassium (a medication used to treat high blood pressure) with instructions to hold the medication if the systolic blood pressure was less than 110. The MAR, dated 4/1/26 to 4/30/26, indicated the following were administered on the following dates when Resident 13's systolic blood pressure was below the physician's ordered hold parameter: a. On 4/28/26, amlodipine, losartan potassium and 2 of the 3 doses of hydralazine. b. On 4/30/26, amlodipine and losartan potassium. During an interview, on 5/12/26 at 10:53 a.m., LPN 5 indicated when vital signs were outside of the physician's ordered hold parameters, the nurse would document the vitals on the MAR and indicate the medication was held. 4. The clinical record for Resident 117 was reviewed on 5/11/26 at 8:44 a.m. The diagnoses included, but were not limited to, hypertension and systolic and diastolic congestive heart failure. A care plan, dated 6/13/25, indicated Resident 117 had altered cardiovascular status and to administer medications according to the physician's orders. A progress note, dated 3/31/26, indicated Resident 117 was sent to the emergency department, on 3/26/26, with severe hypotension (low blood pressure). The hospital records indicated the resident was taken off all hypertension medications during the hospital stay and was on midodrine (a medication used to treat low blood pressure) which helped elevate his blood pressure. A physician's order, dated 3/29/26, indicated to administer two (2) tablets of midodrine 5 milligrams every 6 hours for hypotension until 4/12/26 and with instructions to hold the medication if the systolic blood pressure was greater than 110. The MAR, dated 4/1/26 to 4/12/26, indicated the medication was administered on the following dates when Resident 117's systolic blood pressure outside the physician's ordered hold parameter: a. On 4/2/25, 1 of 4 doses. b. On 4/4/26, 1 of 4 doses. c. On 4/5/26, 2 of 4 doses. d. On 4/6/26, 3 of 4 doses. e. On 4/8/26, 1 of 4 doses. f. On 4/9/26, 2 of 4 doses. g. On 4/11/26, 1 of 4 doses. h. On 4/12/26, 2 of 4 doses. A current facility policy, titled Resident Height and Weight, undated and received from the DON on 5/12/26 at 2:54 p.m., indicated .It is the policy of this facility that a resident's height and weight will be accurately obtained.Document weight in EHR.residents will be weighed monthly thereafter, unless physician or diagnosis indicates otherwise. A current facility policy, titled Medication Administration, undated and received from the DON on 5/12/26 at 2:54 p.m., indicated .Administer medication only as prescribed by the provider.Observe the five rights in giving each medication .the right dose .Medications that are refused or withheld or not given will be documented.Record pertinent information prior to giving medication if appropriate.Documentation of medications will follow accepted standards of nursing practice. 410 IAC (Indiana Administrative Code) 410 IAC 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure a comprehensive care plan for a cardiac pacemaker was implemented for 1 of 1 resident reviewed for comprehensive care planning. (Resident 100)Findings include:The clinical record for Resident 100 was reviewed on 5/11/26 at 2:36 p.m. The diagnoses included, but were not limited to, presence of a cardiac pacemaker, congestive heart failure, and atherosclerotic heart disease.A progress note, dated 1/16/26, indicated Resident 100 was admitted to the facility. A skin assessment was completed and no skin issues other than a pacemaker were noted.An admission evaluation, dated 1/16/26, indicated Resident 100 utilized a cardiac pacemaker device.A physician's note, dated 1/19/26, indicated Resident 100's medical history included, but were not limited to, heart failure with reduced ejection fraction and pacemaker dependence.Resident 100's care plans did not include her pacemaker.During an interview, on 5/12/26 at 11:55 a.m., the MDS Coordinator indicated the pacemaker was not included and should have been. She indicated there was not an item place for pacemakers in the MDS assessment but a diagnosis code or documentation of a pacemaker in the nursing assessment should trigger the care plan.During an interview, on 5/12/26 at 12:08 p.m., Unit Manager 5 indicated items could be added into a resident's care plan by nursing, social service, and the MDS Coordinator.A current facility policy, titled Plan of Care Overview, undated and received from the Director of Nursing (DON) on 5/12/26 at 2:54 p.m., indicated .for the purpose of this policy the Plan of Care, also Care Plan is written treatment provided for a resident that is resident-focused and provides for optimal personalized care.It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents.410 IAC (Indiana Administrative Code) 3.1-35(a)410 IAC (Indiana Administrative Code) 3.1-35(b)(1)410 IAC (Indiana Administrative Code) 3.1-35(d)(1)

Based on observation, interview and record review, the facility failed to ensure physician's orders for oxygen administration were in place for 1 of 2 residents reviewed for respiratory care. (Resident 101)Findings include: During an observation, on 5/8/26 at 9:45 a.m., Resident 101 was observed to receive oxygen at 4.5 liters per minute via nasal cannula. The clinical record for Resident 101 was reviewed on 5/8/26 at 12:03 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes.A physician's order for the use of oxygen was not located at the time of the record reviewDuring an interview, on 5/12/26 at 8:14 a.m., the Director of Nursing indicated physician's orders for oxygen should have been in the record prior to the initiation of the oxygen.A current facility policy, titled Supplemental Oxygen Using Nasal Cannula, undated and received from the Director of Nursing on 5/13/26 at 8:20 a.m., indicated .Supplemental oxygen may be administered to residents via various routes including through the use of a nasal cannula at the order of a physician or provider 410 IAC (Indiana Administrative Code) 410 IAC 16.2-3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure Personal Protective Equipment (PPE) was worn in an Enhanced Barrier Precaution (EBP) room while providing care and wound care was completed according to the standard of practice for 2 of 2 residents randomly observed for infection control. (Resident 80 and 77) Findings include: 1. During an observation, on 6/11/25 at 9:42 a.m., CNA 2 completed catheter care for Resident 80. CNA 2 performed catheter care from start to finish without putting on a gown and Resident 80 was in EBP. An EBP sign was posted on Resident 80's door which indicated Personal Protective Equipment (PPE), which included gowns for close contact care, was required. The clinical record for Resident 80 was reviewed on 6/13/25 at 2:58 p.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy, retention of urine, and type 2 diabetes mellitus with diabetic chronic kidney disease. A physician's order, dated 4/30/25, indicated Enhanced Barrier Precautions was required for Resident 80 for personal hygiene and when providing personal hygiene. A care plan, dated 5/19/25, indicated Resident 80 had an indwelling Foley catheter and interventions for EBP while providing peri-care and while providing care to urinary catheter. During an interview, on 6/11/25 at 9:42 a.m., CNA 2 indicated that gowns needed to be worn if the resident was on EBP. During an interview, on 6/13/25 at 2:12 p.m., the Infection Preventionist (IP) indicated CNA 2 missed putting on a gown for catheter care. 2. During a continuous wound care observation, on 6/11/25 at 10:21 a.m., Wound Nurse 7 provided wound care to Resident 77. She took the bandage off a sacral wound and began to clean it with one (1) piece of gauze. She cleaned the wound from the inside of the wound bed to the outside. Then with the same piece of gauze, she cleaned the wound back towards the inside of the wound, then towards the outside again, and then briefly cleaned the inside of the wound bed again all with the same piece of gauze. Wound Nurse 7 broke clean to dirty technique by using the same piece of gauze and cleaning the outside of the wound bed to the inside of the wound bed multiple times. During an interview, on 6/11/25 at 10:50 a.m., Wound Nurse 7 indicated it was not typical to clean from the outside of the wound bed back to the inside of the wound bed using the same piece of gauze. She should have gotten a new piece of gauze to continue to clean the wound. During an interview, on 6/12/25 at 10:30 a.m., Clinical Support Nurse 4 indicated staff should not go back and forth from clean to dirty areas with the same piece of gauze. During an interview, on 6/16/25 at 11:00 a.m., Clinical Support Nurse 4 indicated they did not have a policy for clean to dirty technique. A current facility policy, titled Catheter Care, received from the Director of Nursing (DON) on 6/12/25 at 12:08 p.m., indicated .Catheter care .check physician orders .Observe Standard Precautions .Doff and discard .if worn .other personal protective equipment A current facility policy, titled Enhanced Barrier Precautions, received from the Director of Nursing (DON) on 6/12/25 at 10:33 a.m., indicated .Enhanced Barrier Precautions [(EBP)] refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include .providing hygiene .Device care .urinary catheter .EBP are indicated for residents with any of the following .Indwelling medical devices [(even if the resident is not known to be infected)] .Indwelling medical device examples include .urinary catheters .It is not necessary for staff to don PPE prior to entering the resident room but will don PPE when providing high contact care activities as described above A current facility policy, titled Skin Care & Wound Management Overview, undated and received from Clinical Support 4 on 6/12/25 at 10:30 a.m., indicated .Skin care and wound management program includes, but is not limited to .Application of treatment protocols based on clinical best practice standards for promoting wound healing The undated National Library of Medicine techniques for aseptic dressing and procedures, retrieved on 6/18/25 at 10:48 a.m., at https://pmc.ncbi.nlm.nih.gov/articles/PMC4579997/ indicated, .Start from the dirty area and then move out to the clean area .Make sure you do not re-introduce dirt or ooze by ensuring that cleaning materials (i.e. gauze, cotton balls) are not over-used. Change them regularly (use once only if possible) and never re-introduce them to a clean area once they have been contaminated 3.1-18(b)(2) 3.1-18(j)

Based on observation, interview and record review, the facility failed to ensure food items stored in the unit kitchen refrigerators were dated for 2 of 4 kitchenettes reviewed for food storage. (3000 and 4000 units) Findings include: 1. During an observation, on 6/9/25 at 9:56 a.m., the 3000-unit kitchenette refrigerator had a white Styrofoam container for Resident 17 and a white Styrofoam container for Resident 20. Neither container had a date to show when the items were placed for storage. During an interview, on 6/9/25 at 10:01 a.m., Infection Preventionist 8 indicated the items should have been dated. 2. During an observation, on 6/9/25 at 11:55 a.m., the 4000-unit kitchenette refrigerator had a clear container with a red lid stored in the refrigerator without a name or date. There was a bag of yogurt and a container of fruit stored in the refrigerator without a name or date. There was also a container of spread for Resident 19 without a date. During an interview, on 6/9/25 at 12:00 p.m., RN 9 indicated the items should have been dated and if the items belonged to staff members, then they should have been stored in the employee break room. A current facility policy, titled Storage of Resident Food, undated and received from the Executive Director on 6/9/25 at 12:27 p.m., indicated .Staff will date the container when food or beverages are brought into the facility 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure medications were stored in their original containers, were labeled with an open date, and outdated medications were discarded in 2 of 4 medication carts (3000 and 4000 units) and in 1 of 2 medication refrigerators (4000 unit) reviewed for medication storage. (4000 Unit) Findings include: 1. During an observation, on 6/9/25 at 10:29 a.m., with Infection Preventionist 8, the 3000-unit medication cart 2 was found to have the following items opened and not dated: a. one bottle of latanoprost eye drops was open and was not dated. b. one vial of Lantus insulin was open and was not dated. c. one Lantus insulin pen was open and was not dated. 2. During an observation, on 6/9/25 at 11:13 a.m., with RN 9, the 4000-unit medication cart 1 was found to have the following items opened and not dated: a. one full Lantus insulin pen was open and was not dated. b. one vial of Humalog insulin was open and was not dated. c. one half full Lantus insulin pen was open and was not dated. d. one lispro insulin pen was open and was not dated. During an interview, on 6/9/25 at 11:20 a.m., RN 9 indicated insulin needed to have an open date because it could only be kept for 30 days once it was opened. 3. During an observation, on 6/9/25 at 11:04 a.m., the 4000-unit medication storage refrigerator had a Lantus insulin opened with an expiration date of 5/24/25. During an interview, on 6/9/25 at 11:07 a.m., RN 9 indicated the medication was not to be used after 5/24/25. A current facility policy, titled Storage of Medications, undated and received from the Director of Nursing on 6/9/25 at 1:03 p.m., indicated .All medications dispensed by the pharmacy are stored in the pharmacy container with the pharmacy label .Outdated .are immediately removed from inventory, disposed of according to procedures for medication disposal 3.1-25(j) 3.1-25(k)(6) 3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure staff followed the facility policy and procedure for reconciliation of controlled medications for 2 of 3 narcotic reconciliation logs reviewed for medication storage. (3000 and 4000 units) Findings include: 1. During an observation, on 6/9/25 at 10:29 a.m., with Infection Preventionist 8, the SHIFT CHANGE/CONTROLLED SUBSTANCE INVENTORY TRACKER document for the 3000-unit medication cart 1 was missing signatures to show the narcotics had been reconciled and accounted for on the following shifts: June 1, 2025, was missing a signature for the off-going nurse on the day shift. There was a missing signature for the on-coming nurse for the day shift. There was no date filled in on the form. There was a missing signature for the off-going nurse for the day shift. There was no date filled in on the form. There was a missing signature for the on-coming nurse for the day shift. There was no date filled in on the form. There was a missing signature for the off-going nurse for the day shift. There was no date filled in on the form. There was a missing signature for the on-coming nurse for the night shift. There was no date filled in on the form. There was a missing signature for the off-going nurse for the night shift. There was no date filled in on the form. During an interview, on 6/9/25 at 10:29 a.m., Infection Preventionist 8 indicated the narcotic inventory tracker was to be signed every shift. 2. During an observation, on 6/2/25 at 11:04 a.m., with RN 9, the SHIFT CHANGE/CONTROLLED SUBSTANCE INVENTORY TRACKER document for the 4000-unit medication cart 1 was missing signatures to show the narcotics had been reconciled and accounted for, on 6/5/25, for the off-going nurse for the evening shift. During an interview, on 6/9/25 at 11:21 a.m., RN 9 indicated staff were to sign the narcotic count sheets every shift. A current facility policy, titled Medication Controlled Drugs and Security, undated and received from the Director of Nursing on 6/9/25 at 1:03 p.m., indicated .Controlled drugs as well as the controlled drug count sheets and cards, are counted every shift change by the nurse reporting on duty with nurse reporting off duty .The inventory of the controlled drugs count sheets and number of cards must be recorded on the narcotic records and signed for correctness of count 3.1-25(e)(3)

Based on interview and record review, the facility failed to ensure blood pressure medications were administered according to the physician's orders for 2 of 4 residents reviewed for quality of care. (Resident 20 and 27) Findings include: 1. The clinical record for Resident 20 was reviewed on 6/11/25 at 2:35 p.m. The diagnoses included, but were not limited to, essential primary hypertension, chronic obstructive pulmonary disease, and pulmonary fibrosis. A current care plan, dated 10/6/20, indicated the resident had the potential for unstable blood pressures. A physician's order, dated 4/2/25, indicated to give Lasix (a diuretic which could lower blood pressure) 20 mg (milligrams) once day with special instructions to hold the medication for a systolic blood pressure of less than 100. A Medication Administration Record (MAR), dated April 2025, indicated Lasix was given with no systolic blood pressure recorded on 4/7/25, 4/8/25, 4/9/25, 4/11/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/21/25, 4/22/25, 4/23/25, 4/24/25, 4/25/25, 4/26/25, 4/27/25, 4/28/25, 4/29/25, and 4/30/25. A MAR, dated May 2025, indicated Lasix was given with no systolic blood pressure recorded on the MAR or in the vitals section of the electronic medical record on 5/1/25, 5/2/25, 5/3/25, 5/4/25, 5/5/25, 5/6/25, 5/7/25, 5/8/25, 5/9/25, 5/13/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/20/25, 5/21/25, and 5/22/25. On 5/26/25, Lasix was given with a systolic blood pressure of 97. During an interview, on 6/13/25 at 10:48 a.m., Unit Manager 6 indicated the nurse should have taken the resident's blood pressure when giving a medication which had a hold parameter, held the medication if needed, and made a nurse's note. If the nurse obtained a blood pressure reading, it would have been recorded in the medical record. 2. The clinical record for Resident 27 was reviewed on 6/11/25 at 9:26 a.m. The diagnoses included, but were not limited to, essential primary hypertension, acute on chronic diastolic congestive heart failure, acute respiratory failure with hypoxia, paroxysmal atrial fibrillation, and acute pulmonary edema. A current care plan, dated 1/13/22, indicated the resident had hypertension with an intervention to administer medications per the physician's orders. A physician's order, dated 6/7/24, indicated to give hydralazine 50 mg every 12 hours as needed for a systolic blood pressure greater than 160. A MAR indicated Resident 27's systolic blood pressure was greater than 160 and the hydralazine medication was not administered on the following dates: a. On 3/24/25, with a systolic blood pressure of 166. b. On 5/18/25, with a systolic blood pressure of 165. c. On 6/2/25, with a systolic blood pressure of 171. d. On 6/5/25, with a systolic blood pressure of 163. e. On 6/9/25, with a systolic blood pressure of 165 at 9:03 a.m. and 1:22 p.m. f. On 6/11/25, with a systolic blood pressure of 172 at 11:48 a.m. and 11:57 a.m. During an interview, on 6/13/25 at 10:48 a.m., Unit Manager 6 indicated if the resident had an as needed medication for high blood pressure, the nurse would give the medication according to the order and document it. During an interview, on 6/16/25 at 11:29 a.m., the Director of Nursing indicated the as needed hydralazine should have been administered based on the physician's order. A current facility policy, titled Medication Administration, received from the Infection Preventionist on 6/13/25 at 3:45 p.m., indicated .Administer medication only as prescribed by the provider .Record pertinent information prior to giving medication if appropriate .Blood pressure recorded 3.1-37(a)

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed, revised, and developed by the interdisciplinary team for 2 of 3 residents reviewed for comprehensive care plans. (Resident 27 and 19) Findings include: 1. The clinical record for Resident 27 was reviewed on 6/11/25 at 9:26 a.m. The diagnoses included, but were not limited to, anxiety disorder and moderate recurrent depressive disorder. The major depressive disorder diagnosis was modified on 4/4/25. A therapist progress note, dated 4/8/25, indicated the resident had a problem of moderate recurrent major depressive episodes with a diagnosis of moderate recurrent major depressive disorder. A physician's order, dated 4/22/25, indicated to give duloxetine (an antidepressant medication) 20 mg (milligrams) at bedtime. An annual MDS (Minimum Data Set) assessment, dated 5/2/25, indicated the resident had a diagnosis of depression and was taking an antidepressant medication. A current care plan, dated as reviewed and revised on 5/27/25, did not indicate the resident was taking an antidepressant or had a diagnosis of depression. It did not include any interventions to monitor for effectiveness or side effects of the addition of an antidepressant medication or for caring for the resident experiencing current depression. During an interview, on 6/16/25 at 11:29 a.m., the Clinical Support Nurse indicated the diagnosis and antidepressant medication should have been added to the care plan. 2. During an interview, on 6/9/25 at 10:38 a.m., Resident 19 indicated she had a history of sexual abuse, and she attended virtual therapist appointments every Friday for Post Traumatic Stress Disorder (PTSD). She had attended the visits for several years prior to being admitted into the facility. The clinical record for Resident 19 was reviewed on 6/12/25 at 9:43 a.m. The diagnoses included, but were not limited to, bipolar II disorder, PTSD, and depression. A physician's order for the psychiatric services was not located in the electronic health record. A physician's order, dated 5/20/25, indicated Resident 19 was taking Lamictal (a mood stabilizer) 25 milligrams twice a day for bipolar disorder. A MDS assessment, dated 5/29/25, indicated Resident 19 was admitted into the facility with diagnoses of bipolar disorder and PTSD. The comprehensive care plans, dated 6/12/25, did not include PTSD or bipolar disorder. A trauma informed care assessment had not been completed upon admission into the facility. During an interview, on 6/13/25 at 3:06 p.m., the Director of Nursing (DON) indicated PTSD, and bipolar disorder was not included in Resident 19's comprehensive care plan and should have been. Resident 19 should have had a trauma/PTSD assessment initiated. During an interview, on 6/16/25 at 10:19 a.m., the Social Service Director indicated a resident with a diagnosis of PTSD should have had a PTSD assessment initiated. During an interview, on 6/16/25 at 11:14 a.m., the Clinical Support Nurse indicated the facility did not have a policy regarding comprehensive care plans. A current facility policy, titled Plan of Care Overview, received from the Executive Director (ED) on 6/16/25 at 10:59 a.m., indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents .Review care plans quarterly and/or with significant changes in care A current facility policy, titled Trauma Informed Care, received from the ED on 6/16/25 at 10:59 a.m., indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, emotional needs and concerns of the residents. The purpose of this policy is to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice .Each resident will be screened for a history of trauma upon admission. If the screening indicates that the patient has a history of trauma and/or trauma-related symptoms, the baseline care plan will identify the trauma and the baseline interventions implemented upon admission .Additional screening/evaluation is completed by the facility social worker or designee when completing the social history assessment and prior to developing the comprehensive care plan .A physician order will be obtained for the patient to be evaluated by a mental health professional .The services provided or arranged by the center, as outlined by the comprehensive care plan, must be provided by qualified person in accordance with each residents written plan of care and .be culturally-competent and trauma-informed 3.1-35(a) 3.1-35(b)(1) 3.1-35(d)(1) 3.1-35(d)(2)(A) 3.1-35(d)(2)(B) 3.1-35(e)

Based on observation, interview and record review, the facility failed to identify and treat a resident's behavior symptom of hoarding for 1 of 1 resident reviewed for behavioral health. (Resident 70) Finding includes: During an observation, on 7/16/24 at 12:57 p.m., Resident 70 was sitting on the bed in her room. There was a clear plastic container of strawberries and some other round fruit on the resident's bed. The fruit had a large amount of varying colors from light to dark fuzzy mold growing on the fruit. There were piles of items stacked all over the room and on top of plastic tubs. The resident was very irritable. The clinical record for Resident 70 was reviewed on 7/18/24 at 10:23 a.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, acute pulmonary edema, and atrial fibrillation. A care plan, dated 1/10/23, indicated the resident had mood problems related to a disease process and the loss of independence. The interventions included, but were not limited to, administer medications as ordered, behavioral health consults as needed, communicate with the resident/resident representative regarding mood state, encourage the resident to express feelings, and encourage the resident to participate in activities of choice. A care plan, dated 1/31/23 and last revised on 1/21/24, indicated the resident was at risk for impaired psychosocial well-being related to a history of trauma and/or trauma related symptoms. The resident had past trauma from childhood regarding showers and preferred baths and washing up at the sink. The interventions included, but were not limited to, approaching the provision of care and services with dignity and respect and encouraging the resident to make informed decisions regarding care. The care plans did not include the resident's hoarding of food or collecting items in her room. A Nurse Practitioner (NP) psychiatric note, dated 4/4/24, indicated the resident was angry and argumentative. The resident refused to answer most questions and was not agreeable to any medication changes. The note did not include the resident had a tendency to hoard items including food. A physician's order, dated 6/20/24, indicated to monitor every shift for the behaviors of crying spells, self-isolation, change in appetite, restlessness, and aggression. The behaviors did not include the hoarding of items including potentially hazardous food. During an interview, on 7/17/24 at 11:50 a.m., LPN 3 indicated the clear container which had the molded fruit was on the stack of magazines in the resident's room and no longer contained fruit. LPN 3 indicated the resident had trauma as a child and was paranoid. The resident did not eat the spoiled fruit. The staff would wait until the resident was out of her room for a shower and then they would clean the room and get rid of trash. During an interview, on 7/18/24 at 11:11 a.m., the Social Services Designee (SSD) indicated the resident had quite a few quirks. The resident had quite a few things in her room and had a tendency to hoard things. She did not have much while growing up and was very protective of her food and would collect things. The staff would have to bring the resident's attention to the spoiled food, and she had wanted the staff to trim the mold off the strawberries. It was difficult to get things away from her and to get her to understand the health risks. The SSD indicated she did not see anything in the resident's care plan about her hoarding food. During an observation and interview, on 7/18/24 at 11:27 a.m., QMA 5 walked out of Resident 70's room with two clear trash bags full of Styrofoam containers and cups along with other trash. QMA 5 indicated the resident liked to hoard things and would fuss when the staff tried to remove items from the room. QMA 5 told the resident she would get her some fresh milk. During an interview, on 7/18/24 at 11:46 a.m., the Administrator indicated the resident had some anxiety and liked to keep a lot of personal belongings in her room. The resident had a history of wanting to hang onto to things. During an interview, on 7/18/24 at 4:24 p.m., the Clinical Support Nurse indicated she was not aware the resident hoarded food and other items in her room until the surveyor started asking questions. A current policy, titled Behavior Management General, not dated and received from the Director of Nursing on 7/18/24 at 1:50 p.m., indicated .It is the policy of this facility to identify and safely manage residents who are exhibiting behaviors related to psychiatric diagnoses or who may present a danger to themselves or others .Residents will be provided with a resident centered behavior management plan to safely manage the resident and others .Assess for problematic/dangerous behaviors .Safety of the resident and others is a high priority .Document the assessment of behavior in electronic health records .Contact the physician for new onset of unusual behaviors .Assess needs and treat appropriately .Complete a Care Plan .Include resident specific interventions .Discuss plan with resident and family 3.1-37(a) 3.1-43(a)(1)

Based on interview and record review, the facility failed to ensure the physician was notified when a resident had a weight change in a timely manner for 1 of 4 residents reviewed for nutrition. (Resident 3) Finding includes: The clinical record for Resident 3 was reviewed on 7/18/24 at 11:28 a.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and hypertension. A physician's order, with a start date of 6/27/24, indicated to weigh the resident daily. A daily weight paper log indicated the following weights: On 6/25/24, the resident's weight was 149 pounds. On 6/26/24, the resident's weight was 143.6 pounds. On 6/27/24, the resident's weight was 142.4 pounds. On 6/28/24, the resident's weight was 142.9 pounds. On 6/29/24, the resident's weight was143 pounds. On 6/30/24, the resident's weight was 143.7 pounds. A vitals tab in the electronic health record (EHR) indicated the following weights: On 7/1/24, the resident's weight was 141.9 pounds. On 7/2/24, the resident's weight was 141 pounds. The resident's weight went from 149 pounds to 141 pounds in 7 days (a greater than 5% weight loss). During an interview, on 7/19/24 at 3:37 p.m., the Clinical Support Nurse indicated there were no notes in the medical record about the weight loss until later. An encounter note, dated 7/19/24, indicated the physician saw the resident today about a significant weight change and CHF. There were no notes in the electronic health record until 17 days later after the weight change occurred. A current policy, titled Resident Height and Weight, undated and received from the Clinical Support Nurse on 7/19/24 at 11:15 a.m., indicated .Weight loss concerns are reported to the practitioner and discussed at the weekly clinical meetings 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure there was a system in place for communication with a resident who did not speak English as the primary language for 1 of 1 resident reviewed for communication. (Resident 91) Finding includes: During an observation, on 7/17/24 at 11:35 a.m., Resident 91 was lying in bed with her eyes open. Other residents were playing bingo in the common area. The record for Resident 91 was reviewed on 7/17/24 at 4:39 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, generalized muscle weakness, need for assistance with personal care, and a cognitive communication deficit. A care plan, dated 6/2/24, indicated the resident had a potential for isolation due to being new to the facility and the desire to sleep most of the time. The resident would benefit from social interaction and cognitive stimulation. The interventions included, but were not limited to, providing an activity calendar to view and select activities of interest, provide friendly visits to encourage attendance, and to provide verbal and tactile cues as needed. The care plan did not include interventions for the resident's primary language of Korean. A care plan, dated 6/13/24 and last revised on 7/10/24, indicated the resident was at risk for impaired psychosocial well-being related to personal health practices, cultural needs and preferences and/or linguistic needs/preferences. The interventions included, but were not limited to, approach the provision of care and services for those residents with cultural differences with dignity and respect, promote effective communication between staff and resident, and honor specific preferences. The care plan did not include what the cultural preferences or linguistic needs were for the resident. A care plan, dated 6/13/24 and last revised on 7/17/24, indicated the resident had a communication problem related to speaking primarily Korean. The interventions included, but were not limited to, allow the resident time to answer questions and to verbalize feelings, communicate with the resident and/or representative regarding the resident's capabilities and needs, provide the following tools to aide in communication in the resident's primary language including an interpreter, communication board, and utilize the language line for the interpreter needs. During an interview, on 7/17/24 at 4:39 p.m., LPN 3 indicated the resident would motion with her hands for gestures and the staff could figure out what she wanted by the hand gestures. The resident would speak a few words of English at a time. Everything in the resident's room was written in English and LPN 3 was not sure if the resident could read English. The resident did not have a dementia diagnosis and she did not know what the resident's diagnosis of cognitive communication deficit was related to. During an observation, on 7/18/24 at 10:59 a.m., with CNA 2, the resident was lying in bed in her room. There was a Styrofoam cup, not dated, with some type of supplement drink in the cup. CNA 2 opened the lid to the cup and indicated the supplement appeared like it had been there for a while and she would get a new cup. The resident was pointing and appeared upset that the cup was being removed from the room. The resident smiled when a new Styrofoam cup was brought into her room. The wipe off board in the room had items written in English. During an observation, on 7/18/24 at 11:20 a.m., with the Social Services Designee (SSD), the resident was asked if she could read English. The SSD handed the resident the activity calendar posted on the wipe off board and asked if she could read it. The resident answered, my son and then stated, my eyes. The resident was not able to read the activity calendar. During an interview, on 7/18/24 at 11:52 a.m., the Administrator indicated he thought the resident's diagnosis of the cognitive communication deficit was due to the resident's language barrier. The resident did not have a diagnosis of dementia. Usually there would be some type of communication board with the resident's primary language available. The resident's primary language was Korean. During an interview, on 7/18/24 at 3:42 p.m., the Rehab Director indicated the speech therapist completed the resident's Brief Interview for Mental Status (BIMS) with the resident in English. The resident was able to follow commands in English. The resident's BIMS, dated 6/20/24, had a score of 2 which indicated the resident had a severe cognitive impairment. During an interview, on 7/18/24 at 3:47 p.m., the Clinical Support Nurse indicated they did not have the resident's BIMS score from the previous facility. The facility did not know if the resident's BIMS had declined, if the low BIMS score was due to the language barrier or possibly due to the resident having a urinary tract infection on admission. The notes from the previous facility indicated the resident's family translated for her and she had some mild confusion. During an interview, on 7/18/24 at 3:56 p.m., the Clinical Support Nurse indicated the facility did not have a policy on communication with resident's who had primary languages other than English. A current policy, titled Resident Rights, not dated and received from the Administrator upon entrance indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .The purpose of this policy is to guide the employees in the general principles of dignity and respect of caring for residents .Residents will be treated with dignity and respect including but not limited to .To have a method to communicate needs to staff .Residents have a Right to .Be treated with respect .Participate in activities .Be free from discrimination .Receive proper medical care including but not limited to .To participate in decisions that affects the resident's care 3.1-38(a)(2)(E)

Based on interview and record review, the facility failed to have a comprehensive care plan for a resident with congestive heart failure (CHF) for 1 of 4 residents reviewed for care planning. (Resident 3) Finding includes: The clinical record for Resident 3 was reviewed on 7/18/24 at 11:28 a.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and hypertension. An encounter note, dated 6/26/24, indicated the resident presented to the facility with a past medical history including hypertension, gastroesophageal reflux disease (GERD), irritable bowel disease (IBS), type 2 diabetes, chronic hyponatremia (low sodium levels), chronic anemia, and CHF. A physician's order, with a start date of 6/27/24, indicated to weigh the resident daily. A nutrition care plan, initiated on 7/2/24, indicated Resident 3 had a potential for altered nutrition related to mechanically altered diet, diet restrictions, and disease process. The goals included, but were not limited to, maintain weight without significant change. Interventions included, but were not limited to, obtaining weekly weights if unplanned weight loss was identified. The care plan did not include the resident's diagnosis of CHF or any interventions for CHF. During an interview, on 7/19/24 at 11:33 a.m., the Clinical Support Nurse indicated there was no care plan for CHF. A current policy, titled Plan of Care Overview, undated and received from the Director of Nursing on 7/18/24 at 4:15 p.m., indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and support the resident's goals choices, and preferences including, but not limited to, goals related to the their daily routines and goals to potentially return to a community setting 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to exercise reasonable care for the protection of a resident's cell phone holder from loss or theft for 1 of 1 resident reviewed for personal property. (Resident 16) Findings include: During an interview, on 7/16/24 at 3:36 p.m., Resident 16 indicated a phone holder which he had purchased and modified to fit onto his motorized wheelchair had been missing for a while. He indicated he had asked Head of Housekeeping 4 to check in the laundry for the missing phone holder and was told the phone holder was not found in the laundry. The clinical record for Resident 16 was reviewed on 7/17/24 at 4:06 p.m. The diagnoses included, but were not limited to, generalized pain, major depressive disorder, dwarfism, and anxiety disorder. A social service note, dated 5/20/24, indicated the resident spoke with Talk Therapist 7 about modifying a phone holder for his wheelchair. A social service note, dated 6/28/24, from Talk Therapist 7, indicated Resident 16 was feeling disgruntled that the phone holder he purchased and modified was missing. He reported he had discussed it with Head of Housekeeping 4, who advised she would look for the missing phone holder. The facility was unable to able to provide a grievance form (a form which provides written documentation of a concern over something believed to be wrong or unfair) for the missing phone holder. During an interview, on 7/18/24 at 10:54 a.m., the resident indicated he would like someone to look for the missing phone holder inside of a box on top of a cabinet in his room. He was unable to check inside the box because the box was out of reach for him. He had not yet asked anyone to look inside the box. During an interview, on 7/18/24 at 11:09 a.m., Central Supply 2 indicated the missing phone holder was not found inside the box. During an interview, on 7/18/24 at 11:34 a.m., LPN 3 indicated she was not aware of the missing phone holder. She filled out a grievance form for the missing phone holder. During an interview, on 7/19/24 at 2:00 p.m., Head of Housekeeping 4 indicated if a resident had an item go missing, protocol would be followed. Head of Housekeeping 4 recalled the discussion with Resident 16 about his missing phone holder and indicated she looked for the missing item in the laundry. The missing phone holder was not located in the laundry. She indicated she was still looking for the item. During an interview, on 7/22/24 at 8:56 a.m., the Executive Director (ED) indicated he spoke with Housekeeping Supervisor 4 about the missing phone holder. Housekeeping 4 did not file a grievance at the time the phone holder was reported missing. A policy, titled Abuse & Neglect & Misappropriation of Property, undated and received by the ED on 7/22/24 at 5:34 p.m., indicated .Instructions for Reporting .If a resident states that his or her belongings are missing, the facility must determine whether the item ever existed in the facility and/or do a quick search. i. As soon as it is determined that the item did exist within the facility but was not found during the initial search, the facility must make a report of misappropriation of resident property . 3.1-9(b) 3.1-9(c)

Based on observation, interview and record review, the facility staff failed to answer a call light for 1 of 1 call light observed flashing on unit 3000. (room [ROOM NUMBER]) Finding includes: During a random observation, on 12/18/23 at 9:59 a.m., the call light for room [ROOM NUMBER] was observed flashing white. The room was located close to the nursing station. QMA 5 was observed to straighten items at nursing station, then go to the end of the hall. A nurse was also visible in the hall passing medications. CNA 1 was then observed to come through the 3000 unit at 10:03 a.m., pass the nursing station, turn right, and move to the end of the hall. CNA 1 was then observed standing at the end of the hall with her back against the wall on her cell phone. The QMA was passing medication to the last room on the left. During an interview, on 12/18/23 at 10:06 a.m., when asked why she did not respond to the call light, CNA 1 indicated she was waiting for her nurse to help her transfer a resident. She had left the resident in the shower and went to get assistance to transfer the resident. On 12/18/23 at 10:07 a.m., a staff member entered the unit and went to answer the call light. None of the three (3) staff members currently working on the unit responded to the call light. During an interview, on 12/18/23 at 10:42 a.m., the Director of Nursing indicated her expectation was for staff to answer the call lights. If they had a phone call they needed to take, staff were to inform the nurse and excuse themselves from the unit, however that was secondary to patient care. A facility in-service, dated 10/16, 10/18, 10/20 and 10/21/23, indicated .Cellphones/Air pods .Cellphones and air pods are not allowed to be in use while the employee is working on the floor CNA 1 was signed-in for the in-service on 10/21/23. A facility policy, titled Resident Rights, undated and received from the Director of Nursing on 12/18/23 at 1:28 p.m., indicated .Staff will answer call needs promptly This Federal Tag relates to Complaint IN00421402. 3.1-3(t)

Based on observation, interview and record review, the facility failed to check/change a colostomy bag prior to the bag bursting, failed to follow facility protocol when changing and cleaning the resident, and failed to provide a clean brief for 1 of 1 resident reviewed colostomy care. (Resident C) Finding includes: During an interview, on 12/18/23 at 10:08 a.m., Resident C was resting in bed with the television on. Resident C allowed observation of her colostomy bag. The bag was observed to be intact, distended, and full of feces. There was a brown dried substance noted on the resident's skin at the lower end of the colostomy bag. Resident C indicated sometimes they (facility staff) changed the bag. The record for Resident C was reviewed on 12/18/23 at 10:36 a.m. Diagnoses included, but were not limited to, type 2 diabetes, anemia, and chronic obstructive pulmonary disease (COPD). A physician's order indicated to change the ostomy bag as needed. During an observation, on 12/19/23 at 4:28 a.m., LPN 4 was observed sitting at the nursing station with her cell phone in hand. She was swiping and reading. The nurse put her phone away and left the nursing station. She went to check Resident B who was being cared for by the CNA, then went to check Resident C. On 12/19/23 at 4:31 a.m., Resident C was observed resting in bed. LPN 4 donned gloves and went to the left of Resident C and pulled back the blankets/sheets. Resident C had feces on her gown at waist height and feces at the top of her brief. Also visible was a colostomy bag which had been partially covered with the brief. LPN 4 then indicated the colostomy bag had busted. Feces was observed on the resident's abdomen. LPN 4 then went to the nightstand, removed a new colostomy bag and hygiene wipes, placed them at the foot of the bed, removed her gloves and discarded them in the trash. She indicated she needed to go and get scissors. As she exited the room, she indicated she was going to perform hand hygiene outside the room. At 4:33 a.m., LPN 4 reentered the room, performed hand hygiene using alcohol-based hand sanitizer (ABHR), donned gloves, and cleaned the scissors with alcohol pads. She then cut a hole in the back of the colostomy bag where the wafer (portion which fits over the ostomy and secures the bag in place) was located. She approached the resident's left side, pulled back the brief and indicated, gosh it's really busted here. Feces was observed under the bag on the resident's skin and on the inside of the front of the brief. She removed and discarded the bag. Using the hygiene wipes she cleaned the feces from the skin; each time using one hand to pull the wipes and the other hand to hold the wipe's container down while pull the wipe out. She repeated the process four times. While LPN 4 was cleaning the feces from the resident's skin, Resident C asked what made the nurse come and look at the colostomy bag. The nurse indicated this gal wanted to visit you and see, good thing she came. The nurse discarded the soiled wipes into the trash, removed her gloves, went to the restroom, and performed hand hygiene with soap and water. LPN 4 donned new gloves and applied the self-adhesive wafer/bag to the area. The nurse then removed the soiled gown and place a new gown on the resident. LPN 4 indicated she would have the CNA come in and change the resident's soiled brief. LPN 4 removed one glove and discarded it, picked up the soiled gown and scissors, and put the wipes away in the nightstand drawer. During an interview, on 12/19/23 at 4:56 a.m., LPN 4 indicated she could change the brief, but she did not get her stuff done and she would have the CNA change the brief. A facility in-service, dated 10/16, 10/18, 10/20 and 10/21/23, indicated .Cellphones/Air pods .Cellphones and air pods are not allowed to be in use while the employee is working on the floor A facility policy, titled Routine Resident Care, undated and received from the Director of Nursing on 12/19/23 at 8:32 a.m., indicated .Licensed Staff will include the following services based upon their scope of practice, but not limited to .bowel and bladder management .Toileting, providing care in incontinence A facility policy, titled Colostomy Appliance Bag Change, undated and received from the Director of Nursing on 12/19/23 at 8:32 a.m., indicated .Observe Standard Precautions .Cleanse surrounding skin area and stoma with mild soap and water This Federal tag relates to Complaint IN00421402 and Complaint IN00421407. 3.1-47(a)(3)

Based on interview and record review, the facility failed to provide medications/treatments per the physician's order and failed to document in the Medication and Treatment Record the reason for the omission of the medications/treatments for 2 of 3 residents reviewed for medication administration. (Resident B and C) Findings include: 1. During an interview, on 12/18/23 at 9:27 a.m., Resident B indicated she did not receive her anticoagulant injection daily. During an interview, on 12/20/23 at 12:48 p.m., Resident B was observed in her bed doing an activity. She indicated she did not receive her anticoagulant injection yesterday. The record for Resident B was reviewed on 12/18/23 at 10:20 a.m., and again on 12/20/23 after the resident voiced concerns about her medication. Diagnoses included, but were not limited to, cutaneous abscess of the abdomen (a pocket of puss in the abdomen), type 2 diabetes, and obesity. The resident had a BIMS (Brief Interview for Mental Status) score of 14 on the quarterly assessment, dated 10/24/23, which indicated she was cognitively intact. A care plan, initiated on 4/13/23, indicated Resident B was on an anticoagulant/antiplatelet medication and to provide the medication per the medical provider's orders. A physician's order indicated to give Enoxaparin Sodium (an anticoagulant) 40 milligrams/0.4 milliliters (mg/ml) subcutaneously (injected into the fatty tissue just under the skin) every morning. The Medication Administration and Treatment Record (MAR/TAR) indicated there was no documentation of the administration of the Enoxaparin Sodium on 11/16/23 at 8:00 a.m., and on 12/19/23 at 8:00 a.m. Other omissions found in the MAR/TAR were: a. A physician's order for a daily wound assessment to the bilateral upper arms was missing documentation on 11/23, 11/25 and 11/26/23. b. A physician's order to measure colostomy output every shift was missing documentation on the day shift 11/5, 11/6 and 11/15/23 and on the night shift 11/6/23. During an interview, on 12/20/23 at 11:33 a.m., the Director of Nursing (DON) was informed of the missing anticoagulant injection. The DON indicated she had a QMA on the unit yesterday (12/19/23). 2. The record for Resident C was reviewed on 12/18/23 at 10:36 a.m. Diagnoses included, but were not limited to type 2 diabetes, anemia, and chronic obstructive pulmonary disease (COPD). A care plan, initiated on 10/6/20, indicated Resident C used an antidepressant Trazodone for depression and insomnia and to give the antidepressant medications as ordered by the physician. A physician's order indicated to give Trazodone (an antidepressant) 50 mg at bedtime for depression. The Medication Administration and Treatment Record (MAR/TAR) indicated there was no documentation of the administration of the Trazodone on 11/25/23 at bedtime. A physician's order indicated to give Fluticasone Propionate Nasal Suspension (a nasal spray used for asthma and allergies) every morning and at bedtime. The MAR/TAR indicated there was no documentation of the administration of the Fluticasone Propionate on 11/26/23 at bedtime. A physician's order indicated to give Fluticasone-Salmeterol (an inhaler) 250-50 micrograms (mcg) every morning and at bedtime for COPD. The MAR/TAR indicated there was no documentation of the administration of the Fluticasone-Salmeterol on 11/26/23 at bedtime. A physician's order indicated to give guaifenesin extended release (used to help clear mucus) 600 mg every 12 hours. The MAR/TAR indicated there was no documentation of the administration of the guaifenesin on 11/26/23 at 9:00 p.m. A physician's order indicated to give two (2) sennosides-docusate (a medication for constipation) 8.6-50 mg every morning and every bedtime. The MAR/TAR indicated there was no documentation of the administration of the sennosides-docusate on 11/26/23 at bedtime. A facility policy, titled Medication Administration, undated and received from the Director of Nursing on 12/18/23 at 1:28 p.m., indicated ( .Administer medication only as prescribed by provider .Medications will be charted when given ) This Federal Tag relates to Complaint IN00421402. 3.1-25(a)

Based on interview and record review, the facility failed to ensure the medication/treatment records were documented after the administration of medications or treatments and failed to ensure the correct diagnoses was linked to a medication for 5 of 5 residents reviewed for complete and accurate documentation. (Residents F, C, D, E and 89) Findings include: 1. The record for Resident F was reviewed on 04/17/23 at 1:30 p.m. Diagnoses included, but were not limited to, chronic kidney disease, acute kidney failure, and type 2 diabetes mellitus. During the review of the Medication and Treatment records, the following were missing documentation in the January, February, and March records. Admelog (an insulin) was missing documentation on 01/13/23, 01/14/23 and 01/15/23 at 8:00 a.m., and 5:00 p.m. This order was initiated on 01/12/23 at 5:00 p.m. Admelog before meals and at bedtime was missing documentation on 01/05/23 at 11:30 a.m., 4:00 p.m., and 9:00 p.m. This order was initiated on 01/05/23 at 7:30 a.m. Colostomy output amount was missing documentation on 01/07/23 for the night shift, and on 01/20/23 on the evening shift. The daily wound assessment of the buttocks was missing documentation on 01/17/23 on the day and evening shifts, 01/11/23 on the night shift, 01/21/23 on the night shift, and on 01/28/23 on the day shift. The daily wound assessment of the groin area was missing documentation on 01/11/23 for the night shift, 01/17/23 for the day and evening shifts, 01/20/23 on the evening shift, 01/21/23 on the night shift, and 01/28/23 on the day shift. The daily wound assessment of the right buttocks was missing documentation on 01/17/23 on the day and evening shifts, 01/20/23 on the evening shift, 01/21/23 on the night shift, and 01/28/23 on the day shift. The daily wound assessment of the left buttocks was missing documentation on 1/11/23 on the night shift, 01/17/23 on the day and evening shifts, 01/20/23 on the evening shift, 01/21/23 on the night shift, and 01/28/23 on the day shift. The daily wound assessment of the groin/ischium was missing documentation on 01/17/23 on the day and evening shifts, 01/20/23 on the evening shift, and 01/28/23 on the day shift. The indwelling catheter care of cleaning with soap and water was missing documentation on 01/20/23 on the evening shift. The indwelling catheter output was missing documentation on 01/17/23 for the day and evening shifts, 01/17/23 for the day and evening shifts, and 01/20/23 for the evening shift. Colostomy output amount was missing documentation on 02/02/23 for the night shift, 02/05/23 for the evening shift, and on 02/13/23 on the night shift. The daily wound assessment of the left buttocks was missing documentation on 02/03/23 for the evening and night shifts, 02/05/23 for the evening shift, and 02/12/23 for the evening shift. The daily wound assessment of the right groin was missing documentation on 02/03/23 for the evening and night shifts, 02/05/23 for the evening shift, and 02/12/23 for the evening shift. Colostomy output amount on 03/02/23 for the day shift was not documented. The indwelling catheter output on 03/01/23 for the day shift was not documented. 44598 2. The record for Resident C was reviewed on 4/12/22 at 11:25 a.m. Diagnoses included, but were not limited to, hypertension, depressive episodes, cardiac pacemaker, and osteoarthritis. A Medication Administration Record (MAR), dated for the month of March 2023, indicated the following were not signed as administered or not administered: a. monitor antidepressant side effects every shift on 3/28/2023. b. behavior monitoring for antidepressant every shift on 3/28/23. c. behavior monitoring interventions every shift on 3/28/23. d. monitor for pain every shift on 3/28/23. e. provide cup with lid for hot liquids every shift on 3/23/23. A MAR, dated for the month of April 2023, indicated the following were not signed as administered or not administered: a. Docusate Sodium (stool softener) 100 mg (milligrams) on 4/18/23 through 4/30/23. b. blood pressure twice a week every shift on 4/18, 4/20, 4/25 and 4/27/23. A Treatment Administration Record (TAR), dated for the month of February 2023, indicated the following were not signed as administered or not administered: a. monitor for bilateral lower extremities edema on 2/4, 2/13, 2/25 and 2/26/23. b. monitor for heart failure every shift on 2/4, 2/13, 2/25 and 2/26/23. c. monitor for shortness of breath every shift 2/4, 2/13, 2/25 and 2/26/23. A TAR, dated for the month of March 2023, indicated the following were not signed as administered or not administered: a. monitor for bilateral lower extremities edema on 3/19 and 3/21/23. b. monitor for heart failure every shift on 3/19, and 3/21/23. c. monitor for shortness of breath every shift 3/19 and 3/21/23. A TAR, dated for the month of April 2023, indicated the following were not signed as administered or not administered: a. monitor for bilateral lower extremities edema on 4/16/23. b. monitor for heart failure every shift on 4/16/23. 3. The record for Resident D was reviewed on 4/17/22 at 1:48 p.m. Diagnoses included, but were not limited to, spinal stenosis, cervical region, unspecified injury at C3 and C4 level of cervical spinal cord, paraplegia, and neuromuscular dysfunction of bladder. A MAR, dated for the month of January 2023, indicated the following were not signed as administered or not administered: a. behavior monitoring and interventions every shift 1/12/23 (night shift), 1/18 (evening shift), 1/27/23 (night shift), 1/28/23 (night shift), and 1/29/23 (night shift). A TAR, dated for the month of January 2023, indicated the following were not signed as administered or not administered: a. Triad Cream to sacrum twice a day on 1/20/23 (day shift). b. Triad Cream to sacrum twice a day on 1/20/23 (evening shift). c. Daily wound assessment to sacrum every shift 1/17/23 and 1/20/23 (day shift). d. Daily wound assessment to sacrum every shift 1/21/23 (evening shift). e. Indwelling urinary catheter care every shift 1/20/23 (evening shift). f. Indwelling urinary catheter measure and record output every shift 1/17/23 (evening shift). g. Indwelling urinary catheter measure and record output every shift 1/20/23 (evening shift). h. Indwelling urinary catheter measure and record output every shift 1/21/23 (night shift). i. Low air loss mattress check for proper placement and function every shift 1/20/23 (evening shift). A TAR, dated for the month of February 2023, indicated the following were not signed as administered or not administered: a. Triad Cream to sacrum twice a day on 2/5/23 (evening shift). b. Daily wound assessment every shift 2/5/23 (day shift). c. Flush catheter every shift 2/5/23 (evening shift). d. Indwelling urinary catheter measure and record output every shift 2/2/23, 2/5/23, and 2/13/23. A MAR, dated for the month of February 2023, indicated the following were not signed as administered or not administered: a. behavior monitoring and interventions every shift on 2/1/23 and 2/9/23. A MAR, dated for the month of April 2023, indicated the following were not signed as administered or not administered: a. Docusate Sodium (stool softener) 100 mg on 4/18/23 through 4/30/23. b. blood pressure twice a week every shift on 4/18, 4/20, 4/25, and 4/27/23. A TAR, dated for the month of February 2023, indicated the following were not signed as administered or not administered: a. monitor for bilateral lower extremities edema on 2/4, 2/13, 2/25, and 2/26/23. b. monitor for heart failure every shift on 2/4, 2/13, 2/25, and 2/26/23. c. monitor for shortness of breath every shift 2/4, 2/13, 2/25, and 2/26/23. A TAR, dated for the month of March 2023, indicated the following were not signed as administered or not administered: a. monitor for bilateral lower extremities edema on 3/19 and 3/21/23. b. monitor for heart failure every shift on 3/19, and 3/21/23. c. monitor for shortness of breath every shift 3/19 and 3/21/23. A TAR, dated for the month of April 2023, indicated the following were not signed as administered or not administered: a. monitor for bilateral lower extremities edema on 4/16/23. b. monitor for heart failure every shift on 4/16/23. 4. The record for Resident E was reviewed on 4/13/23 at 1:39 p.m. Diagnoses included, but were not limited to, protein calorie malnutrition, hypertension, thrombocytopenia (low platelet level), and colostomy. A MAR, dated for the month of December 2022, indicated the following medications were not signed as administered or not administered: a. omeprazole 20 mg daily on 12/2 and 12/3/22. A TAR, dated for the month of December 2022, indicated the following medications were not signed as administered or not administered: a. daily wound assessment every shift 12/5/22. A TAR, dated for the month of January 2023, indicated the following medications were not signed as administered or not administered: a. daily wound assessment every shift 1/5/23. b. colostomy output every shift 1/20/23. 5. The record for Resident 89 was reviewed on 04/14/23 at 9:10 a.m. Diagnoses included, but were not limited to, type 2 diabetes, type 2 diabetes with diabetic neuropathy, and heart failure. A physician's order, initiated on 03/24/23, indicated to give Gabapentin (an anticonvulsant and nerve pain medication) 300 milligrams twice a day for health maintenance. During an interview, on 04/17/23 at 11:08 a.m., the Director of Nursing indicated Resident 89 had diabetic neuropathy. She then checked the order for Gabapentin and found the diagnosis for the medication was health maintenance. It was not a correct diagnosis. During an interview, on 04/17/23 at 8:59 a.m., the Director of Nursing (DON) indicated nurses were to sign off the MAR/TAR when service/care was provided, if the care/service was not provided the nurse needed to contact the physician and let them know. During an interview, on 04/17/23 at 9:00 a.m., the Corporate Support Nurse indicated missing documentation in the MAR/TAR did not necessarily mean service/care was not done. The facility did call nurses and ask if the care/service was completed. The facility did monitor for missing documentation. During an interview, on 04/17/23 at 9:10 a.m., Unit Manager 4 indicated the MAR/TAR was to be signed off when services had been provided. During an interview, on 4/17/23 at 4:40 p.m., the DON indicated if the MAR (Medication Administration Record) and TAR (Treatment Administration Record) had holes it was not done. They should be signed off on the MAR and TAR if they were given or not given and the reason not given should be documented. A current policy, titled Physician Orders, undated and received from the Executive Director on 04/14/23 at 3:17 p.m., did not address ensuring the correct diagnosis was use for the medications to be administered. A current policy, titled Clinical Documentation Standards, dated 2014 and received from the Director of Nursing on 04/17/23 at 10:25 a.m., indicated .Nurses will follow the basic standard of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical record This Federal tag relates to Complaint IN00404230, IN00401290, IN00392088, and IN00391751. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to follow an antibiotic stewardship program which included antibiotic use protocols and a system to monitor antibiotic use for 6 of 12 months reviewed for antibiotic stewardship. Finding includes: A review of the Facility Assessment Tool, dated 11/2021 through 10/2022, indicated the facility had an antibiotic stewardship program. The Director of Nursing (DON) started gathering information, documenting, and tracking infections for the program on 4/14/23. During an interview, on 4/17/23 at 9:24 a.m., the DON indicated she did not have any information filled out or track infections and trends until a few days ago. She started to fill out the Antibiotic Stewardship binder on 4/14/23 and only had information from 4/2022 through 10/2022 filled out so far. During an interview, on 4/17/23 at 11:28 a.m., the DON provided a binder titled Antibiotic Stewardship. The binder did not contain information of tracking infections past 10/2022. They were to use McGeer Criteria forms and she had not completed any McGeer Criteria forms and indicated they just started to gather information for the Antibiotic Stewardship on 4/14/23. A current policy, titled Infection Prevention Program, dated as reviewed 2/24/22 and received from the Executive Director on entrance, indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Residents have a right to reside in a safe environment that promotes health and reduces the risk of acquiring infections. The facility infection program is comprehensive in that it addresses detection, prevention and control of infections among residents and employees 3.1-18(b)(3)

Based on observation, interview and record review, the facility failed to have sufficient staff with the appropriate competencies and skills sets to provide nursing care to residents to ensure their safety and care needs were met. Multiple residents called 911 to the facility during the night shift to seek help in care needs and while the police were at the facility, they observed the lack of available staff to ensure safety and medical needs were addressed. The police department had been called a minimum of 13 times since [DATE]. Residents, family and staff interviews indicated a lack of staff to provide personal and medical care. (Resident B, C, N, M, E and Q) The immediate jeopardy began on [DATE] when insufficient staff were observed by the local police and 911 Emergency Medical Technician (EMT) services. The Executive Director (ED), Director of Nurses (DON) and Regional Director of Clinical Services (RDOC) were notified of the immediate jeopardy at 5:04 p.m., on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview, on [DATE] at 2:45 p.m., a detective from the Police Department (PD) indicated he had multiple complaints from residents calling 911 for service in the facility. The detective spoke at length regarding his concern for the residents of the facility. During an interview, on [DATE] at 11:22 a.m., the detective indicated since [DATE], the police had been dispatched a minimum of 13 times to the facility. He had never encountered a situation like this before. He feared for the residents' safety. 1. Officer case reports, received and reviewed from the detective on [DATE] at 3:00 p.m., indicated the following: On [DATE], the police responded to a Sick Person/Specific diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When the police spoke to the resident, she indicated she also called the facility number and had reached a nurse and finally received her medications right before the officers arrived. The officers noted a clear liquid puddle under the resident's bed. The resident indicated it was urine. As the officers were leaving the facility, they were flagged down by a family member who indicated the resident who called the police had been screaming for approximately one hour and the level of care at the facility was poor. The officers noted she appeared concerned for the residents. On [DATE], the police responded to an abuse/neglect incident at the facility. A resident on the 5000 wing had called dispatch to report she was not receiving proper treatment. The officers arrived as a staff member was in the process of exiting the building. The officers explained why they were there, and the staff pointed the officers to the wing they needed and exited the building. When they arrived at the nurses' station, a staff member was not there. A non-verbal resident was at the nursing station, holding a piece of paper which stated his mouth was hurting and he needed his medication. The officer sat at the nurses' station for ,d+[DATE] minutes before a Certified Nurse Aide (CNA) arrived. They advised the CNA why they were there, and they were trying to get the gentleman at the nurses' station and the resident who called the police some help. The CNA told the officers she was the only person on the wing, and she would get to them when she could. The report noted the CNA seemed very irritated and agitated. The officers then made their way to check the resident who called dispatch. The resident indicated to the officers she needed changed, had been in the same clothes the last ,d+[DATE] hours and she was soiled. She was thirsty and had not had water in a while. She indicated to the officers, when she told the CNA on the wing what she needed, the CNA told her she was tired and was not going to overwork herself. Unable to find a nurse on the wing, the officers proceeded to another wing. He explained the situation to the staff on the other wing and another CNA volunteered to come help the residents. While walking with the officers, the CNA indicated the facility cannot keep employees, employees were constantly calling in and the patients were not receiving the proper care they needed. Before the officers left the building, the nurse for the 5000 unit approached the officers. The nurse told the officers, she did her best to provide care to the residents but there were way more residents than nurses and CNAs. The quality of the employees hired was also an issue. She sent an employee home this night due to her continuing to fall asleep on the job. On [DATE], a resident's family member contacted the police department to report she felt her family member was being neglected, she was contacting the Indiana Department of Health and was transferring her family member to another facility. The police department notified the Adult Protective Services. On [DATE], while on routine patrol in the city, an officer was dispatched at approximately 3:48 a.m., to the facility, in reference to a welfare check. The complainant, Resident B, contacted communications requesting police assistance. As the officer looked throughout the hallways for a member of the facility staff, he was unable to locate any nurse or other employee in the area. There were audible call button notifications sounding at the nursing station, and at least two rooms had flashing lights outside indicating the occupants may need to speak with staff. As he began looking into open doors to see if a nursing staff member was attending to another resident, he observed a white male, identified as Resident C, laying on the floor on his back with his feet on the bed. There was significant blood about the bed linen and floor. Resident C's hospital gown exposed his genitals, which appeared to be covered in blood. Resident C's right hand was also wrapped and appeared to be bleeding. He continued his efforts to locate a nurse, until it became clear he would not locate one faster than the Fire Department (FD) assistance could be summoned. Medics from the FD arrived on-scene to begin assessing and treating Resident C. The medic advised they had run on Resident C earlier in the day and he was being transported to a local hospital, by ambulance for treatment. The Fire Department report, dated [DATE], indicated upon arrival EMTs were not greeted by staff and no staff were to be found. EMTs were called by the police department after they found the Resident C on the ground. The resident was found wearing a tank top with no bottoms on, only a sheet on the bed, no blanket. The resident had dried blood on his penis and fresh blood coming from from gauze wrapped around his right elbow. The EMTs had ran on this resident earlier in the day for a suspected stroke. They began looking for staff and when they eventually found staff they advised they needed paperwork for Resident C as they were transporting him to the hospital. Staff was not able to provide any information on the resident. After several minute of waiting, staff provided paperwork for the resident. During an interview with Resident C's family, on [DATE] at 11:33 a.m., the family member indicated they had been contacted by the police department to inform them Resident C had been found on the floor of his room and had been taken to the hospital. The family member indicated during the conversation with the officer at the time of the notification, the officer told the family it took them 7 minutes to get someone to let them into the facility and 20 minutes to find any staff. The family member indicated the facility notified them around 7:00 a.m., the resident had been sent to the emergency room for treatment. They further indicated Resident C was never the same and passed away sometime in early [DATE]. Resident C's medical record was reviewed on [DATE] at 3:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided on the 5000 unit. Resident C's progress notes indicated the following: On [DATE] at 5:29 a.m., EMTs (Emergency Medical Technician) made the decision to take Resident C to the ED (emergency department), they were on site for another patient with behavioral issues and noted this patient had fallen and was bleeding. On [DATE] at 7:09 a.m., at approximately 4:00 a.m., the resident was discovered on the floor at bedside by an officer passing by the resident's room. Bleeding was noted by the CNA to the left arm where there was already a previous bandage. The EMT was already present at the time and requested paperwork be prepared to transport the resident to the local hospital due to the bleeding noted. The resident was confused and unable to explain what happened at that time. 2. During an interview, on [DATE] at 10:53 a.m., a family member of Resident N indicated they stayed with the resident ,d+[DATE] because they felt there was not enough staff and staff who were working were not knowledgeable enough to care for their family member. The family member indicated staff routinely came to the resident's room, turned off the call light and never came back. The family member indicated, on one occasion, the family was being assisted to dress Resident N after being incontinent of liquid stool. There was liquid stool on the floor, however the staff member instructed the family member to assist the resident to stand. She felt the resident would slip and fall and refused to assist the resident to stand until the liquid stool was cleaned from the floor. Resident N's record was reviewed [DATE] at 11:32 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident N resided on the 5000 unit. 3. During an interview, on [DATE] at 10:20 a.m., Resident M, an alert and oriented resident, indicated she had been at the facility for a long time and had moved to the 5000 unit about ,d+[DATE] months ago. When questioned, Resident M indicated she was scheduled to receive a shower twice a week. She was unable to shower herself because she felt unsteady in the bathroom due to the tile floor. Resident M indicated, at some point in time in the recent past, she had been assisted by staff to the shower, given towels and toiletries and told to take her own shower because there wasn't enough staff to assist her. The resident indicated she refused and now only took one shower a week. Resident M's record was reviewed on [DATE] at 11:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident M resided on the 5000 unit. 4. During an interview, on [DATE] at 11:10 a.m., a resident's family member who wished to remain anonymous, indicated on the evening of [DATE] at around 6:00 p.m. to 7:00 p.m., the family member observed five nursing staff standing at the nursing station on unit 5000. The family member indicated there were at least 4 call lights blinking down the hallway on the outside of the resident rooms, with an audible alarm heard to be sounding in the vicinity of the nursing station. Staff were talking and laughing and none of the staff members were observed to answer the call lights. The family member was disturbed by this. The same family member also indicated, during the night of [DATE] at around 4:00 a.m., she observed the police to be in the facility. The family member stated a resident could be heard screaming from her room down the hall and the family member told the police officer the resident had been screaming for help for about two hours prior to their arrival. This family had also pulled their family member's call light before in an attempt to receive assistance for the resident to be taken to the bathroom. This family member stated on at least one occasion, a staff member came to the room, turned the light off and stated she would have to get someone to assist her. The family member indicated, after a long period of time, the CNA came back to the room and stated she was unable to find anyone to assist her. 5. Resident E's record was reviewed on [DATE] at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident E resided on the 5000 unit. An Admission Skin Evaluation, dated [DATE], indicated the only skin alteration/pressure area was to her chest. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Practitioner (NP) progress note, dated [DATE], indicated the resident was admitted with wounds on her buttocks. The resident requested a Foley catheter be placed due to her constant bowel and bladder incontinence. The NP ordered a Foley catheter to be placed for wound healing. An Admission Record, an Order Summary, and a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, written by the Medical Director, on [DATE] at 12:39 p.m., indicated Resident E had a Foley catheter in place. She had an allergy to iodine and [MEDICATION(S)] (a form of iodine) was used to insert the catheter. The resident complained of vaginal itching and [MEDICATION(S)] (a medication used to treat itching) 25 milligrams two times a day as needed was ordered. A nursing progress note, dated [DATE] at 4:01 p.m., indicated the resident had blood in her urine. A NP progress note, dated [DATE] at 11:33 a.m., indicated the resident's catheter was discontinued due to her unresolved/persistent pain on her insertion area. A progress note, written by the Medical Director, on [DATE] at 12:40 p.m., indicated the resident had a Foley catheter inserted but now it has been removed due to continued discomfort. A progress note, written by the Medical Director, on [DATE] at 6:23 p.m., indicated the resident was still reporting some vaginal and lower abdominal discomfort. The resident had a Foley catheter inserted and [MEDICATION(S)] was used, the resident reported she had an iodine allergy. During an interview, with the NP, the resident and spouse present, on [DATE] at 1:00 p.m., the NP indicated she ordered a Foley catheter to be placed primarily because the staff was unable to get to the resident enough to change her and keep her dry, for wound healing. During an interview, on [DATE] at 12:30 p.m., Resident E indicated she had a Foley catheter in place before. The nurse used [MEDICATION(S)] and she was allergic to iodine compounds and she immediately felt discomfort. During an interview, on [DATE] at 11:00 a.m., Resident E indicated a Foley catheter was placed to keep her dry because the nursing staff was not checking and changing her enough. As soon as the Foley catheter was inserted, she immediately felt itching at the site externally and pain internally. She told the nurse right away and asked her what she used to clean her with the nurse indicated to her [MEDICATION(S)], she immediately told her what, I am allergic to Iodine. She had pain the entire time the catheter was inserted and on the fourth day she developed blood in her urine. During an interview, on [DATE] at 12:30 p.m., Resident E indicated she needed to be checked and changed at least every two hours because she urinated a lot. There were times she was only changed when she got up in the morning before she was transferred to her chair and then not again till she is put back in bed in the evening. The resident, at that time, was noted to have a urine smell. During an interview, on [DATE] at 11:00 a.m., with a Resident E and spouse, the resident indicated yesterday she was changed in the morning and the next time she was changed was not until 4:00 p.m., when she was put back in her bed. She was not changed during the night and when she woke up in the morning, her brief, sheets, and bed mattress were completely saturated with urine. She had never refused to be changed and she had put her call light on several times telling the staff she was wet and needed to be changed. She was told they have a list of residents to clean up and change and there were resident's higher on the list and they will get to her. 6. During an interview, on [DATE] at 12:00 a.m., an anonymous nurse indicated a resident on the 2000 unit, Resident Q, called police because he said he was having a [CONDITION(S)]. The nurse who was working that night and was the only nurse assigned to both the 2000 and 3000 units. She did not get to speak to the police while they were there for Resident Q because the nurse was on the 3000 unit caring for residents with gastrostomies (g-tubes) and intravenous (IV) medications. It was not unusual for one nurse to be assigned two units or to work with no CNAs. The nurse became tearful when she described she had complained to a corporate person about inadequate staffing. The corporate person told her they did not know what to say other than they would pray. When the nurse asked the corporate person what she should do if someone coded (required CPR), the person offered no answer. During an interview, on [DATE] at 12:05 a.m., Resident Q indicated they often had only one nurse for all the units, and one aide for all units on the night shift (10:00 p.m. to 6:00 a.m.). Sometimes he used the stopwatch feature of his phone to time how long it took staff to respond to his call light. It was not unusual to wait an hour and a half. He had urinary and bowel accidents in bed waiting for help. He could hear other residents calling out for help. He heard a lady screaming for help because she had fallen. One night, he was brought back to the facility by ambulance around 2:00 a.m. The ambulance people banged on the door and pushed the alarm to try to get someone to open the doors while he waited in the ambulance. They were not able to get into the facility until 4:00 a.m., when a staff member leaving the facility let them in. When he got into bed, laying on his stomach, talking to a family member on the phone, he got a feeling in his left leg and left arm. He said Aunty, I think I'm going to have a [CONDITION(S)]. Then his right arm shot one way and his leg another. He started holding onto his bed rail. His Aunt called 911. Resident Q used his call light and screamed at the top of his lungs, but no one came. His Aunt called the facility, but no one answered. When the fire department arrived, he could hear them banging on the door. There were no aides or nurses at the nurses' station because they did not have enough people to work. When they got him to the hospital and put him in the medical bed, the [CONDITION(S)] went out of control. Resident Q was observed to have long, sharp fingernails with yellow and brown substances under the nails. The resident indicated he got his own nail clippers because staff were not trimming his nails and then someone took his clippers. The Fire Department report, dated [DATE], indicated they responded on an emergent [CONDITION(S)] call. Resident Q called 911 himself after staff did not respond to his call light. The EMTs looked around the unit the resident was on and could not locate staff. Resident Q's medical record was reviewed on [DATE] at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission minimum data set (MDS) assessment, dated [DATE], indicated his cognitive status was intact. He had no [CONDITION(S)], [CONDITION(S)] or behavioral symptoms. He required extensive assistance by one person for bed mobility and toileting, and extensive assistance by two people for transfers and personal hygiene. He did not walk. He was frequently incontinent of urine and bowel. Resident Q's progress note, dated [DATE] at 10:01 p.m., indicated the resident called the nurse to the room stating he was having [CONDITION(S)] activity. The nurse received an order to send him to the emergency room . A progress note, dated [DATE] at 3:58 a.m., documented he returned to the facility from the emergency room with an order to increase his [MEDICATION(S)] (anti-epileptic). Resident Q's care plan, dated [DATE], documented he had activities of daily living self-care performance deficits related to diabetes, congestive heart failure, obesity and respiratory failure. He required assistance with grooming, dressing, bathing, and locomotion and extensive staff participation to use the toilet. 7. A Fire department report, dated [DATE], indicated they received a call from a resident who wanted her blankets removed. Dispatch was unable to reach the facility. They went to the residents room. At this time, the resident indicated she felt the staff were verbally abusive. They activated the call button for the nurse. The nurse arrived a little over 10 minutes after they arrived at the facility. The nurse advised she just started her shift and did not know the resident. The nurse told the resident if she felt she was being abused to report it to the day shift. The nurse indicated she could not stay and talk because she had to get back to her computer. They advised the resident to call back if needed and if it was emergent to call 911. A Fire department report, dated [DATE], indicated they were dispatched for a resident who had a fall. There was no one at the nursing home to give them information on the resident. A Fire department report, dated [DATE], indicated they were dispatched for a call directly from a resident who was upset she could not get a nurse to respond to her call light since last night. Upon arrival to the hospital, the hospital nurse advised they did not receive a prior report from the nursing home regarding the resident. A special note section indicated while the fire department was at the facility at no time did nursing come to the residents room to provide any information although EMTs spoke to them saying hello and informing them why they were there. No paperwork besides the general information sheet was provided. EMTs were able to pull medications, history and allergies from previously running on this resident. They did ask the facility for DNR paperwork, history and medication list however it was not provided. All the residents belongings were taken with her except for her robe which could not be located due to the resident requested to not return to the facility. A Fire department report, dated [DATE], indicated they were dispatched due to a fall. Upon arrival staff pointed them to the room they needed. Staff did not come to the room to help move the resident or ask questions. During transport a brown pill was found on the floor. On the way out, staff was notified they found a pill and placed it on the bedside table. They were delayed on the scene for 20 minutes waiting on paperwork During an interview, on [DATE] at 5:15 a.m., QMA (Qualified Medication Aide) 1 indicated it was not normal for there to be 3 CNA's on the 5000 unit. There were times when there was only 1 CNA on the 2000 unit and 1 CNA on 5000 unit. She added both units were extremely demanding with many residents requiring assistance with their personal care. QMA 1 indicated aides were unable to turn and reposition residents and change all incontinent residents on these units. When questioned what happens if an employee calls in, the QMA stated the facility tried to replace the staff person, but sometimes are unable to find a replacement so they end up working short staffed and do the best they can. During an interview, on [DATE] at 5:30 a.m., CNA 3 indicated she worked the night shift and was concerned with staffing. She typically worked with 1 nurse and sometimes with one other CNA but more often it was just a nurse and herself. She indicated she could not give all the care the way she should she is one person. Staffing tonight, was an exception and she didn't know why there were 3 aides scheduled on one floor. She tried to check and change incontinent residents every 2 hours but sometimes when she was by herself she could not do it and the residents would not get the care they deserve. During an interview, on [DATE] at 5:53 a.m., an anonymous staff member indicated the amount of CNA's that worked tonight was very unusual. Normally she worked with only 1 CNA on nights. She indicated she had made a complaint to the State Department of Health 2 different times in the past for staffing related concerns. The residents are not getting the care they should be because there was not enough staff to answer the call lights and do the care which was needed. She often did not feel safe and did not feel the residents were safe. She had seen an increase in pressure wounds because they were not able to turn and change the resident's as often as they should be. During an interview, on [DATE] at 5:57 a.m., QMA 5 indicated she worked night shift with a nurse and 1 other aide but sometimes it was just herself and a nurse. She had to work much harder and often the residents did not receive the care they should because the facility had been under-staffed. Recently it had gotten worse and things were not good. During an interview, on [DATE] at 6:00 a.m., CNA 6 indicated she had worked mostly on the day shift. She had decreased her hours because the facility had been so under-staffed, she had not been able to give the care she wanted to and the care the residents deserve. The weekends are horrible there have been times when she was the only aid for the whole floor and she could not get all the call lights which go off. During an interview, on [DATE] at 11:30 a.m., Licensed Practical Nurse (LPN) 2 indicated there was an LPN, a QMA and 3 aides working today. This was not the typical amount of staff scheduled on day shift, but since the State had been in the facility they have had more staff scheduled to work than usual. She also indicated the lack of staffing was affecting patient care in a negative way. During an interview, on [DATE] at 11:18 p.m., QMA 1 indicated she was at the facility when the police arrived for a resident on the 5000 unit. She was working in another unit and let them in. She did not know where the staff were on the 5000 unit when the police came and indicated there had been staffing issues. During an interview, on [DATE] at 11:35 a.m., CNA 3 indicated, when police were called, it was usually by a resident on the 5000 unit, Resident B. Police would check on Resident B and then come find one of us. The last time the police were there, there was a staffing issue. There wasn't enough staff, and the staff who were working in the 5000 unit couldn't be found. Call lights were not being answered. During an interview, on [DATE] at 9:45 a.m., the Staff Scheduler indicated she tried to staff night shifts as follows: 3 nurses for 3 units (1 per unit), and 5 to 6 CNAs, accounting for her PPD (per patient day) budget based on census. She indicated her goal was for 2.5 PPD, with a budget/goal of .58 Registered Nurses (RNs), .987 LPNs, .1 QMAs, and 1.95 CNAs per day. The PPD was calculated as follows: resident census, multiplied by the PPD (2.5) and then divided by hours of staff (nurse hours were 8 hours per shift and CNA hours were 7.5 hours per shift. During an interview, on [DATE] at 10:05 a.m., the Regional Director of Clinical Services indicated the budgeted PPD was 3.66, and the budget was .5 PPD for RNs total in a 24-hour period. The scheduler may be using a different number because she did not schedule unit managers or the Infection Preventionist nurses. Nurse managers provided patient care, the IP nurse did not. The budgeted PPD was .5 RN, .83 LPN, .1 QMA, and 2.008 CNA. The facility's daily staffing sheet, posted at the front of the facility for public view and dated [DATE], indicated the census was 85. The public posting indicated the following staff worked during the time police responded to a 911 call ([DATE] at 3:49 a.m.): 0 RNs, 3 LPNs and 5 CNAs from 10:00 p.m. on [DATE] to 6:00 a.m. on [DATE]. The facility's Daily Schedule, dated [DATE], indicated the following staff were scheduled to work on the night of [DATE] to the morning of [DATE]: 2 LPNs, 1 agency nurse, and 6 CNAs. Only one nurse was scheduled to cover the 2000 and 3000 halls. The facility's Time Detail reflected the following staff clocked in to work on the night of [DATE] to the morning of [DATE]: 2 LPNs, 1 QMA, and 2 CNAs (1 less nurse and 3 less CNAs than were publicly posted and/or scheduled to work). The facility's daily staffing sheet, dated [DATE], indicated the census was 82. The public posting indicated the following staff worked during the time Resident B alleged to police she did not receive proper care (the evening shift of [DATE]): 0 RNs, 5 LPNs, and 7 CNAs from 2:00 p.m. to 10:00 p.m. The facility's Daily Schedule, dated [DATE], indicated 2 LPNs, 3 QMAs, and 7 CNAs were scheduled to work from 10:00 p.m. on [DATE] from 2:00 p.m. to 10:00 p.m. The facility's Time Detail reflected the following staff clocked in to work during that time: 3 QMAs, 3 CNAs, and 2 Hospitality Aides. Agency staff sign-in sheets dated [DATE] reflected 1 LPN, 1 QMA, and 3 CNAs also worked. (There was only one nurse in the facility, 4 nurses less than were posted and/or scheduled to work). The facility's public daily staffing sheet indicated the following staff worked during the time police responded to a 911 call at the facility ([DATE] at 3:02 a.m.): 2 RNs, 1 LPN, and 6 CNAs from [DATE] at 10:00 p.m. to [DATE] at 6:00 a.m., for a census of 82. The facility's Daily Schedule dated [DATE] indicated 2 RNs, 1 LPN, 1 QMA, and 5 CNAs were scheduled to work on [DATE] from 10:00 p.m. to [DATE] at 6:00 a.m. The facility's Time Detail reflected the following staff clocked in to work during that time: 2 RNs, 1 LPN, 1 QMA, and 3 CNAs. The agency sign-in sheets dated [DATE] reflected 1 nurse and 3 additional CNAs worked. The facility's public daily staffing sheet, dated [DATE], indicated the census was 81. The public posting indicated the following staff worked during a time police responded to a 911 call ([DATE] at 5:40 a.m.): 2 RNs, 1 LPN, and 5 CNAs worked on [DATE] from 10:00 p.m. to [DATE] at 6:00 a.m. The facility's Daily Schedule dated [DATE] indicated 2 RNs, 1 QMA, and 4 CNAs were scheduled to work on [DATE] from 10:00 p.m. to [DATE] at 6:00 a.m. The facility's Time Detail reflected the following staff clocked in to work during that time: 2 RNs, 1 QMA, and 3 CNAs. The agency sign-in sheets dated [DATE] reflected 1 additional CNA worked. (One less nurse and 1 less CNA than were posted and/or scheduled to work). The facility's Resident Matrix, dated [DATE], documented the following impact on resident acuity (level of care): 17 residents with Alzheimer's or dementia, 1 resident receiving nutrition by feeding tube, 3 residents on hospice, 4 residents with a urinary catheter, 1 resident with a [CONDITION(S)], 3 residents with pressure ulcers, 4 residents with falls, and 7 residents on transmission-based precautions, and 4 with unplanned weight loss. The current Facility's Assessment Tool, dated [DATE] to [DATE], provided by the Clinical Support Director on [DATE] at 10:45 a.m., reflected the average daily census was 80 residents. The total number needed or average or range of staff included, but was not limited to: - 18 licensed nurses providing direct care per day - 26 nurses aides per day and 2 restorative aides per day The facility's publicly posted staffing sheets for the days/times police were called to the facility reflected the following. - On [DATE], there were a total of 12 nurses (96 hours, 6 less nurses than required by the Facility's Ass[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure pressure ulcers were not acquired in the facility and identified at greater than a Stage 2, failed to complete assessments, follow-up on progression of pressure ulcers and send to wound clinic timely for assessment and treatment follow-up for 2 of 3 residents reviewed for pressure ulcers. (Resident B and C) The Immediate Jeopardy began (MONTH) 20, 2019 when the facility failed to identify and assess the formation of pressure ulcers until the wounds were Stage 3 up to Unstageable pressure ulcers, failed to follow-up and assess wound for new treatment orders and failed to ensure resident were seen by the wound clinic timely for treatment intervention or physician assessment. The Administrator, Director of Nursing (DON), Regional Director of Clinical Operations and the Regional Director of Operations were notified of the Immediate Jeopardy on 6/19/19 at 3:24 p.m. The Immediate Jeopardy was removed on 6/20/19, but noncompliance remained at the lower scope and severity isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include: 1. The record for Resident B was reviewed on 6/17/19 at 12:37 p.m. [DIAGNOSES REDACTED]. A plan of care, dated 4/24/17, indicated the resident was at risk for skin impairment due to fragile skin and incontinence, with interventions that included, but were not limited to, daily skin inspection and notify nurse of skin integrity impairments. A plan of care, dated 2/25/19, indicated the resident had a Stage 4 ulcer to his left gluteal fold and a Stage 2 to his sacrum. Interventions included, but were not limited to, assess and monitor wound healing weekly, measure length, width, depth where possible, assess and document status of wound perimeter, wound bed and healing progress and wound consult per physician orders. Physician orders [REDACTED]. A Skin Grid Pressure V6, dated 2/20/18 at 4:44 p.m., indicated this was a new pressure ulcer first observed on 2/20/19, house acquired to the left gluteal fold, pressure ulcer measured 2.0 cm (centimeters) x 2.0 cm x 0.1 cm Stage-Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed), Edges-Distinct, outlined, clearly visible, attached, even with wound base. Wound bed appearance had eschar present, wound bed color was necrotic. Exudate amount was serous, medium amount. No odor and the periwound appearance was bright red and/or blanched. There was no tunneling present. Current/new treatment orders-cleanse with NS (Normal Saline), pat dry, apply calcium alginate to the wound bed and cover with a dry dressing. A progress note, dated 2/20/19, at 8:41 p.m., indicated a new open area left gluteal fold. Skin Grid Pressure V6 reports indicated: 2/27/19: left gluteal fold 2 cm x 2 cm x 0.1 cm, coded as a Stage 1, with granulation (formation of new tissue) present, pink, no tunneling, wound not improving with orders changed to add [MEDICATION NAME] to existing treatment. 3/6/19: had same measurements and staging, no differences (Name of Hospital) notes from 3/10-3/16/19 admission, indicated Resident B was admitted for low hemoglobin (Hbg) of 6.1 and had a pressure ulcer, that was extremely foul smelling. The resident looked unkept, had a fever, elevated white blood cell (WBC) count (indicating possible infection) and possible osteomylitis (bone infection) of the left ischial (lower and back part of hip area) wound that needed debridement. An X-ray of the wound indicated soft tissue gas extending to the area of the ischium (lower and back part of hip bone). Wound Vac to be placed on discharge and regular follow-up with wound clinic. The resident was found to have significant ischial wound, concerning for infection, possible osteomylitis. This will need to be looked at and watch closely as patient does have some debility. A MRI (Magnetic Resonance Imaging) report, dated 3/12/19, indicated the resident had a fistulous tract (abnormal connection/tract between two hollow spaces) extending deep to the level of the left ischium. The resident was placed on [MEDICATION NAME] (antibiotic) 500 milligrams twice a day for 5 weeks. Discharge instruction included the resident was to be seen at the wound clinic in one week. The resident returned to the facility on [DATE] and was not seen at the wound clinic until 3/29/19. (Name of Wound Clinic) notes dated 3/29/19 indicated: Return to the clinic on 4/8/19 for follow-up. Sacrum: Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling.) 4.5 cm x 2 cm x 0.2 cm, had 30 % granulation, beefy red granulation and slough. A new order was given for [MEDICATION NAME] as the primary dressing and to use foam adhesive border for one week. Left Ischium: Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling) 4.8 cm x 4.5 cm x 4.5 cm, with undermining at 11 o'clock of 2 cm to 4 cm, malodorous exudate, base had beefy red granulation, had pink granulation, had slough, was covered by necrotic tissue, and had exposed muscle tissue. New orders were given to cleanse with normal saline, use dakin's solution (antibacterial agent), packed with kerlix as primary dressing, use abdominal (abd) pad and paper tape for one week. The facility Skin Grid Pressure indicated: 4/3/19 left gluteal fold, 4.5 cm x 2 cm x 0.2 cm, Stage IV, in- house acquired, granulation, pink, continue wet to dry dressing. 4/5/19 Sacrum first observed 3/29/19, 4.8 cm x 4.5 cm x 0.2 cm, Stage 4 , pink, and continue treatment. The resident was in the hospital from 4/5-12, 2019 for altered mental status: (Name of Hospital) note indicated a chronic wound and was on intravenous antibiotics. Facility Skin Grid Pressure dated 4/17/19, indicated: Coccyx: 4.7 cm x 4.2 cm x 0.2 cm, Stage 2, granulation, pink wound improving, continue treatment of [REDACTED]. Left gluteal fold: 4.8 cm x 4.4 cm x 4.3 cm , Stage 4, granulation, pink red, continue treatment During an interview on 6/18/19 at 11:20 a.m., the (Wound Clinic Manager) indicated Resident B visits to the wound clinic were as follows for (MONTH) and (MONTH) 2019: 3/12/19 at 1:30 p.m.-canceled rescheduled for 3/26/19 at 1:00 p.m. (admitted to St. Vincent Hospital Carmel 3/9/19 and discharged on [DATE]) 3/26/19 at 1:00 p.m.-canceled and rescheduled for 3/29/19. 3/29/19-Initial assessment of Left gluteal wound. He came to the wound clinic by stretcher. Return to clinic date on 4/8/19. 4/8/19 at 9:15 a.m.-missed appointment (appt) (NO SHOW) 4/16/19-Telephone call from nurse at Bridgewater for clarification of appointment times. Verified next appt was to be 4/23/19 at 2:00 p.m. and wound fax orders after he came, but he did not come to that appt, but came on 4/25/19 4/23/19-missed appt (Rescheduled appt for 4/25/19 at 2:00 p.m.) 4/25/19 at 2:00 p.m.-follow up appt. He came to the wound clinic by stretcher. Return to clinic on 5/9/19. (Name of Wound Clinic) note for 4/25/19 indicated: Return visit for 5/9/19 Physician comments: Stage 4 ischial ulcer extended deep into the left buttocks, palpable raw bone, ischial tuberostiy, fairly clean, had pink granulation and slough, had tunneling of 5 cm at 12 o'clock, was 2.6 cm x 2.5 cm x 4 cm, and dakin's solution packing for treatment. The wound clinic note indicated the sacrum was resolved. May 2019 Weekly Skin Checks indicated: 5/6/19 yes to .Are there any skin conditions or changes, ulcers, or injuries .Comments/Summary: Resident has wounds that have charting available for them 5/13/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .site 53 Sacrum .54 Left gluteal fold 5/20/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .site other Comments/Summary: Refer to Skin Grid Pressure 5/27/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .site 54 left gluteal fold Refer to Skin Grid Pressure .Comments/Summary: Refer to Skin Grid Pressure . Review of (MONTH) 2019 records for Resident B had not Skin Grid reports with assessment of the ischial wound or follow-up for the closed sacrum wound. The Treatment Administration Record for (MONTH) 2019, indicated the ordered treatments were completed for the wounds including a treatment to cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] and cover with a foam dressing daily. There were no wound clinic notes for (MONTH) 2019. During in interview on 6/18/19 at 11:20 a.m., the (Wound Clinic Manager) indicated his visits were as follows for (MONTH) 2019. 5/9/19-missed appointment 6/6/19-Initial assessment of left gluteal wound because after not being seen for 30 days they were discharged and they have to be made a new patient. He came to the wound clinic by stretcher. A progress note dated 5/9/19, indicated the resident was sent to the hospital for a transfusion at hospital. This was the day the resident was to be seen in the wound clinic. During an interview with the Administrator, on 6/19/19 at 12:49 p.m., she indicated the resident did not go to wound clinic appointment and no follow-up appointments were made. Progress notes for (MONTH) had no mention of the wound or wound clinic appointments being rescheduled. During a confidential interview on 6/17/19, the interviewee indicated the resident missed wound clinic appointments in (MONTH) and was not sure why and had to reschedule the appointment and made the appointment for 6/6/19. The interviewee indicated the resident was admitted to the hospital [MEDICAL CONDITION] to the bone. Progress note on 6/3/19 indicated the daughter was informed of transportation to wound clinic on for 6/6/19. (Name of Wound Clinic) Note for 6/9/19 indicated: Stage 4 ulcer on the left ischium that had been there for approximately 5 months. The pressure ulcer measured 2 cm x 1.5 cm x 5 cm. There was a sinus tract (tunneling) which measured 7 cm at 1 o'clock. There was undermining (tissue under the wound edges become eroded, resulting in a pocket beneath the wound edge) of 3 cm at 12 o'clock. The wound had beefy red granulation tissue and slough and muscle tissue was exposed. Stage 4 pressure ulcer to the sacrum that had an approximate 5 month duration. The pressure ulcer measured 7.7 cm x 7 cm x 0.3 cm. The pressure ulcer base had pink granulation, had slough and was covered with necrotic eschar. The pressure ulcer bed had exposed muscle tissue. Skin examination: .Stage 4 pressure ulcer of left Ischium that extends to hip joint. Gangrenous (death of tissue, caused by bacterial infection) large sacral ulcer need debridement treatment plan: [REDACTED] patient admitted to the hospital for IV antibiotics and for [MEDICAL CONDITION]. local anesthesia for sharp debridement. Excisional debridement of sacral ulcer performed. Large patch of eschar skin removed that exposed abscess. the entire ulcer was unroofed, removing large piece of gangrenous skin and exposed raw bone, eroded fragments of bone from the coccyx, deep abscess cavity. Left ischial ulcer extends deeply to left hip down to bone, necrotic bone is palpable, excisional debridement removed necrotic slough and necrotic bone. Pt (patient) has osteomylitis to pelvis and left hip. Needs admission for extensive wound care A (Name of Hospital) history and physical, dated 6/6/19 at 3:33 p.m., indicated: The resident was admitted to the hospital with [REDACTED]. The note indicated .I do not think this wound is curable. It would require an extensive surgery and likely muscle flaps to close . Assessment and Plan: Problem:[MEDICAL CONDITION], etiology sacral decubitus ulcer/osteomylitys vs infiltrate, Intravenous [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) A (Name of Hospital) Progress note dated 6/17/19 indicated: .Has very large ulcer in the sacral area with exposed bone. I think this is the source of his recent infection. Blood cultures are growing ,[MEDICAL CONDITION]. (a gram positive bacteria/intestinal bacteria). This is likely coming from the large ulcer in his sacral area. The ulcer would require diverting [MEDICAL CONDITION] and muscle flaps to heal. This is an incurable infection. I would not give him long term antibiotics . he has now developed [MEDICAL CONDITION]. Hospice is planned for the near future On 6/19/19 at 12:40 p.m., the Administrator, the DON, the Regional Director of Clinical Operations and the Regional Director of Operations were informed of the concerns with Resident B's pressure ulcers and asked if they could provide any additional information related to the development of the 2/20/19 pressure ulcer, the 3/29/19 pressure ulcer and any documentation of the wounds and wound clinic visits for (MONTH) 2019. On 6/19/19 at 2:20 p.m., the Regional Director of Clinical Operations indicated she had no additional information to provide related to the pressure ulcers for Resident B. 2. On 6/15/19 at 4:11 p.m., during a facility tour on the 2000 hall, the ADON (Assistant Director of Nursing) indicated Resident C had a pressure ulcer of the coccyx, but she was unsure of the stage. Upon entering Resident C's room there was a very strong foul odor. At that time, the ADON assisted the resident to turn onto her left side and LPN 3 pulled the paper disposable underpad down, which was stuck to her bottom. The disposable underpad was saturated with a greenish yellow drainage and the resident's dressing, which was dated 6/13/19 (Thursday) with (nurse initials) was so saturated it was no longer securely taped at the bottom of the dressing. LPN 3 indicated at that time, the dressing needed to be changed due to the amount of drainage and he would get the supplies. The resident, at the time of the observation, indicated she had this wound prior to admission and her wound physician came here to the facility to see her and that same wound physician had been treating her wound outside the facility prior to her admission. On 6/15/19 at 4:42 p.m., RN 4 verified the dressing to the right buttock was dated 6/13/19 (Thursday), with (nurses initials). She completed the dressing change. She removed the old dressing from the wound, which was saturated with greenish/yellow drainage. During an interview, on 6/15/19 at 6:15 p.m., RN 4 indicated the resident's dressing change was ordered for three times a week on Mondays, Wednesdays and Fridays and PRN (as needed for soilage and dislodgement). She checked the resident's dressing that morning to see if it needed to be changed and it did, but she did not change it because she was busy and did not have time. She generally checked the resident's dressing once a shift and had not gotten around to checking it that particular shift yet. The record review for Resident C was completed on 6/17/18 at 3:54 p.m. [DIAGNOSES REDACTED]. A plan of care, dated 4/19/19, indicated the resident had a potential impairment to skin integrity related to fragile skin with interventions that included, but were not limited to, keep skin clean and dry. A plan of care, dated 4/26/19, indicated the resident had a pressure ulcer and potential for pressure ulcer development related to immobility with interventions that included, but were not limited to, administer treatments as ordered and monitor for effectiveness. Physician orders [REDACTED]. The ETAR (Electronic Treatment Administration Record) lacked an order to change the resident's right ischium dressing PRN (as needed). The ETAR, dated 6/1/19 to 6/30/19 included, but was not limited to the following order: 5/31/19--Right Ischium: Calcium Alginate with foam border only one time a day every Monday, Wednesday and Friday for wound care. The Wound Physician wrote an order, dated 5/29/19, indicating Calcium Alginate/foam border only to right ischium three times a week and PRN. Admission Observation Tool-V5, dated 4/17/19 at 4:30 p.m., indicated the resident had skin areas in the following areas: Left trochanter (hip), which was a pressure ulcer measuring 3.5 cm x 2.0 cm x 0 cm (centimeters) Stage 1. Right heel which was a pressure ulcer measuring 2.0 x 2.0 x 0 cm. Stage I. Left heel, which was other measuring 3.0 x 3.0 x 0 cm. Stage I and classified as Boggy (mushy heel). Sacrum, which was a pressure ulcer measuring 4.0 x 3.0 x 0 cm with no staging. Right Gluteal fold, which was a pressure ulcer measuring 3.0 x 3.0 x 3.0 cm Stage IV. April 2019 Weekly Skin Checks indicated: 4/24/19 yes to Are there any skin conditions or changes, ulcers, or injuries .B3 Site/Description (No documentation available): 26) Left trochanter (hip), (53) Sacrum .B5. Comments/Summary: skin on sacrum is very fragile. wound dressing every day May 2019 Weekly Skin Checks indicated: 5/1/19 yes to .Are there any skin conditions or changes, ulcers, or injuries .B3. Site/Description: 26) Left trochanter (hip)/almost healed, 31) Right buttock/small drainage, no odor .B5. Comments/Summary: wound dressing change every day. 5/8/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .B3. Site/Description: (No documentation available) .B5. Comments/Summary: skin condition the same as before, one pressure ulcer on the right buttock. left side is almost healed. 5/15/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .B3. Site/Description: (No documentation available) .B5. Comments/Summary: skin condition is the same as before. left hip wound healed. right bottom wound is the same size, no odor, small drainage. 5/23/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .B3. Site/Description: (No documentation available) 5/30/19: no to .Are there any skin conditions or changes, ulcers, or injuries .B3. Site/Description: (No documentation available) (Documentation was electronically signed on 6/12/19) 5/30/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .B3. Site/Description: (No documentation available) (Documentation was electronically signed on 6/12/19) June 2019 Weekly Skin Checks indicated: 6/6/19: yes to .Are there any skin conditions or changes, ulcers, or injuries .B3. Site/Description: 31) Right buttock/pressure ulcer-admitted with (Documentation was electronically signed on 6/13/19) Skin Grid Pressure V7 reports indicated: 5/22/19: Progression of wound since last assessment: no change, date first observed: 4/17/19, pressure ulcer right buttock, 4.2 x 3.8 x 2.8 cm coded as a Stage IV, granulation tissue present, small amount serous drainage, wound improving, continue with current treatment orders of pack with saline moist gauze daily. 5/29/19: Progression of wound since last assessment: deteriorated, pressure ulcer right buttock, 7.8 x 5.6 x 3.5 cm coded as a Stage IV, granulation tissue present, medium amount blood tinged drainage, odor present, signs and symptoms of infection, Additional comments: Resident seen by (Name of Wound care Physician), call was placed to office yesterday due to deterioration of the wound. Wound was noted to increase in size, with increased drainage and odor. New orders received to change treatment to calcium alginate 3 x (times) week to right buttock wound and to do preventative foam to left buttockwound is not improving and the treatment orders were changed to calcium alginate three times a week. Wound Care Progress Note from (Name of Wound Physician's first visit note), dated 5/29/19, indicated Resident C had a right ischium pressure wound coded at a Stage IV measuring 10.0 x 5.7 x 3.6 cm. A new order was written to place calcium alginate/foam border to right ischium only three times a week and as needed, left ischium place cream only on good skin daily and discontinue gauze to right ischium. Resident C's record lacked wound assessments to show the progression of healing from 4/17/19 to 5/22/19 for the following pressure wounds: Left trochanter (hip), left heel, right heel, sacrum, and right gluteal fold. Nursing Assessment--Integumentary/Incision/Wound Assessment from (Name of Hospital) dated 6/17/19 at 2:45 p.m., indicated Resident C had pressure ulcers in the following areas on admission to the hospital: The resident's right buttock coded as an Unstageable pressure ulcer injury with purulent drainage and the surrounding tissue was [MEDICAL CONDITION] and red. The resident's left buttock was coded as an unstageable pressure ulcer injury. An Ostomy Note dated 6/18/19 at 3:09 p.m., from (Name of Hospital) indicated Resident C had the following pressure ulcers when she was admitted to the hospital: Right ischial pressure injury wound, coded as a Stage IV ulcer, moderate amount of drainage, large amount of reddened, scaly skin around the wound bed with several other similar locations on the other side of the buttocks (the appearance was consistent with Psoriasis), the resident reported she has battled. The wound measured 5.0 x 4.0 cm. The wound tracted posteriorly and inferiorly towards the pubis approximately 5 cm. New treatment order was santyl ([MEDICATION NAME] agent) moist saline gauze packing with a large sacral foam dressing to secure it. Change the dressing daily. Left ischial pressure injury wound, coded as an unstageable ulcer, foam dressing to cover. A Wound Care Note from (Name of Hospital), dated 6/19/19 at 10:00 a.m., indicated Resident C had pressure ulcers upon her admission to the hospital: Right Ischium wound was a pressure ulcer with the wound bed color was 80% red with 20% yellow slough. Tunneling and undermining were present. The periwound was macerated and there was serosanguinous drainage from the wound. Left Ischium wound was a pressure ulcer with the wound bed color 90% yellow slough with serous drainage. During an interview, on 6/19/19 am 10:43 a.m., Resident C's Wound Care Physician, with the DON in attendance, indicated if the dressing was saturated, dislodged or found off, it was his expectation the dressing would be replaced by the nursing staff at that time. On 6/19/19 at 12:40 p.m. the Administrator, the DON, the Regional Director of Clinical Operations and the Regional Director of Operations were informed of the concerns with Resident C's pressure ulcers and asked if they could provide any additional information related to Resident C's pressure wounds and any documentation of the wound. During an interview, on 6/19/19 at 1:09 p.m., the Regional Director of Clinical Operations indicated this resident did not have any other Skin Grid Pressure-V7 assessments from her admission on 4/17/19 until 5/22/19. She did not know of any other documentation regarding the assessment of the pressure ulcers other than the Admission Observation Tool-V5, dated 4/17/19 at 4:30 p.m. The first assessment of the right buttock pressure ulcer after the admission assessment, dated 4/17/19, was documented on 5/22/19. There were no other pressure ulcer wound assessments available. 6/20/19 at 5:20 p.m., the DON indicated the first wound assessment of this resident's pressure ulcer to the right ischium was 5/22/19. The assessment was completed when she discovered the wound was not being assessed and monitored by the wound team. A current policy titled Skin Care & Wound Management Overview dated 7/1/2016, provided by the Director of Nursing on 6/19/19 at 1:53 p.m., contained the following, .Definition: A pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a boy prominence, as a result of pressure or pressure in combination with shear and/or friction .Procedure/Prevention: 2. Complete an Admission Observation Tool. Identify areas of skin impairment and pre-existing signs .Treatment: 1. Select and complete the appropriate form a. Pressure Ulcer Documentation. Complete for all pressure ulcers. b. Skin Impairment Documentation. Complete for all skin impairment issues that require measurement to indicate if healing is occurring. 2. Review and select the appropriate treatment for [REDACTED]. Obtain a physician's orders [REDACTED]. 7. Evaluate effectiveness of interventions during the clinical meeting The Immediate Jeopardy that began on 2/20/19 was removed on 6/20/19 when the facility completed facility wide skin assessments of all resident to ensure pressure ulcers were identified for intervention and treatment, completed braden skin risk assessments, inserviced staff on pressure ulcer prevention, assessment and treatment, audited all wound clinic appointments for timeliness and began the monitoring process to ensure on-going assessment of skin to prevent the development of pressure ulcers, to ensure implementation of current pressure ulcer prevention, intervention, assessment and treatments and ensure wound clinic appointments were timely. The noncompliance remained a a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. This Federal tag relates to Complaint IN 593. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observations, interviews and record reviews, the facility failed to properly position a resident with a Gastrostomy tube ([DEVICE]) during care with a known history of aspiration pneumonitis and a recent hospitalization for a [DIAGNOSES REDACTED]. The Immediate Jeopardy began on (MONTH) 6, 2019, when the facility failed to properly position a resident with a [DEVICE] and a recent hospitalization for admission with a known history of aspiration pneumonitis during care. The Executive Director (ED), Interim Director of Nursing, and the Regional Director of Clinical Operations were notified of the Immediate Jeopardy (MONTH) 6, 2019 at 1:00 p.m. The Immediate Jeopardy was removed on (MONTH) 8, 2019, but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: On 5/6/19 at 5:35 a.m., while providing incontinence care to Resident B, one of two CNA'S lowered the head of the bed flat while the resident's [DEVICE] feeding was infusing at 50 ml (milliliters) per hour. The resident was observed using his accessory muscles of respirations (muscles only used when under high demand or respiratory dysfunction) to breathe while he laid flat. After the CNA's were questioned regarding the resident's head of bed (HOB) being flat and his tube feeding continued to infuse at the current rate, CNA 1 raised the HOB, while CNA 3 placed the resident's feeding pump on hold. At that time, when the CNA'S were questioned regarding who was responsible for placing the resident's feeding pump on hold, CNA 3 indicated she was not sure who was responsible for placing it on hold. She indicated, Honestly, sometimes I turn it off, but not all the time. CNA 3 was observed placing Resident B's feeding pump on hold, while indicating she often placed resident's feeding pumps on hold to provide care if the nurse was not available to do it. She was observed pointing to a button on Resident B's feeding pump, which indicated run. She indicated when she was finished with the resident's incontinence care, she pushed the run button, which started the feeding pump back up again. After the feeding pump was placed on hold CNA 1 lowered the HOB to a flat position again and the CNA's finished the resident's incontinent care. During an interview on 5/6/19 at 6:15 a.m., LPN 4 indicated the nurses were responsible for placing the feeding tube pumps on hold and restarting them. On 5/6/19 at 7:25 a.m., the Interim DON (Director of Nursing) was informed regarding Resident B's HOB being lowered with his tube feeding infusing at 50 ml per hour, CNA 3 was observed to place the resident's feeding pump on hold, then restarting it when his incontinence care was finished. The Interim DON indicated staff needed re-educated regarding [DEVICE]s. The record review for Resident B's record was completed on 5/6/19 at 9:00 a.m. [DIAGNOSES REDACTED]. (Name of Hospital) ER Physician Exam dated 5/2/19 , indicated .Medical Decision Making: he looks markedly better after aggressive suctioning here with therapy .talked about admission for continue work-up for concerns [MEDICAL CONDITION] in this complicated debilitated person .Recheck: MD Notes/Patient Care Notes: Impression: .#4 aspiration pneumonitis #5 [DEVICE] . Health Issues . ED Diagnosis: [REDACTED].Other foreign object in respiratory tract part unspecified causing other injury, initial encounter 5/2/19 The resident was readmitted to the facility on [DATE]. The resident's care plans were reviewed and there were no care plans found in his record addressing his [DEVICE] care regarding to keep the head of his bed raised to at least 30 degrees at all times. During an interview on 10:51 a.m., the Interim DON indicated the current document titled Nurse Aide Orientation/Training Guide provided by the Staffing Development Coordinator (SDC) indicated this was the facility's competency booklet for the CNA. A current document titled CNA Assignment Sheet 4000 undated, provided by CNA 9 on 5/6/19 at 11:33 a.m., did not contain any information regarding how the CNA'S were to care for the resident with his [DEVICE]. CNA 9 indicated she generally did not work on this unit, but all the assignment sheets were the same and the CNA'S looked at these as a guide to determine how to care for their residents. On 5/6/19 at 5:35 a.m., CNA's 1 and 3 were observed completing pericare for Resident B. The resident was observed to have contractions of his bilateral hands and feet. CNA's were observed to have to raise his bilateral arms on and off pillows due to the resident was unable to raise his own arms or move his bilateral hands. At that time CNA 1 indicated the resident was unable to move his hands or arms to pull his [DEVICE] out. The resident's progress notes were reviewed and the following were noted: On 3/2/2019 at 6:08 a.m., Patient's G tube came out, will send to ED to have it replaced. On 3/2/2019 at 6:44 a.m., Pt [DEVICE] came off, no active bleeding. pt sent out to ER for replacement. MD notified, unable to reach family at this time, day shift to update family. On 4/23/2019 at 9:13 p.m., Patient pull out PEG tube. Nurse is not comfortable continue care or replacing tube. Request patient be sent to ER. Send out to ER for PEG replacement. On 4/24/2019 at 10:53 p.m., Writer followed-up with (Name of Hospital) and was notified per hospital nurse that resident was admitted for observation after [DEVICE] reinsertion. Unit Manager made and floor nurse made aware at this time. During an interview on 5/6/19 at 11:42 a.m., the Interim DON indicated the SDC was having a hard time finding information to indicate what the CNA's responsibilities were regarding the [DEVICE]s. On 5/6/19 at 12:54 p.m., Regional Director of Clinical Operations provided a copy of the Indiana State Department of Health Nurse Aide Curriculum Chapter 14, dated (MONTH) 1998, Revised (MONTH) (YEAR), contained the following, .****Please note-bolded steps in the RCP's indicate Critical Steps .Lesson #14: .Key Terms: Aspiration-inhalation of food or drink into lungs which has the potential to cause pneumonia or death .Gastrostomy Tube ([DEVICE])-tube placed through the abdomen directly into the stomach and used to provide nourishment .III. Caring for a Resident with a Tube Feeding and the Resident at Risk for Aspiration A. Tube Feedings: 1. Feeding tubes are used when food cannot pass normally from the mouth into the esophagus and then into the stomach. The resident who is unable to take food or fluids by mouth, or is unable to swallow, may be fed through a tube .3. A gastrostomy tube ([DEVICE]) is a tube that is placed directly into the stomach for feeding .5. The resident who has a feeding should be observed frequently. If the pump is not working properly, the resident may receive the wrong amount of food or the fluid may enter too quickly. This can cause nausea, vomiting, and aspiration . Aspiration pneumonia may result if feeding enters the lungs .8. The [DEVICE] may become dislodged from the stomach, or the skin may become irritated at the site of insertion. Infection can occur with either tube, if infection control practices are not carefully followed. 9. The resident with a feeding infusing should not lie flat. The head of the bed should be elevated at least 30 degrees. Some procedures will need to be changed slightly for the resident with a feeding tube. For example, an occupied bed cannot be flattened to change the linen or to provide incontinence care with the feeding infusing. If the bed must be flattened, seek the nurse's assistance to turn off the pump prior to the procedure and turn the pump back on after the procedure. Your major responsibility concerning the resident with a feeding tube is to make regular observations and promptly report any problems . D. Risk of Aspiration. 1. Any resident with ordered thickened liquids, a pureed or mechanical soft diet, or having a [DIAGNOSES REDACTED]. 2. Residents at risk of choking/aspiration should be encouraged to sit up or remain with the head of the bed elevated for at least 30 minutes (or as long as tolerated) following consumption of food or fluids . A current policy titled [DEVICE] Patency dated 4/29/14 and revised 8/12/16, provided by the Interim DON (Director of Nursing) on 5/6/19 at 9:45 a.m., contained the following: .Policy: .Enteral feedings will be delivered by one of two methods: bolus or continuous feeding. Continuous feedings will utilize an electronic programmable pump to deliver the required amount over time. Continuous delivery may include intermittent periods when nutrition is not being delivered such as during showers or other procedures or when the physician order [REDACTED]. Residents on continuous or intermittent feeding will have the HOB (Head of Bed) elevated minimally 30 degrees during feeding and one hour after feeding . The immediate jeopardy that began on 5/6/19, was removed on 5/8/19, when the facility incorporated a system to ensure residents with [DEVICE]s who were at risk for potential complications such as; aspiration pneumonia up to death due to improper positioning and care of [DEVICE]s were positioned properly. A magnetic angle locator was placed on each resident's bed who had a [DEVICE] to allow the staff to have a method to validate the angle of the head of the bed at a minimum of 30 degrees. Each residents' care plan was updated. All the [DEVICE] resident's who were fed with their [DEVICE]s had a respiratory assessment completed. Nurses, CNA'S and QMA'S were educated on the proper positioning of the head of the residents' bed as it related to the enteral nutrition policy, Indiana State Department of Health Nurse Aide Curriculum regarding Activities of Daily Living--Nutrition/Hydration. III. Caring for a Resident with a Tube Feeding and the Resident at risk for aspiration and the facility policy Enteral Nutritonal Guideline. The Immediate Jeopardy was removed on (MONTH) 8, 2019, but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy because not all staff had been educated, and ensure monitoring of residents's with G tubes for compliance with proper positioning. This Federal tag relates to Complaint IN 607. 3.1-44(a)(2)

Based on record review and interview the facility failed to ensure physician orders [REDACTED]. (Resident D and B) This deficient practice resulted in Resident D being admitted to the hospital for Urinary Tract Infections and metabolic [MEDICAL CONDITION] secondary to UTI. Findings include: 1. The record for Resident D was reviewed on 09-28-15 at 1:30 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's MDS (Minimum Data Set) assessment, dated 09-23-15 indicated the resident was frequently incontinent of bladder. The current plan of care indicated the resident had bladder incontinence related to impaired mobility. Interventions to this plan of care included Monitor/document for s/sx. (signs and symptoms) of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increase temp. (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The record contained a physician order [REDACTED]. (catherize) if unable to get a clean catch urine. A Progress Note dated 09-06-15 indicated the resident was alert with confusion. Continues to c/o (complain of) dysuria. In and Out cath. per sterile technique to collect specimen for UA C & S done at 2330 (11:30 p.m.) A Progress Note dated 09-06-15 indicated a partial UA report have been called to (name of physician practice) No new orders at this time. The Progress Notes, dated 09-07-15 at 7:11 a.m., indicated Pt. (patient) exhibiting signs of disorientation and significant decline in mental status. Was attempting to give pt. pain medication. Pt. began chewing the spoon in an animal like manner and growling. Pt. was becoming loud with garbled and non coherent speech. Pt. did have urinalysis which did reveal abnormal findings. Culture no available at that time. Pt. symptoms called to (name of physician practice) and nurse who advised to send pt. to ER (emergency room ) due to no sensitivity result and not wanting to start pt on an ineffective ATB (antibiotic). The resident was transported to the local area hospital on 09-07-15 and admitted . A review of the hospital assessment and testing indicated the resident had an E. Coli (Escherichia Coli) urinary tract infection and metabolic [MEDICAL CONDITION] secondary to UTI. The nursing staff failed to obtain the urine specimen in a timely manner as ordered by the physician which resulted in the resident being transported to the local area hospital. 2. The record for Resident B was reviewed on 09-28-15 at 11:45 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's MDS assessment, dated 08-25-15, indicated the resident was occasionally incontinent of bowel and bladder. The resident's current plan of care indicated the resident has risk for bladder incontinence r/t (related to) active infections with symptoms of UTI, Physical limitations. Interventions to this plan of care included Monitor/document for s/sx. of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increase temp., urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. A review of the physician progress notes [REDACTED]. have (sic) increase confusion. Family requesting UA (urinalysis) . The record indicated the urine specimen was collected on 08-21-15 and reported to the facility on [DATE]. The urine culture indicated the resident's urine was amber in color, cloudy in clarity, contained 2+ in protein with few bacteria and mucus present. The culture and sensitivity indicated the organism was [MEDICATION NAME] faecalis > (greater than) 100 CFU (colony forming units) / ml (milliliters), and Pseudomonas. The physician was notified on 08-26-15, and [MEDICATION NAME](an antibiotic) 250 mg (milligrams) two times a day for seven days. A review of the Medication Administration Record [REDACTED] The resident did not receive the physician ordered medication again until 08-29-15, when the licensed nurse discovered an error when the order was entered into the electronic medical record as Cipro Tablet 250 mg - give one tablet by mouth two times a day every 7 day(s) for UTI for 7 days. The order was corrected and the antibiotic restarted on 08-29-15 and continued through 09-04-15. During an interview on 10-01-15 at 9:30 a.m., the Director of Nurses indicated the Licensed Nurse failed to enter the information correctly in the Electronic Medical record. This Federal tag relates to Complaints IN 598 and IN 240. 3.1-41(a)(1)

Based on record review and interview, the facility failed to ensure adequate supervision and assistive devices were identified and implemented to prevent a resident (Resident C) from suffering injuries when she fell from her wheelchair and received injuries to her head and left lower leg which required emergency transport to the hospital and subsequent treatment, including stitches. This deficient practice affected 1 resident of 3 reviewed for safety interventions in a sample of 5. Findings include: The record of Resident C was reviewed on 7/02/12 at 10:00 a.m. [DIAGNOSES REDACTED]. Resident C was admitted to the facility on [DATE]. An initial Minimum Data Set assessment, dated 3/23/12, indicated Resident C was moderately cognitively impaired, did not ambulate, and required staff assistance for all activities of daily living. A hospital "Discharge Summary," dated 3/08/12, indicated Resident C had been admitted to the hospital on [DATE] with a gangrenous right lower extremity. She underwent an above the knee amputation on 3/03/12, and was discharged to the facility on [DATE] for rehabilitation and wound care. A "Morse Fall Risk Scale" assessment was done on 3/09/12, with a resultant score of 75. A "Morse" score of 45 or higher is considered to be at high risk for falls. The assessment documented that Resident C had a history of [REDACTED]. Physician's admission orders [REDACTED]. A nurse's progress note dated 3/09/12 at 7:09 p.m., indicated Resident C had wheelchair and bed alarms and her bed in low position. Nurse's progress notes indicated: 3/08/12 9:31 p.m., "Received a (age of Resident C) old female pt. (patient) who is a new above the knee amputee on the right leg...She is legally blind, and not likely to notify staff of her needs, therefor staff needs to periodically check on her." 3/09/12 10:39 p.m., "...Pt. does not let staff know her needs...." 3/11/12 5:40 a.m. "Pt hallucinating during the night. Three separate occasions, the Pt. said "please help me to bed, I am outside...." 3/12/12, "Pt. has been transferred to (acute care hospital) for evaluation after sliding to the floor in the dining room. She sustained a cut to right eyebrow and a big skin tear to her lower left leg. Chair alarm was on and functioning. Leg rests were attached properly." During an interview with the Director of Nursing (D.O.N.) on 7/03/12 at 1:45 p.m., she indicated the above incident occurred at 6:00 p.m. on 3/12/12. She did not know the size of the eyebrow wound. She indicated the lower leg injury was 7 by 5 centimeters. She indicated that 911 was called and that staff applied pressure to both wound areas to control bleeding until the Emergency Medicine Technicians arrived and assumed care. Resident C returned to the facility on [DATE] after a 4 day hospital stay. A hospital "Health Patient Transfer Report" for Resident C, dated 3/16/12, indicated: "The patient is a (age of Resident C) old female who was brought to the ER from her nursing home after the patient fell out of her wheelchair and hit her head on the wood floor...there was a positive loss of consciousness...she does have approximately a 1.5 cm (centimeter) laceration over her right eyebrow. She does complain of left lower extremity pain by her skin tear. Review of systems: She does complain of head pain at her laceration and left lower extremity pain where there is a skin tear. Impression: 1. A (age of Resident C) year old who fell from a wheelchair and hit her head on the wood floor. 2. Question of odontoid fracture with question epidural versus subdural hematoma..." Resident C was discharged from the hospital back to the facility on [DATE]." A nurse's progress note of 3/16/12 at 9:48 p.m. indicated: "Received a (age of Resident C) yr old female pt. from (acute care hospital)...she has stitches above her right eyebrow, due to a recent fall...She has a skin tear to her lower left leg...There's need to anticipate her needs, as she's not likely to communicate her needs to staff." Care plans for Resident C initiated beginning 3/09/12 indicated no care plans for fall risk or other safety measures prior to Resident C returning from the hospital on [DATE]. Occupational and physical therapy evaluations were completed on 3/09/12. Neither evaluation had any assessment of, or recommendations for interventions, for Resident C's risk for injury secondary to falls, including but not limited to, a lack of assessment for wheelchair positioning or safety devices. During an interview on 7/03/12 at 4:00 p.m., with the Executive Director and Director of Nursing present, the D.O.N. indicated she believed the facility's responsibility to meet the safety needs of Resident C had been met, because the facility had implemented bed and chair alarms, a low bed, and had done a fall risk assessment on admission. She indicated she was aware no other safety assessments or interventions had been done. She indicated she believed that the facility was not obligated to develop care plans to meet a resident's individual needs prior to 21 days after a resident's admission to the facility. This federal tag relates to Complaint IN 370. 3.1-45(a)(2)