Every finding on record at Carmel Health & Living Community

Based on interview and record review, the facility failed to ensure a resident received supervision during incontinence care to prevent the resident from being rolled off the bed onto the floor for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B being hospitalized with an eight-millimeter frontal subdural hematoma.Findings include:During an interview, on 11/12/25 at 2:31 p.m., a family member of Resident B indicated she received a telephone call, on 10/1/25 at 6:00 a.m., Resident B had rolled out of bed when an aide was in the room. Typically, there were two staff members with her when care was provided due to Resident B's weight. She did not know where the other person was at the time of the fall. The resident was admitted to the hospital with a traumatic brain injury and bleeding on the brain.The clinical record for Resident B was reviewed on 11/13/25 at 11:50 p.m. The diagnoses included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis following a cerebral infarction which affected the left non-dominant side, and depression.An Occupation Therapy (OT) note, dated 9/30/25, indicated Resident B demonstrated left lateral leaning while in bed and required total assistance to reposition her hips and trunk to midline.A facility post-fall assessment, dated 10/1/25 at 5:50 a.m., indicated Resident B was lying in a supine position next to the bed after a witnessed fall. The resident was lying in bed prior to the fall. Staff were providing care to the resident, so she was partially clothed when she rolled out of the bed onto the floor. She was incontinent with urine. She received a skin tear to her bilateral arms and foot. She hit her head, so neuro checks were initiated, and she was sent to the hospital.A physician's progress note, dated 10/1/25 at 5:47 a.m., indicated Resident B had a witnessed fall earlier. She rolled out of bed during incontinent care in preparation for dialysis. She rolled over, rolled too far, and ended up on the floor. She attempted to grab the bed to prevent the fall and sustained three skin tears on her bilateral hands and feet with bleeding secondary to anticoagulation. She had a large skin tear observed on the right forearm and left hand. She also had a small skin tear on her right foot. She complained of back pain.A hospital neurosurgery consultation note, dated 10/1/25 at 9:15 a.m., indicated Resident B was brought into the hospital due to a fall at her facility. The resident indicated she was weak on her left side from a stroke. The facility staff rolled her but did not catch her and she rolled onto the floor. Imaging revealed a subdural hematoma (a type of bleeding inside the head where blood collects under the brain's outer covering. The blood collection could press against the brain and cause damage, was often life-threatening, and commonly resulted from a head injury). Neurosurgery was consulted. She complained of neck pain. Her CT (Computed Tomography) scan indicated she had an eight-millimeter-thick right frontal convexity subdural hematoma.A facility document, dated 10/2/25, indicated CNA 4 was educated on safe bed mobility assistance for residents. Staff were expected to provide proper bed mobility assistance using safe techniques to prevent resident falls and injuries. This included maintaining close supervision and ensuring bed height and the rails were adjusted as needed. Failure to follow the above expectations would result in progressive counseling, up to and including formal write-ups.A facility document, dated 10/2/25, indicated LPN 5 was educated on not leaving the room during care. Staff were expected to remain with the residents throughout the duration of care to ensure safety, provide assistance as needed, and maintain resident dignity. Leaving the resident during care was not acceptable and posed a risk of falls, injury, and emotional distress. Staff must complete the care task before exiting the room and ensure the residents were safe and comfortable prior to leaving the room. Failure to follow the above expectations would result in progressive counseling, up to and including formal write-ups.During an interview, on 11/12/25 at 11:43 a.m., the Executive Director (ED) indicated Resident B did not come back to the facility after her discharge from the hospital.During an interview, on 11/12/25 at 2:06 p.m., Speech Therapist 2 indicated Resident B's physical therapy evaluation indicated she was dependent on all activities of daily living care, which indicated she required a two-person physical assist for bed mobility. The evaluation recommended a Hoyer lift for transfers, which required a two-person physical assist. During an interview, on 11/12/25 at 2:24 p.m., CNA 3 indicated Resident B was a two-person physical assist for bed mobility due to the resident being unable to assist staff with turning. Each side of her bed was open to the room. She did have assist bars on her bed, which she was able to hold onto to steady herself. During an interview, on 11/12/25 at 3:07 p.m., CNA 4 indicated, on 10/1/25 at approximately 5:10 a.m., Resident B turned her call light on because she was incontinent with bowel and bladder and needed to be changed. CNA 4 and LPN 5 cleaned the resident up, but while cleaning her up, they noticed her bottom was excoriated. LPN 5 left the room to get some cream to treat her excoriated bottom. Resident B was lying on her left side facing the window. CNA 4 was on the resident's right side by the room door. CNA 4 had one hand on Resident B's back and her other hand on Resident B's thigh. Resident B's leg suddenly rolled over. As her leg rolled over the side of the bed, the rest of her body followed. Resident B could not turn onto her right side in the bed because of her stroke. CNA 4 could not get to that side of the bed to assist her to the floor. 911 was called and when the Emergency Medical Services (EMS) arrived at the facility, nine (9) EMS personnel were required to assist the resident off the floor and onto the stretcher. CNA 4 indicated Resident B's bed was too small for the resident to fit in comfortably due to her size.During an interview, on 11/12/25 at 3:49 p.m., LPN 5 indicated CNA 4 went into Resident B's room, on 10/1/25 at approximately 4:30 a.m., to get her ready for dialysis. While LPN 5 and CNA 4 were getting her cleaned up, LPN 5 noticed the resident's bottom was excoriated. LPN 5 left Resident B's side to get some cream for her bottom. Resident B was facing LPN 5 and CNA 4 was at her back. There was not much room in the bed for Resident B. The bed was a small size, and Resident B needed a bariatric bed. She weighed over 300 pounds.During an interview, on 11/13/25 at 10:44 p.m., the Environmental Service Director indicated all the beds on the unit where Resident B lived were collapsible beds. The collapsible bed was a standard bed frame and the sides of the bed extended from 36 inches to 42 inches. If the resident weighed over 300 pounds, then their bed would be extended to the 42-inch mark. The Environmental Service Director was observed to extend a bed from 36 inches to 42 inches. After the bed was extended, a bariatric mattress was placed on the bed. The Environmental Service Director indicated the hospital referral sent to the facility prior to admission would have indicated what size bed the resident needed. If the hospital indicated the resident needed a bariatric bed, then the collapsible bed would have been pulled out to 42 inches and a bariatric mattress placed on the bed.During an interview, on 11/13/25 at 10:55 p.m., the Central Supply staff member indicated he was responsible for making sure a bed was set up for a bariatric resident. Resident B's bed was the collapsible bariatric bed (42 inches). Typically, any resident who weighed 300 pounds and over, would have their bed expanded to 42 inches. Resident B also had a low air loss mattress instead of the traditional bariatric mattress.A current document for the Panacea 3500 bed, titled Direct Supply Owner's Manual, undated and provided by the ED on 11/13/25 at 12:25 p.m., indicated .Warning.use only as directed.The mattress should be a hospital-type mattress to allow for proper bed articulation. The mattress must be properly sized to meet entrapment zone dimensional guidelines published by the Food and Drug Administration (FDA).Warning-This device is only a tool as part of an overall care plan. Failure to comply with all instructions, warnings and precautions, or using the device for a purpose other than the recommended use, could result in bodily injury or death. This device is not designed to replace good caregiving practices including, but not limited to, Direct resident supervision.Warnings-General.Body weight should be evenly distributed over the surface of the bed.Do not allow resident to lie, sit or lean in such a way that the entire body weight is placed only on raised head or foot sections of the bed. This includes while assisting the resident in repositioning or transferring in or out of bed.Ensure the individual using this bed is properly positioned, particularly when the bed is being operated or moved. Do not let any body parts protrude over the side or between parts, especially when the bed is being operated or moved.This citation relates to Intake 26576113.1-45(a)(1)3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error for 1 of 1 resident reviewed for medication errors. (Resident 7) This deficient practice resulted in Resident 7 being hospitalized for toxic metabolic encephalopathy due to a high dose of medication and her end stage renal disease.Findings include:During an interview, on 9/24/25 at 11:52 a.m., Resident 7 indicated she went to the hospital after receiving medication which caused her to see things that were not there. She did not remember a lot about the occurrence, but her daughter became very concerned and insisted she be sent to the hospital.The clinical record for Resident 7 was reviewed on 9/23/25 at 1:17 p.m. The diagnoses included, but were not limited to, end stage renal disease, dependent on renal dialysis, toxic encephalopathy, zoster without complications, and adverse effect of drug medication.A care plan, dated 9/9/22, indicated Resident 7 received hemodialysis due to end stage renal disease.A nursing progress note, dated 7/4/25 at 11:56 a.m., indicated a telehealth video call was initiated by LPN 11 regarding increased pain and blisters to Resident 7's left buttock for the past week. The telehealth Nurse Practitioner 10 gave a diagnosis of shingles (a varicella-zoster virus) with a treatment plan of valacyclovir (an antiviral medication) 1 gram (gm) three times a day for 7 days.A physician's order, dated 7/4/25, indicated to administer valacyclovir 1 gm three times a day for 7 days.A review of the valacyclovir order entered into the electronic health record indicated there were safety alerts which were acknowledged by LPN 11 on 7/4/25 at 12:31 p.m. The alerts included, but were not limited to, severe alert, drug-to-condition interaction, valacyclovir 1 gm should be used with extreme caution with a chronic kidney disease stage 5 glomerular filtration rate of less than 15, a condition related to end stage renal disease. The override reason was the prescriber was aware of this potential risk and the resident's condition would be monitored.A progress note, dated 7/5/25 at 11:03 p.m., indicated a second telehealth video call was initiated and Resident 7 was reported as very anxious and complained of not being able to sleep. Resident 7 started valacyclovir 1 gm, on 7/4/25, and now seemed very giggly and stated she felt drunk. A physician's order was placed to administer hydroxyzine 25 mg and Benadryl 25 mg one time for insomnia and anxiety.An addendum to the second telehealth video call was made and indicated Resident 7 had experienced an onset of confusion which was not baseline behavior. Resident 7 had already received the one-time dose of hydroxyzine and Benadryl.A nursing progress note, dated 7/6/25 at 6:15 a.m., indicated Resident 7 was observed to be confused and not fully making sense. She indicated she could see colors and stripes on the walls. Telehealth was notified and a new order was given for a urinary analysis with culture and sensitivity and lab work.A nursing progress note, dated 7/6/25 at 9:35 a.m., indicated Resident 7 had been seen last night (7/5/25) by a telehealth video call for hallucinations and confusion. STAT (to be given high priority) labs were ordered and had yet to arrive at the facility to be obtained.A nursing progress note, dated 7/6/25 at 10:36 a.m., indicated Resident 7's daughter arrived at the facility after receiving a phone call from the facility explaining Resident 7 was confused and was experiencing hallucinations with laughing and crying fluctuations. The daughter indicated it was taking too long for labs and requested Resident 7 to be transferred to the hospital.The medication administration record, dated 7/4/25 to 7/6/25, indicated Resident 7 received 5 doses of valacyclovir and refused the dose on 7/6/25 at 6:00 a.m.A hospital document, dated 7/6/25 through 7/12/25, indicated Resident 7 arrived in the emergency room for hallucinations and confusion for the past 2 days after being started on a full dose of Valtrex (valacyclovir) in the last 3 to 4 days for Shingles. Resident 7 was admitted into the hospital for toxic metabolic encephalopathy due to the high dose Valtrex considering her end stage renal disease. Resident 7's encephalopathy slowly resolved after a couple of days once the Valtrex was stopped. The lab results obtained, on 7/6/25, while in the hospital included, but were not limited to, creatinine 6.18mg/do (high), GFR 6mL/min (low), and CrCl (creatine clearance rate) 7mL/min (low) resulting in toxic metabolic encephalopathy, a suspected side-effect of Valtrex 1 gm three times a day for the past few days with no dose reduction for end stage renal disease.A Nurse Practitioner note, dated 7/22/25, indicated Resident 7 was recently admitted into the hospital for altered mental status after receiving full dose Valtrex which improved after the medication had been stopped.During an interview, on 9/23/25 at 2:50 p.m., the Assistant Director of Nursing (ADON) indicated the telehealth providers had access to the electronic health record and all facility physician progress notes.During an interview, on 9/23/25 at 3:00 p.m., the Clinical Support Nurse 2 indicated the telehealth service was an on-call service and a new provider would see the resident for each telehealth visit. The telehealth providers had access to all the residents' records and when the telehealth provider gave an order the facility nurse entered the order into the resident's record. The valacyclovir dose for end stage renal disease would need to be reduced based on the resident's creatinine clearance rate. Clinical Support Nurse 2 reviewed Resident 7's labs and indicated her most recent kidney function labs did not include a creatine clearance rate, but it could have been determined by using a calculation formula for dosing.During an interview, on 9/24/25 at 10:36 a.m., Clinical Support Nurse 1 indicated the facility contacted the telehealth service and discussed the adverse drug event and all agreed the valacyclovir should have been stopped at the time of the second telehealth video call. The facility conducted a mock order entry for valacyclovir in Resident 7's electronic health record which resulted in 6 dosage alerts. The nurse which transcribed the order for valacyclovir was interviewed but the nurse was unable to recall if she informed the prescribing provider of the alerts.During an interview, on 9/24/25 at 10:36 a.m., Clinical Support Nurse 2 indicated during the mock order, 6 alerts were identified, and each alert was related to kidney disease and dosage.During an interview, on 9/25/25 at 12:21 p.m., LPN 7 indicated a lot of medication alerts were given for a lot of different medications. If the medication she entered resulted in alerts, she would contact the prescribing provider to inform the provider of the alerts and verify if the medication was to be given.During an interview, on 7/25/26 at 5:21p.m., the telehealth NP 10 indicated she received a telehealth video call from LPN 11, on 7/4/25, where she ordered valacyclovir 1 gm three times a day for 7 days. At the time of the video call, NP 10 could see Resident 7 had a diagnosis of chronic kidney disease, stage 3, but indicated end stage renal disease (ESRD) was not listed and she was not aware of the most recent labs. If she had been made aware of the diagnosis of ESRD and the resident's kidney function labs, she would have prescribed a renal dose of the medication and not a full dose. A person with a GFR below 15 would need a renal dose. The telehealth service could communicate with the facility by text messages and video call. She indicated LPN 11 did not contact her via text message or video call related to the valacyclovir order alerts and was unaware the valacyclovir order presented any alerts.A recent publication of PDR.net (physicians' desk reference) indicated .Valtrex is a deoxynucleotide analogue DNA polymerase inhibitor indicated for.Herpes Zoster.Warnings and precautions.Acute renal failure: May occur in elderly patients (with or without reduced renal function), patients with underlying renal disease who receive higher-than-recommended doses of Valtrex for their level of renal function.Use with caution in elderly patients and reduce dosage in patients with renal impairment.Dosage recommendations for adult patients with reduced renal function.Indication.Herpes zoster.Creatinine Clearance (mL/min).10-29 1 gram every 24 hours.<10 500mg every 24 hours.Patients requiring hemodialysis should receive the recommended dose of Valtrex after hemodialysis.Central nervous system adverse reactions, including agitation, hallucinations, confusion, delirium, seizures, and encephalopathy, have been reported in both adult and pediatric patients with or without reduced renal function and in patients with underlying renal disease who received higher-than-recommended doses of Valtrex for their level of renal function. Elderly patients are more likely to have central nervous system adverse reactions. Valtrex should be discontinued if central nervous system adverse reactions occur.A current facility policy, titled Transcribing Orders, undated and received from the Clinical Support Nurse 2 on 9/24/25 at 1:45 p.m., indicated .Physician orders will be transcribed to dedicated medical records timely, completely and accurately using acceptable standards of practice.Physician Telephone Orders.Must be timely. Orders should be written at the time they are received to avoid confusion later.Must be verified.Noted the prescribing physician's name along with the name and title of the name of the licensed professional who is documenting the order.3.1-48(c)(2)

Based on observation, interview and record review, the facility failed to ensure medications were dated when opened, were stored in the original pharmacy packaging, and a medication administration record matched the pharmacy label for a narcotic pain medication for 3 of 5 medication carts (500 Unit, 300 Unit and 700 Unit), 1 of 3 medication storage refrigerators (300 Unit), and 1 of 1 resident (Resident 55) reviewed for drug labeling and storage.Findings include:1. During an observation, on 9/23/25 at 8:17 a.m., with LPN 5 in attendance, the 500 Unit medication cart was found to have the following: a. One 30 milliliter (ml) bottle of morphine with approximately 15 ml left was found without an open date. b. Two 30 ml bottles of morphine with approximately 16 ml left in both bottles were found without an open date. One bottle had a damaged label. 2. During an observation, on 9/23/25 at 11:23 a.m., with LPN 7 in attendance, the 300 Unit medication cart was found to have the following: a. In the drawer of the cart was a clear plastic pouch with the name and room number of Resident 3 written in black and stapled closed. The pouch contained one oval yellow pill, one oval pink pill, one long oval yellow pill, and one round orange pill. The pills were not in the original pharmacy packaging. During an interview, on 9/23/25 at 11:23 a.m., LPN 7 indicated the medications belonged to a resident who did not take them. It was not from her shift. b. One bottle of morphine with approximately four (4) ml left was found without an open date. During an interview, on 9/23/25 at 11:31 a.m., LPN 7 indicated the medication should have had an open date. 3. In the medication storage room, on the 300 Unit, the refrigerator contained one bottle of tuberculin solution (used for tuberculosis testing) found open and without an open date. During an interview, on 9/23/25 at 11:34 a.m., LPN 7 indicated the bottle should have had an open date. The tuberculin solution was good for 30 days after opening. 4. During an observation, on 9/23/25 at 2:18 p.m., with RN 3 in attendance, the 700 Unit medication cart was found to have the following: a. One tube of neomycin-bacitracin-poly-HC eye ointment. The tube was observed to be well used (crushed) and was missing an open date. b. One bottle of olopatadine eye drops was found open without an open date. During an interview, on 9/23/25 at 2:18 p.m., RN 3 indicated the date had been on the top of the lid of the medication container. 5. During an observation and interview, on 9/23/25 at 3:32 p.m., the Assistant Director of Nursing (ADON) indicated when a PRN (as needed) medication was ordered and the resident had routine order for the same medication, the nurses could use the PRN dose from the scheduled medication card. The Assistant Director of Nursing reviewed Resident 55's Oxycodone drug record and the medication administration record (MAR) and indicated the medication label on the drug record did not match the medication order on the MAR. She indicated the instructions related to how many times a day had changed, and the nurse should have put a sticker with the new order on the old card. She was unsure how the nurses were verifying the 5 rights of administration without the correct label. The clinical record for Resident 55 was reviewed on 9/19/25 at 2:55 a.m. The diagnoses included, but were not limited to, pain, opioid dependence, and long-term use of drug therapy. A physician's order for Oxycodone 10mg (milligrams) was changed from two times a day to three times a day on 6/6/25. A physician's order for Oxycodone 10 mg was changed from two times a day as needed to two times a day every 12 hours as needed on 6/10/25. The controlled drug record, dated 6/4/25 to 6/14/25, indicated to administer Oxycodone 10 mg two times a day. The controlled drug record, dated 6/15/25 to 6/25/25, indicated to administer Oxycodone 10 mg two times a day. A current facility policy, titled MEDICATION LABELING, undated and received from the Executive Director on 9/23/25 at 10:34 a.m., indicated .Should the attending physician change a medication order for amount to be administered, the nurse may place a change of order-check chart label on the container indicating there is a change in directions for use. A current facility policy, titled Medication Administration General Policies &Procedures, undated and received from the Clinical Support Nurse 2 on 9/24/25 at 1:45 p.m., indicated .Medications are administered as prescribed in accordance with good nursing principles and practices.The label on each medication container shall be read 3 times and compared against the order on the MAR.The nurse or approved designee is responsible for checking to see that the drug and the dosage schedule on the resident's MAR matches the label on the drug's container. The nurse is to check the physician's order for the correct dosage schedule if.The drug container is marked with a signal-type label indicating a recent change in directions for use. A current facility policy, titled MEDICATION LABELING, undated and received from the Executive Director on 9/23/25 at 10:34 a.m., indicated .Contents are not to be transferred from one container to another .Medication containers having soiled, damaged, incomplete, illegible or confusing labels are returned to the dispensing pharmacy for re-labeling A current facility policy, titled MEDICATION ADMINISTRATION: GENERAL POLICIES & PROCEDURES, undated and received from Corporate Support Nurse 2 on 9/24/25 at 1:45 p.m., indicated .Check expiration date on package/container. When opening a multi-dose container or pen, place the date on the container 3.1-25(g)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(4) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(k)(7)

Based on observation, interview and record review, the facility failed to ensure narcotic reconciliation was documented as completed, medications were available without interruptions in administration, and to ensure accurate administration documentation and destruction by obtaining two nurse's signatures for 3 of 3 medication carts (500 Unit, 700-1 Unit, 800 Unit) and 2 of 2 residents (Resident 138 and 55) reviewed for pharmacy services.Findings include:1. A facility narcotic reconciliation document, for the 500 Unit, was missing signatures to indicate the narcotic reconciliation was completed on 9/10/25 for the on-coming night shift, on 9/13/25 for the on-coming night shift, on 9/15/25 for the on-coming and off-going evening shift, and on 9/17/25 for the on-coming night shift. During an interview, on 9/23/25 at 8:27 a.m., LPN 6 indicated the nurses were to sign on/off on the narcotic count sheet every shift. 2. A facility narcotic reconciliation document, for the 700-1 Unit, was missing signatures to indicate the narcotic reconciliation was completed on 9/22/25 for the on-coming and off-going evening shift. 3. A facility narcotic reconciliation document, for the 800 Unit, was missing signatures to indicate the narcotic reconciliation was completed on 9/1/25 for the on-coming and off-going evening shift. During an interview, on 9/23/25 at 2:36 p.m., LPN 8 indicated staff were to sign the narcotic count sheet when they took over the cart and when they surrendered the cart. During an interview, on 9/24/25 at 9:52 a.m., Clinical Support Nurse 2 indicated the facility assured the narcotic count was completed using the sign on and off count sheets used at the end of each shift. 4. The clinical record for Resident 138 was reviewed on 9/19/25 at 9:58 a.m. The diagnoses included, but were not limited to, benzodiazepine dependence, congestive heart failure, fluid overload, and age-related debility. A progress note, dated 9/16/25 at 3:55 p.m., indicated Resident 138 was admitted to the facility. A hospital Discharge summary, dated [DATE], indicated to take Valium (a benzodiazepine used for anxiety, seizures, muscle spasm, and alcohol withdrawal) 5 milligrams (mg) one half tablet two times daily. A physician's order, dated 9/17/25 and an end date of 9/17/25, indicated to give Valium 5 mg twice per day. The Medication Administration Record (MAR) indicated the morning dose was not given with a comment of need new script. A physician's order, dated 9/17/25, indicated to give Valium 5 mg one half tablet two times daily. The MAR indicated the evening dose was unavailable. Resident 138 missed 3 doses of Valium after she was admitted to the facility. A nursing progress note, dated 9/17/25 at 11:29 p.m., indicated Resident 138 requested Valium earlier in the shift. The medication should be delivered later tonight. Resident 138 indicated she thought she was experiencing withdrawal symptoms and called 911 herself. During an interview, on 9/22/25 at 12:05 p.m., RN 20 indicated the facility did not have Valium in the dosage Resident 138 was prescribed in the Emergency Drug Kit (EDK). The facility could do a stat (high priority) order to get the medication delivered quicker. She was not sure if there was documentation of a stat order. During an interview, on 9/23/25 at 11:02 a.m., Unit Manager 22 indicated he was unsure about the details of the Valium issue, but the facility could do stat orders for the pharmacy to deliver medication quicker. During an interview, on 9/24/25 at 11:16 a.m., Clinical Support Nurse 2 indicated when the nurse entered the order for Resident 138 on admission, they entered Valium 5 mg 1 tablet twice per day, instead of 5 mg one half tablet twice per day. The order was put in incorrectly and they had to fix it. 5. During an interview, on 9/18/25 at 12:07 p.m., Resident 55 indicated the facility ran out of her pain medication quite often. She had gone several days without a medication pain patch. During an interview, on 9/19/25 at 12:27 p.m., Resident 55's daughter indicated her mother's pain patch had been unavailable on several occasions. Her mother had gone 3 days without the pain patch in August, and she was concerned with her mother having withdrawal symptoms. During an interview, on 9/24/25 at 8:21 a.m., Resident 55 indicated she had chronic pain due to back related issues. She had a pain patch and took a pain pill. If the pain patch fell off before it was due to be changed, a new one would not be placed until the date it was due to be changed. Sometimes, the nurse would cover the pain patch with clear dressing to help the patch stay on, but not every nurse did. The clinical record for Resident 55 was reviewed on 9/19/25 at 2:55 a.m. The diagnoses included, but were not limited to, pain, opioid dependence, and long-term use of drug therapy. A care plan, dated 5/21/24, indicated pharmaceutical needs would be provided by the nursing staff. A care plan, dated 5/21/24, indicated Resident 55 had chronic low back pain with chronic and ongoing opioid dependence. A care plan, dated 5/20/24, indicated pain medications were to be given according to the physician's orders and patient request. A physician's order, dated 6/7/25, indicated to administer a Fentanyl 50 mcg/hr (microgram per hour) schedule II patch every 72 hours with instructions to remove the previous patch prior to applying a new patch, rotate sites, and destroy the patch being removed with another nurse. The controlled drug records indicated the facility did not have a record count for Fentanyl from 7/4/25 to 7/10/25 and from 8/15/25 to 8/20/25. The Medication Administration Record (MAR) indicated Fentanyl was unavailable on 7/7/25 and 8/18/25. The controlled drug record indicated when the patch was removed, it must be immediately destroyed and witnessed with two nurse signatures. The Fentanyl patch was removed or fell off and lacked documentation of a nurse's signature and/or a second nurse witness signature for the following dates: On 6/10/25, there was no documentation for removal or witness signature. On 6/11/25, it was documented fell off on MAR, there was no documentation of destruction. On 6/13/25, there was no documentation for a witness signature. On 6/16/25, there was no documentation for a witness signature. On 6/19/25, there was no documentation for removal or witness signature. On 6/22/25, there was no documentation for a witness signature. On 6/25/25, there was no documentation for removal or witness signature. On 6/28/25, there was no documentation for a witness signature. On 7/1/25, there was no documentation for a witness signature. On 7/4/25, there was no documentation for removal or witness signature. On 7/13/25, there was no documentation for removal or witness signature. On 7/16/25, there was no documentation for a witness signature. On 7/19/25, there was no documentation for removal or witness signature. On 7/22/25, it was documented fell off, there was no documentation of destruction. On 7/25/25, there was no documentation for removal or witness signature. On 7/28/25, there was no documentation for removal or witness signature. On 7/31/25, there was no documentation for a witness signature. On 8/3/25, there was no documentation for a witness signature. On 8/6/25, there was no documentation for removal or witness signature. On 8/9/25, there was no documentation for removal or witness signature. On 8/12/25, there was no documentation for removal or witness signature. On 8/15/25, there was no documentation for removal or witness signature. On 8/20/25, there was no documentation for removal or witness signature. On 8/23/25, there was no documentation for removal or witness signature. On 8/26/25, there was no documentation for a witness signature. On 8/30/25, there was no documentation for a witness signature. The MAR, dated July 2025, had inconsistent documentation related to the Fentanyl patch placement and indicated the following: On 7/7/25, from 7 a.m. to 3 p.m., it was documented as unavailable. From 3 p.m. to 11 p.m., it was documented as not in place. From 11 p.m. to 7 a.m., it was documented as on the left shoulder. On 7/8/25, from 7 a.m. to 3 p.m., it was documented as N/A. From 3 p.m. to 11 p.m., it was documented as on the upper back. From 11 p.m. to 7 a.m., it was documented as O. On 7/9/25, all three shifts were documented as N/A The MARs, dated June 2025 and August 2025, also contained inconsistent documentation related to the Fentanyl patch placement. After review of the progress notes, controlled drug records, and the MAR, an actual time frame the Fentanyl was unavailability and the missed administrations for Resident 55 was unable to be determined. During an interview, on 9/23/25 at 11:19 a.m., LPN 12 indicated two nurses would need to sign off on the destruction of the Fentanyl patches. During an interview, on 9/23/25 at 3:58 p.m., the Director of Nursing (DON) reviewed the MAR and indicated the documentation in the MAR was not clear or consistent. During an interview, on 9/23/25 at 3:32 p.m., the Assistant Director of Nursing (ADON) indicated most medications were on auto-refill unless the medication was a narcotic. If the medication needed a new prescription, the pharmacy would contact the facility. Fentanyl patch removal would need a signature from the nurse who removed the patch and a second nurse for destruction of the old patch. A current facility policy, titled Resident Rights, dated 6/6/19 and received from the Clinical Support Nurse 2 on 9/24/25 at 1:31 p.m., indicated .Federal and state law as guarantee certain basic rights to all residents of our community. These rights include the resident's right to.Equal access to quality care.Receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. A current facility policy, titled Medication Administration: General Policies & Procedures, undated and received from the Clinical Support Nurse 2 on 9/24/25 at 1:45 p.m., indicated .Medications are administered as prescribed in accordance with good nursing principles and practices. A current facility policy, titled Drug Disposal, undated and received from the Clinical Support Nurse 2 on 9/24/25 at 1:31 p.m., indicated .The nurse or nurses witnessing the drug destruction is/are responsible for.the following information.entered on a medication destruct record.date of destruction.method of destruction.signatures of the witnesses. A current facility policy, titled Managing Controlled Substances, undated and received from the Clinical Support Nurse 2 on 9/24/25 at 1:31 p.m., indicated .Drugs with high abuse potential are subject to special handling.disposal and record keeping.Schedule II contains drugs with an extremely high abuse potential.it is to be destroyed in the presence of two.licensed nurses.The disposal must be documented on the proof-of-use record on the line representing that dose. A current facility policy, titled CONTROLLED SUBSTANCE RECONCILIATION, undated and received from the Director of Nursing on 9/23/25 at 2:52 p.m., indicated .Each facility should verify the quantity of controlled substances(s) on hand as well as the number of accompanying count sheets at the end of each nursing shift 3.1-25(a) 3.1-25(e)(3) 3.1-25(s)(6) 3.1-25(s)(7) 3.1-25(s)(8)

Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team (IDT) determined self-administration of medications was clinically appropriate and notation of the determinations were documented in the resident's medical record and care plan for 1 of 1 resident reviewed for self-administration of nebulizer treatments. (Resident 113)Findings include:During an observation and interview, on 9/19/25 at 9:54 a.m., Resident 113 was observed to be in her room. She had a nebulizer machine with fluid in the nebulizer medicine cup. Resident 113 indicated the nebulizer was set up for her and she forgot to do it. The clinical record for Resident 113 was reviewed on 9/19/25 at 10:04 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, and generalized anxiety disorder.A physician's order, dated 7/8/25, indicated to administer 3 milliliters of albuterol sulfate 2.5mg/3mL (0.083 %) solution via inhalation upon rising between 7:00 a.m. and before bedtime between 6:00 p.m. and 10:00 p.m.The resident did not have an assessment, physician order, or a care plan to self-administer nebulizer treatments at the time of the record review.During an interview, on 9/19/25 at 10:13 a.m., RN 3 indicated Resident 113 had an evening nebulizer treatment. She had not been in the resident's room yet and she was not sure if the resident could self-administer nebulizer treatments. During an interview, on 9/24/25 at 9:52 a.m., the Clinical Support Nurse 2 indicated the resident needed to have an assessment, physician's order to self-administer medications and the self-administration needed to be care planned.A current facility policy, titled BEDSIDE MEDICATIONS AND SELF-ADMINISTRATION OF MEDICATIONS, undated and received from the Administrator on 9/23/25 at 9:05 a.m., indicated .if a resident desires to self-administer an assessment is conducted 3.1-11(a)

Based on interview and record review, the facility failed to ensure blood pressure medications were held according to the physician's orders for 2 of 3 residents reviewed for quality of care. (Resident 13 and 96)Findings include:1. The clinical record for Resident 13 was reviewed on 9/22/25 at 3:09 p.m. The diagnoses included, but were not limited to, hypotension (low blood pressure), repeated falls, weakness, unsteadiness on feet, hypertensive heart disease without heart failure, and essential primary hypertension. A physician's order, dated 6/3/25, indicated to administer midodrine (a medication used to raise blood pressure) 5 milligrams (mg) every 8 hours with special instructions to hold the medication for a systolic blood pressure greater than 140. A Medication Administration Record (MAR), dated August 2025, indicated the midodrine was administered with systolic blood pressure greater than 140 on the following dates and times:On 8/3/25 at 8:00 a.m., with a systolic blood pressure of 152.On 8/17/25 at 4:00 p.m., with a systolic blood pressure of 142. On 8/27/25 at 4:00 p.m., with a systolic blood pressure of 145. A MAR, dated August 2025, indicated midodrine was held with a systolic blood pressure of less than 140, without documentation the resident had refused, on the following dates and times:On 8/1/25 at 12:00 a.m., with a systolic blood pressure of 124 and at 4:00 p.m., with a systolic blood pressure of 134.On 8/2/25 at 12:00 a.m., with a systolic blood pressure of 134 and at 8:00 a.m., with a systolic blood pressure of 120. On 8/3/25 at 12:00 a.m., with a systolic blood pressure of 129. On 8/6/25, all 3 doses were administered with a systolic blood pressure of 127 and 137 with an administration note which indicated the blood pressure was too high for the medication. On 8/7/25, all 3 doses were administered with a systolic blood pressure of 129 and 136. On 8/8/25 at 12:00 a.m., with a systolic blood pressure of 136.On 8/9/25 at 4:00 p.m., with a systolic blood pressure of 133.On 8/10/25 at 12:00 a.m., with a systolic blood pressure of 139.On 8/11/25 at 12:00 a.m., with a systolic blood pressure of 129 and at 4:00 p.m., with a systolic blood pressure of 124. On 8/12/25 at 12:00 a.m., with a systolic blood pressure of 129. On 8/13/25 at 12:00 a.m., with a systolic blood pressure of 125.On 8/14/25 at 12:00 a.m., with a systolic blood pressure of 139 and at 4:00 p.m., with a systolic blood pressure of 139.On 8/15/25 at 12:00 a.m., with a systolic blood pressure of 119.On 8/19/25 at 12:00 a.m., with a systolic blood pressure of 124 and at 4:00 p.m., with a systolic blood pressure of 139.On 8/20/25 at 12:00 a.m., with a systolic blood pressure of 125.On 8/24/25 at 12:00 a.m., with a systolic blood pressure of 134 and at 4:00 p.m., with a systolic blood pressure of 125. On 8/25/25 at 12:00 a.m., with a systolic blood pressure of 136. On 8/26/25 at 4:00 p.m., with a systolic blood pressure of 128. On 8/27/25 at 12:00 a.m., with a systolic blood pressure of 129.On 8/28/25 at 4:00 p.m., with a systolic blood pressure of 127. On 8/29/25 at 12:00 a.m., with a systolic blood pressure of 131. A Medication Administration Record (MAR), dated September 2025, indicated the midodrine was administered with systolic blood pressure greater than 140 on the following dates and times:On 9/1/25 at 4:00 p.m., with a systolic blood pressure of 146.On 9/3/25 at 4:00 p.m., with a systolic blood pressure of 154. On 9/5/25 at 4:00 p.m., with a systolic blood pressure of 146.On 9/7/25 at 8:00 a.m., with a systolic blood pressure of 144. On 9/8/25 at 8:00 a.m., with a systolic blood pressure of 161.On 9/9/25 at 8:00 a.m., with a systolic blood pressure of 157.On 9/11/25 at 12:00 a.m., with a systolic blood pressure of 144. On 9/12/25 at 8:00 a.m., with a systolic blood pressure of 153. On 9/21/25 at 8:00 a.m., with a systolic blood pressure of 155. A MAR, dated September 2025, indicated midodrine was held with a systolic blood pressure of less than 140, without documentation the resident had refused, on the following dates and times:On 9/2/25 at 12:00 a.m., with a systolic blood pressure of 134 and at 4:00 p.m., with a systolic blood pressure of 137.On 9/3/25 at 12:00 a.m., with a systolic blood pressure of 124. On 9/5/25 at 12:00 a.m., with a systolic blood pressure of 139. On 9/6/25 at 12:00 a.m., with a systolic blood pressure of 130.On 9/7/25 at 12:00 am., with a systolic blood pressure of 124. On 9/8/25 at 12:00 a.m., with a systolic blood pressure of 121.On 9/10/25 at 12:00 a.m., with a systolic blood pressure of 134. On 9/12/25 at 12:00 a.m., with a systolic blood pressure of 123. On 9/16/25 at 12:00 a.m., with a systolic blood pressure of 122 and at 4:00 p.m., with a systolic blood pressure of 136.On 9/20/25 at 12:00 a.m., with a systolic blood pressure of 119.On 9/23/25 at 12:00 a.m., with a systolic blood pressure of 123. During an interview, on 9/25/25 at 9:45 a.m., LPN 9 indicated the midodrine medication should not have been administered when the systolic blood pressure was over 140. The nurse's initials would be in parenthesis if the medication was not given. If the resident refused medication, there would be a comment on the MAR. 2. The clinical record for Resident 96 was reviewed on 9/23/25 at 9:17 a.m. The diagnoses included, but were not limited to, peripheral vascular disease, diastolic congestive heart failure, tachycardia, chronic respiratory failure with hypoxia, stage 2 chronic kidney disease, and essential primary hypertension. A physician's order, dated 9/6/24, indicated to administer clonidine (a medication to lower blood pressure) 0.1 mg as needed for a systolic blood pressure greater than 170 twice a day. A physician's order, dated 9/17/24, indicated to administer clonidine as needed twice a day for a systolic blood pressure greater than 170. A MAR, dated August 2025, indicated clonidine was administered with a systolic blood pressure less than 170 on the following dates:On 8/1/25, in the a.m. and p.m. On 8/2/25, in the a.m. and p.m., On 8/3/25, in the a.m. and p.m., On 8/4/25, in the a.m. On 8/5/25, in the a.m. and p.m. On 8/6/25, in the a.m. On 8/7/25, in the a.m. and p.m. On 8/8/25, in the a.m. On 8/9/25, in the a.m. and p.m. On 8/10/25, in the a.m. and p.m. On 8/12/25, in the a.m. On 8/13/25, in the a.m. On 8/14/25, in the a.m. On 8/15/25, in the a.m. On 8/16/25, in the a.m. and p.m. On 8/18/25, in the a.m. On 8/19/25, in the a.m. and p.m. On 8/20/25, in the a.m. and p.m. On 8/21/25, in the a.m. On 8/22/25, in the a.m. On 8/23/25, in the a.m. On 8/24/25, in the p.m. On 8/26/25, in the a.m. On 8/27/25, in the a.m. and p.m., On 8/28/25, in the a.m. On 8/29/25, in the a.m. and p.m. On 8/30/25, in the a.m. On 8/31/25, in the a.m. A MAR, dated September 2025, indicated clonidine was administered with a systolic blood pressure less than 170 on the following dates: On 9/1/25, in the a.m. On 9/2/25, in the a.m. On 9/3/25, in the a.m. On 9/4/25, in the a.m. On 9/5/25, in the a.m. and p.m. On 9/6/25, in the a.m. On 9/7/25, in the a.m. On 9/8/25, in the a.m. On 9/9/25, in the a.m. On 9/10/25, in the a.m. On 9/11/25, in the a.m. On 9/12/25, in the p.m. On 9/13/25, in the a.m. On 9/14/25, in the a.m. and p.m. On 9/17/25, in the a.m. and p.m. On 9/18/25, in the a.m. and p.m. On 9/20/25, in the p.m. On 9/21/25, in the p.m. On 9/24/25, in the a.m. During an interview, on 9/25/25 at 11:00 a.m., the Clinical Support Nurse 2 indicated the clonidine order should have been as needed for a systolic blood pressure greater than 170 and not given if the blood pressure was less than 170. A current facility policy, titled MEDICATION ADMINISTRATION: GERNERAL POLICIES & PROCEDURES, received from the Clinical Support Nurse 2 on 9/24/25 at 1:45 p.m., indicated .All medications are to be administered only as prescribed by a physician. A current facility policy, titled Resident Rights, dated 6/6/19 and received from the Clinical Support Nurse 2 on 9/24/25 at 1:31 p.m., indicated .Federal and state laws guarantee certain basic rights to all residents of our community. These rights include the resident's right to.Equal access to quality care.Receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. A current facility policy, titled Transcribing Orders, undated and received from the Clinical Support Nurse 2 on 9/24/25 at 1:45 p.m., indicated .Physician orders will be transcribed to dedicated medical records timely, completely and accurately using acceptable standards of practice.Physician Telephone Orders.Must be timely. Orders should be written at the time they are received to avoid confusion later.Must be verified.Noted the prescribing physician's name along with the name and title of the name of the licensed professional who is documenting the order. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure oxygen and nebulizer tubing lines were dated and a physician order was in place for the use of oxygen for 3 of 5 residents reviewed for respiratory care. (Resident 12, 113 and 138)Findings include: 1. During an observation, on 9/18/25 at 10:21 a.m., Resident 12 was receiving oxygen via nasal cannula. The oxygen line did not have a date to show when it was last changed. The resident had a nebulizer machine on a gray plastic dresser. The nebulizer was not in use, and the mask was observed to be stored next to the machine and not in a storage bag. The clinical record for Resident 12 was reviewed on 9/24/25 at 3:23 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), cough, and age-related debility. A physician's order, dated 9/15/23, indicated to change and date the oxygen tubing, humified bottle, and the nebulizer tubing every week on Sunday and as needed. During an interview, on 9/18/25 at 10:28 a.m., QMA 4 indicated the oxygen line, and the nebulizer line should have been dated. The nebulizer mask should have been stored in a bag, but she did not know where the storage bag was. 2. During an observation, on 9/19/25 at 10:32 a.m., Resident 113 was receiving oxygen and had a nebulizer machine with fluid in the nebulizer medicine cup. The oxygen line and nebulizer line were not dated. The clinical record for Resident 113 was reviewed on 9/19/25 at 10:04 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, and generalized anxiety disorder. A physician's order, dated 12/29/22, indicated to change and date the oxygen tubing, humified bottle, and the nebulizer tubing every week on Sunday and as needed. 3. During an observation, on 9/18/25 at 9:58 a.m., Resident 138 was receiving oxygen at 3 liters per minute. During an observation, on 9/18/25 at 3:09 p.m., Resident 138 was receiving oxygen at 3 liters per minute. The clinical record for Resident 138 was reviewed on 9/19/25 at 9:58 a.m. The diagnoses included, but were not limited to, congestive heart failure, fluid overload, and age-related debility. There was no physician's order for oxygen located in the resident's clinical record. During an interview, on 9/18/25 at 3:17 p.m., Registered Nurse (RN) 20 indicated Resident 138 received oxygen, she did not see an oxygen order, and there should be a physician's order for the use of oxygen. During an interview, on 9/18/25 at 3:20 p.m., RN 21 indicated a resident should have a physician's order for the use of oxygen. During an interview, on 9/25/25 at 10:43 a.m., the Clinical Support Nurse 1 indicated the facility did not have a policy related to the nebulizer machine and it fell under the respiratory/oxygen policy/procedure. A current facility procedure, titled .OXYGEN ADMINISTRATION SKILLS VALIDATION dated 3/4/24 and received from the Corporate Support Nurse on 9/19/25 at 11:38 a.m., indicated .Wash hands and gather the necessary supplies.Tape – for labeling the date and initials of the preparer.Date and initial tape and attach to tubing.Verify physician's order for the liter flow, method of delivery, and length of administration prior to administering oxygen. 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure an active physician's order for hemodialysis and monitoring before and after dialysis was obtained for 1 of 1 resident reviewed for dialysis. (Resident 7)Findings include:During an observation, on 9/19/25 at 9:39 a.m., Resident 7 was not in her room, and a staff member indicated the resident had gone to dialysis.During an observation, on 9/22/25 at 9:10 a.m., Resident 7 was not in her room, and a staff member indicated the resident had gone to dialysis.During an observation and interview, on 9/24/25 at 11:52 a.m., Resident 7 was in her room and had just finished eating her lunch after returning from dialysis. She indicated she had been receiving dialysis for a few years.The clinical record for Resident 7 was reviewed on 9/23/25 at 1:17 p.m. The diagnoses included, but were not limited to, end stage renal disease (ESRD), chronic kidney disease stage 3, and dependence on renal dialysis.A care plan, dated 9/9/22, indicated Resident 7 received hemodialysis due to end stage renal disease.A physician's order, dated 7/12/25, indicated to administer midodrine (a medication to treat low blood pressure) before dialysis every Monday, Wednesday and Friday.An active physician's order for dialysis was not located in the electronic health record.Physician's orders which indicated Resident 7 received dialysis on Monday, Wednesday and Friday, was to have a pre dialysis assessment completed before treatment, and a post dialysis assessment completed after treatment was discontinued on 7/6/25.The electronic health record indicated Resident 7 was discharged to the hospital on 7/6/25 and was readmitted into the facility on 7/12/25.A hospital discharge document, dated 7/12/25, indicated the care needs after discharge for post-acute services was dialysis.During an interview, on 9/23/25 at 3:07 p.m., the Assistant Director of Nursing (ADON) reviewed the physician's orders and indicated Resident 7 did not have an active physician's order for dialysis or adequate monitoring in place.During an interview, on 9/25/25 at 3:39 p.m., the Administrator indicated when a resident returned to the facility from the hospital, the hospital discharge papers were reviewed by the nurse. The nurse then placed the orders into the electronic health record. A readmission meeting was held the following day, and orders were to be reviewed. The orders for dialysis were missed.During an interview, on 9/24/25 at 1:37 p.m., the Clinical Support Nurse 2 indicated the facility did not have a policy for physician order reconciliation. Reconciliation of orders was considered standard nursing practice. The morning after the resident returned to the facility, the nursing managers should have met and reviewed all orders to ensure accuracy.A current facility policy, titled Resident Rights, dated 6/6/19 and received from the Clinical Support Nurse 2 on 9/24/25 at 1:31 p.m., indicated .Federal and state laws guarantee certain basic rights to all residents of our community. These rights include the resident's right to.Equal access to quality care.Receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.A current facility policy, titled Hemodialysis Policy, dated 6/4/16 and received from the Clinical Support Nurse 2 on 9/24/25 at 1:31 p.m., indicated .ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the individual resident's goals and preferences.3.1-37(a)

Based on interview and record review, the facility failed to ensure the diagnosis used supported the adequate indications for use of the medication for 2 of 6 residents reviewed for unnecessary medications. (Resident 3 and 11)Findings include:1. The clinical record for Resident 3 was reviewed on 9/22/25 at 11:18 a.m. The diagnoses included, but were not limited to, constipation, anxiety disorder, and pain. A physician's order, dated 8/19/25, indicated to administer sennosides-docusate sodium (a medication used for constipation) tablet twice a day for unsteadiness on feet. A pharmacy Medication regimen review, dated 8/26/25, indicated Resident 3's medications were reviewed by the pharmacist with no recommendations. During an interview, on 9/24/25 at 10:21 a.m., the Director of Nursing (DON) reviewed Resident 3's medication orders and indicated the medication sennosides-docusate sodium did not have the correct supporting diagnosis. During an interview, on 9/24/25 at 10:36 a.m., Clinical Support Nurse 2 indicated the pharmacy reviewed medications, allergies, diagnoses, and interactions. 2. The clinical record for Resident 11 was reviewed on 9/18/25 at 12:46 p.m. The diagnoses included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, cellulitis of the left lower limb, and urinary tract infection. A physician's order, dated 8/1/25, indicated to administer cephalexin 500 milligrams once a day for a urinary tract infection. The order had no end date for the medication. During an interview, on 9/22/25 at 11:31 a.m., Clinical Support Nurse 2 indicated Resident 11 was on the cephalexin for a non-healing foot wound, below the knee amputation, and chronic urinary tract infection. The facility nurse practitioner did not note the chronic urinary tract infection, and he would contact the physician. During an interview, on 9/22/25 at 12:04 p.m., Clinical Support Nurse 2 indicated urinary tract infection (UTI) was an incorrect diagnosis and it should have been prophylaxis for a wound. A current facility policy, titled TRANSCRIBING ORDERS, undated and received from Clinical Support Nurse 2 on 9/24/25 at 1:35 p.m., indicated .Medication orders require .drug .and associated diagnosis A facility document, titled Pharmacy Consultant Agreement, undated and received from Clinical Support Nurse 2 on 9/24/25 at 1:42 a.m., indicated .Pharmacy Consultant Services.General Responsibilities.Ensure the proper labeling of all drugs.and that labeling is based on currently accepted professional standards. 3.1-48(a)(4)

Based on interview and record review, the facility failed to ensure a staff member followed the policy and procedure when administering narcotics for 2 of 2 residents reviewed for pharmaceutical services. (Resident F and G) Finding includes: A document, titled Indiana State Department of Health Survey Report System, dated 12/18/24 at 9:01 a.m., indicated Qualified Medication Aide (QMA) 5 reported to the facility a concern with RN 1. RN 1 was potentially taking residents' narcotic medications due to her signing the narcotic medications out in the count book but not documenting the administration of those narcotic in the residents' medical records. An investigation was initiated, and all the residents' narcotic medications were accounted for, and no discrepancies were found. RN 1 was terminated due to failure to follow facility policy and procedure. The following residents' medical records were reviewed, and their Electronic Medication Administration Record (EMAR) did not have the narcotic medication documented for the dates and times the narcotic count sheet indicated the medication was administered. 1. The clinical record for Resident F was reviewed on 1/8/25 at 3:16 p.m. The diagnoses included, but were not limited to, malignant neoplasm of the rectum, cerebral infarction due to embolism of right middle cerebral artery, mild protein-calorie malnutrition, and gastrostomy status. A physician's order indicated to give an Oxycodone 10 mg (milligrams) tablet every four hours as needed (PRN) for severe pain. The resident's EMAR, dated November 2024, had no documentation to indicate he had received any PRN doses of this medication during the month of November. A facility document, titled Controlled Drug Record, dated 11/9/24, indicated an Oxycodone 10 mg tablet was signed out on the narcotic sheet the following dates and times: 11/09/24 at 12:00 p.m. (RN 1) 11/09/24 at 4:00 p.m. 11/10/24 at 12:00 a.m. 11/10/24 at 1:00 p.m. 11/10/24 at 2:00 p.m. (RN 1) 11/11/24 at 8:00 a.m. (RN 1) 11/11/24 at 12:00 p.m. (RN 1) 11/11/24 at 4:00 p.m. (RN 1) 11/11/24 at 9:00 p.m. (RN 1) 11/13/24 at 7:30 p.m. (RN 1) 11/13/24 at 1:00 p.m. (RN 1) 11/15/24 at 6:30 p.m. (RN 1) 11/15/24 at 8:00 a.m. (RN 1) 11/15/24 at 2:00 p.m. (RN 1) 11/16/24 at 8:00 a.m. (RN 1) 11/16/24 at 2:00 p.m. (RN 1) 11/17/24 at 9:00 p.m. (RN 1) 11/17/24 at 11:00 a.m. (RN 1) 11/17/24 at 2:00 p.m. (RN 1) 11/18/24 at 7:30 a.m. (RN 1) 11/18/24 at 11:00 a.m. (RN 1) 11/20/24 at 8:00 a.m. (RN 1) 11/20/24 at 1:00 p.m. (RN 1) 11/20/24 at 5:00 p.m. (RN 1) 11/20/24 at 10:30 p.m. (RN 1) 11/22/24 at 8:00 a.m. (RN 1) 11/22/24 at 2:00 p.m. (RN 1) 11/23/24 at 12:00 p.m. 11/24/24 unable to determine time given 11/24/24 at 8:00 a.m. (RN 1) A handwritten note on this record indicated Resident has not missed any dose, all meds accounted for. Resident had not complained of any pain. 2. The clinical record for Resident G was reviewed on 1/8/25 at 3:30 p.m. The diagnoses included, but were not limited to, senile degeneration of the brain, severe vascular dementia, malignant neoplasm of the prostate, and depression. A physician's order indicated to give a Hydrocodone-acetaminophen 5-325 mg tablet Give by mouth three times a day PRN for pain The resident's EMAR, dated December 2024, had one (1) PRN dose documented to indicate the resident had received a PRN dose of this medication during the month of December. A facility document, titled Controlled Drug Record, dated 12/4/24, indicated a Hydrocodone-acetaminophen 5-325 mg tablet was signed out on the narcotic sheet the following dates and times: 12/04/24 at 9:00 a.m. (RN 1) 12/04/24 at 6:00 p.m. (RN 1) 12/06/24 at 11:00 a.m. (RN 1) 12/06/24 at 3:00 p.m. (RN 1) 12/06/24 at 10:00 p.m. (RN 1) 12/07/24 at 8:00 a.m. (RN 1) 12/07/24 at 3:00 p.m. (RN 1) 12/08/24 at 8:00 a.m. (RN 1) 12/09/24 at 2:00 p.m. (RN 1) 12/11/24 at 9:00 a.m. (RN 1) 12/11/24 at 2:00 p.m. (RN 1) A handwritten note on this record indicated Resident unable to interview but had not complained of pain. All medication accounted for. A facility document, titled Associate Discipline Form, dated 12/18/24 and provided by Clinical Support Nurse on 1/8/25 at 11:15 a.m., indicated RN 1 was suspended for failure to follow procedure and/or instructions. RN 1 was accused of not following company policy and procedure of signing out narcotics which had been given on both the narcotic count sheet and the EMAR. A facility document, titled Associate Discipline Form, dated 12/19/24 and provided by Clinical Support Nurse on 1/8/25 at 11:15 a.m., indicated RN 1 was terminated for failure to follow procedure and/or instructions. The investigation determined RN 1 did not sign all the narcotic medications she gave on both the narcotic count sheet and the EMAR. She was terminated for failure to follow policy and procedure. During an interview, on 1/8/25 at 4:15 p.m., the Clinical Support Nurse indicated RN 1 was terminated for not following policy and procedure for signing out and documenting the administration of a narcotic medication. The narcotic count sheets were correct, but the narcotic medications were not signed out on the EMAR. A current facility policy, titled Documentation of Medication Administration, dated November 2022 and provided by the Clinical Support Nurse on 1/7/25 at 2:15 p.m., indicated .A medication administration record is used to document all medications administered .A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (EMAR). 2. Administration of medication is documented immediately after it is given A current facility policy, titled Clinical-Policy and Procedure for Scheduled Drugs, dated March 2015 and provided by the Clinical Support Nurse on 1/7/24 at 2:15 p.m., indicated .Immediately after a dose of a scheduled drug is administered, the licensed nurse administering the scheduled drug is to enter all of the following information .Date and time of administration .Dose administered .Signature of nurse administering the dose .Remaining Doses 3.1-25(b)(3)

Based on interview and record review, the facility failed to ensure staff followed physician's orders to hold medications, administer as needed (prn) medications according to the parameters, obtain daily weights, and failed to communicate with a urologist and a hospice provider for 5 of 5 residents reviewed for quality of care. (Residents G, H, F, 33 and 105) Findings include: 1. The clinical record for Resident G was reviewed on 10/30/24 at 11:05 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, essential primary hypertension, anxiety disorder, recurrent major depressive disorder, and moderate vascular dementia with psychotic disturbance. A care plan, dated 7/14/22 and edited 9/9/24, indicated the resident had the potential for hypoglycemia, hyperglycemia, and diabetic complications. The interventions included, but were not limited to, administer accuchecks and any insulin coverage per physician's order. A physician's order, dated 6/8/23, indicated to give 8 units of Humalog U-100 insulin solution subcutaneously three times a day with special instructions to hold the dose if the blood sugar reading was less than 150. A Medication Administration Record (MAR), dated 9/1/24 through 9/30/24, indicated the Humalog was administered: a. On 9/1/24, with a blood sugar of 127. b. On 9/8/24, with a blood sugar of 142. A MAR, dated 10/1/24 through 10/31/24, indicated the Humalog was administered: a. On 10/7/24, with a blood sugar of 148. b. On 10/13/24, with a blood sugar of 144 in the a.m., and a blood sugar of 141 in the p.m. c. On 10/25/24, with a blood sugar of 147. d. On 10/28/24, with a blood sugar of 143. e. On 10/30/24, with a blood sugar of 149. A physician's order, dated 6/5/24, indicated to give a 0.1 milligram (mg) clonidine tablet by mouth twice a day as needed upon rising and before bedtime with special instructions to give for a systolic blood pressure (SBP) greater than 160. A physician's order, dated 7/24/24, indicated to obtain a blood pressure reading daily upon rising. A MAR, dated 9/1/24 through 9/30/24, indicated the as needed clonidine was not administered as ordered: a. On 9/1/24, for a systolic blood pressure of 173 in the a.m., or the p.m. b. On 9/3/24, for a systolic blood pressure of 182 in a.m., or 172 in p.m. c. On 9/7/24, for a systolic blood pressure of 185. d. On 9/16/24, for a systolic blood pressure of 165. e. On 9/18/24, for a systolic blood pressure of 177. f. On 9/20/24, for a systolic blood pressure of 181. g. On 9/25/24, for a systolic blood pressure of 169. h. On 9/27/24, for a systolic blood pressure of 172. i. On 9/28/24, for a systolic blood pressure of 173. A MAR, dated 10/1/24 through 10/31/24, indicated the as needed clonidine was not administered as ordered: a. On 10/6/24, for a systolic blood pressure of 168. b. On 10/9/24, for a systolic blood pressure of 167. c. On 10/17/24, for a systolic blood pressure of 174. d. On 10/21/24, for a systolic blood pressure of 171. A nurse practitioner progress note, dated 10/4/24, indicated the resident had chronic uncontrolled hypertension and to monitor closely. During an interview, on 11/4/24 at 10:30 a.m., the Clinical Support nurse indicated the Humalog doses were supposed to be held when the resident's blood sugar was less than 150. When the dose was held, there would be a 0 for the dose, a blank, or not given on the MAR. During an interview, on 11/4/24 at 12:15 p.m., Unit Manager 4 indicated the as needed clonidine was to be given with the morning and evening medications when the systolic blood pressure was greater than 160. The Humalog should be held according to the physician's hold orders. 50901 2. The clinical record for Resident H was reviewed on 10/29/24 at 3:25 p.m. The diagnoses included, but were not limited to, history of urinary tract infections, neuromuscular dysfunction of the bladder, and dementia. During an interview, on 10/29/24 at 1:57 p.m., the daughter of Resident H indicated she had concerns with the lack of communication at the facility. She indicated Resident H had an outpatient urology appointment on 10/18/24 and was diagnosed with a urinary tract infection (UTI). Resident H was supposed to be started on an antibiotic for the UTI, but when she called the facility to see if Resident H had started the medication, the nurse indicated the facility did not know anything about the antibiotic. A physician's order indicated if the resident had a positive urine culture, to fax the information to the Infection Disease (ID) provider or to call and speak with the staff. The physician's order included the ID provider's fax number and office telephone number. A progress note, dated 10/28/24, indicated Resident H's daughter called the facility inquiring if the antibiotic for the UTI had been started. The nurse did not find any information about the urinalysis testing or prescribed antibiotics. The nurse asked Unit Manager 18 if he had any information on the matter. Unit Manager 18 indicated he had not received anything. During an interview, on 10/30/24 at 2:42 p.m., the Administrator indicated Resident H returned from her outpatient appointment without paperwork. During an interview, on 11/1/24 at 9:58 a.m., RN 9 indicated if a resident returned from an appointment without paperwork, she would first check with the transportation driver to see if the paperwork was left in the vehicle. If the paperwork was not in the vehicle, she would then call the office the resident returned from. During an interview, on 10/31/24 at 11:29 a.m., Unit Manager 8 indicated the standard of practice for the facility was to reach out to the provider within 24 hours if a resident returned from an outside appointment without paperwork. During an interview, on 10/31/24 at 3:07 p.m., a staff member from the outside provider indicated Resident H had an appointment, on 10/18/24, for a urinary catheter change and a urinalysis sample was obtained. The positive urine culture results were faxed to the ID provider's office and to the facility on [DATE] at 8:00 a.m. She received a fax confirmation indicating the fax was sent successfully. She sent the fax again, on 10/30/24 at 2:00 p.m., after the resident's daughter came into the office indicating the resident had not received the antibiotic. There was a 6-day delay in Resident H receiving treatment for the UTI. 3. The clinical record for Resident F was reviewed on 10/29/24 at 3:23 p.m. The diagnoses included, but were not limited to, anxiety and insomnia. A physician's order, dated 6/18/24, indicated Resident F was receiving hospice services. An entry in the hospice communication log, dated 10/21/24, indicated hospice nurse RN 12 communicated new orders to discontinue melatonin (a medication to treat insomnia), discontinue the scheduled nighttime lorazepam (a medication to treat anxiety) and to start Seroquel (an antipsychotic medication) 25 milligram (mg) for insomnia with the facility. During a review of the physician's orders: a. an order for Seroquel 25 mg was not found. b. there was an active order for melatonin 10 mg, to be given before bedtime, indicating staff was administering the medication. c. there was an active order for lorazepam 0.5 milliliter (ml), to be given before bedtime, indicating staff was administering the medication. An entry in the hospice communication log, dated 10/24/24, indicated to increase the Seroquel from 25 mg to 50 mg. A physician order, dated 10/24/24, indicated Seroquel 50 mg was started. During an interview, on 10/30/24 at 11:25 a.m., the Director of Nursing (DON) indicated the hospice nurse would give the order to the nurse in the facility or the unit manager. The hospice nurse would then enter the order in the matrix or write the order on the order sheet. Unit manager 8 checked the binders for anything new added by hospice. While reviewing the Medication Administration Record (MAR), on 10/30/24 at 11:25 a.m., the DON indicated the melatonin, and the lorazepam had been administered from 10/21 to 10/29. During an interview, on 10/30/24 at 2:13 p.m., Unit Manager 8 indicated she was not aware the medications had been discontinued. She indicated hospice would give the order to the nurse and if the unit manager was not there, a copy of the order would be placed under the unit manager's office door. Unit Manager 8 indicated she checked the hospice binders for information added by hospice and had missed the entry regarding discontinuing the melatonin and lorazepam. During an interview, on 10/30/24 at 2:51 p.m., hospice nurse RN 12 indicated the protocol for a new order would be to write the order on the order sheet and give the sheet to the facility nurse. To ensure the facility nurse was aware of what the order was, she would have the facility nurse repeat the order back to her. RN 12 indicated she did this with the facility nurse but was unable to recall the name of the nurse she gave the orders to. She indicated she did not have access to the electronic medical record the facility used and was unable to verify if the orders had been placed. A review of the MAR indicated Resident F had been administered melatonin 10 mg, from 10/21-10/29, after the order by hospice to discontinue the medication. A review of the MAR indicated Resident F had been administered lorazepam 0.5 ml, from 10/21 to 10/29, after the order by hospice to discontinue the medication. 38872 4. The clinical record for Resident 33 was reviewed on 10/30/24 at 2:31 p.m. The diagnoses included, but were not limited to, hypertensive heart disease, hyperlipidemia (high cholesterol), and diabetes. A care plan, initiated on 8/21/18, indicated Resident 33 had a potential for abnormal blood pressures due to hypertension. One intervention, dated 8/21/18, indicated to administer medications per physician's orders. A physician's order, initiated on 6/28/24, indicated to give metoprolol tartrate (a medication for high blood pressure) 25 milligrams, twice a day. The order indicated to hold the medication if the resident's systolic blood pressure was less than 110 or if the pulse was less than 60 beats per minute. The October 2024 Medication Administration Record was reviewed and indicated the blood pressure results were outside of the physician's hold parameters, but the medication was administered: a. On 10/5/24, the resident had a blood pressure reading of 106/63. The blood pressure medication was administered between 7:00 a.m. and 11: 00 a.m. b. On 10/17/24, the resident had a blood pressure reading of 105/59. The blood pressure medication was administered between 7:00 a.m. and 11: 00 a.m. c. On 10/24/24, the resident had a blood pressure reading of 107/69. The blood pressure medication was administered between 7:00 a.m. and 11: 00 a.m. d. On 10/26/24, the resident had a blood pressure reading of 99/62. The blood pressure medication was administered between 7:00 a.m. and 11: 00 a.m. During an interview, on 11/1/24 at 10:32 a.m., Unit Manager 8 indicated the nursing staff were not supposed to give the blood pressure medication, metoprolol, based on the blood pressure reading. They should have held the medication. 48525 5. The clinical record for Resident 105 was reviewed on 10/30/24 at 1:03 p.m. The diagnoses included, but were not limited to, unspecified edema, acute kidney failure, and unspecified fluid overload. A current care plan, with a start date of 10/04/23 and last revised on 9/9/24, indicated the resident had a potential for fluid volume excess/exacerbation related to congestive heart failure. Administer medications as ordered. A physician's order, with a start date of 10/4/24, indicated to obtain and record a daily weight upon rising before breakfast. Please give as needed Lasix (a diuretic) for a weight gain of 3 pounds in a day and 5 pounds in a week. A physician's order, with a start date of 6/13/24, indicated to give Lasix 40 mg once a day as needed for a 3-pound weight gain in a day or 5 pounds in a week. The Medication Administration Record (MAR) indicated daily weights were not obtained on 10/4/24, 10/14/24, 10/21/24, and 10/24/24. The MAR indicated Lasix was not administered per the physician's order for weight gains on 10/7/24, 10/12/24, and 10/29/24. During an interview, on 10/31/24 at 2:14 p.m., the Director of Nursing (DON) indicated she did not see where it was charted as the resident refused weights for those specific dates. There were missing as needed Lasix administrations and missing daily weights. During an interview, on 11/1/24 at 3:08 p.m., the Assistant Director of Nursing (ADON) indicated the resident was missing some daily weights and she was not sure why the Lasix had not been given. The staff should chart any refusals. During an interview, on 11/1/24 at 2:05 p.m., the Corporate Support Nurse indicated the facility did not have a policy for following physician's orders. The facility was unable to provide a policy related to follow up communication with outside providers when a resident returned to the facility without paperwork. A facility document, titled NURSING FACILITY AND HOSPICE SERVICES AGREEMENT, updated July 2020 and received upon entrance, indicated .Hospice and facility shall develop a process by which to exchange information between Hospice IDG and Facility staff regarding .updating of the Coordinated POC .Facility Plan of Care .Plan of Care, Medications and Orders. The most recent Coordinated POC, medication information and physician orders specific to each Hospice Patient 3.1-37(a)

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for a resident diagnosed and treated for insomnia for 1 of 31 residents reviewed for comprehensive person-centered care plans. (Resident F) Finding includes: The clinical record for Resident F was reviewed on 10/29/24 at 3:23 p.m. The diagnoses included, but were not limited to, senile degeneration of the brain (dementia), diastolic heart failure, and insomnia. A physician's order, dated 6/18/24, indicated Resident F was to receive a melatonin 10 milligram (mg) tablet, once a day, before bedtime for insomnia. A physician's order, dated 8/29/24, indicated Resident F was to receive a trazodone (an antidepressant medication) 50 mg tablet, once a day, before bedtime for insomnia. A physician's order, dated 10/24/24, indicated Resident F was to receive a Seroquel (an antipsychotic medication) 50 mg tablet, once a day, before bedtime for insomnia. The comprehensive care plan did not include Resident F's diagnosis of insomnia or the use of melatonin, trazodone and Seroquel. During an interview, on 10/30/24 at 10:12 a.m., RN 10 indicated Resident F did not sleep well at night and was on several medications for insomnia. During an interview, on 11/1/24 at 2:13 p.m., Social Services 14 indicated it was the responsibility of the social service department to review the resident's diagnoses and medications to assure they were added to the care plans. Resident F's diagnosis of insomnia and the medications prescribed were not included in the care plan. During an interview, on 11/1/24 at 2:04 p.m., the Clinical Support nurse indicated the facility did not have a policy for care plans. The facility followed the resident assessment instructions (RAI) manual. 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure a resident did not have smoking articles in their room for 1 of 7 residents reviewed for accident hazards. (Resident 241) Finding includes: During an observation, on 10/28/24 at 12:00 p.m., Resident 241 had an electronic cigarette (e-cigarette) or vape in his room on his bedside table. During an observation and interview, on 10/28/24 at 12:05 p.m., CNA 20 walked in the resident's room with the resident's lunch. The resident slowly grabbed the vape and brought it towards his abdomen as CNA 20 came in the door. The vape was still visible in the resident's hand as the CNA placed his lunch tray down on the table. CNA 20 indicated she was not sure if residents could have vapes stored in their rooms or not. The clinical record for Resident 241 was reviewed on 10/30/24 at 10:57 a.m. The diagnoses included, but were not limited to, opioid dependence, drug induced constipation, unspecified pain, and anxiety disorder. During an interview, on 10/28/24 at 12:11 p.m., Unit Manager 4 indicated he did not believe residents could have a vape in their room. It was a smoke free facility. He would check with the Executive Director (ED). During an interview, on 10/28/24 at 12:19 p.m., the ED indicated residents should not have vapes in their room. A current facility policy, titled SMOKING POLICY, dated 6/6/19 and received from the Executive Director on 10/28/24 at 12:30 p.m., indicated .Residents are not permitted to give smoking articles to other residents and personal smoking articles must be secured to prevent access by other residents. 14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to ensure the correct amount of oxygen was administered as ordered by the physician for 2 of 3 residents reviewed for respiratory care. (Resident 10 and 37) Findings include: 1. During an observation, on 10/28/24 at 3:36 p.m., Resident 10's oxygen concentrator (a device used to provide supplemental oxygen therapy) was set on 3 liters per minute (L). During an observation, on 10/29/24 at 10:25 a.m., Resident 10's oxygen concentrator was set on 3L. During an observation, on 10/30/24 at 2:24 p.m., Resident 10's portable oxygen concentrator was set on 3L. During an observation, on 10/31/24 at 3:10 p.m., Resident 10's portable oxygen concentrator was set on 3L. During an observation, on 11/4/24 at 9:56 a.m., Resident 10's oxygen concentrator was set on 3L. The clinical record for Resident 10 was reviewed on 10/31/24 at 9:05 a.m. The diagnoses included, but were not limited to, heart failure, vascular dementia with mood disturbance, type 2 diabetes mellitus, chronic pulmonary embolism, shortness of breath, and acute and chronic respiratory failure. A care plan, dated 7/31/24 and last edited on 10/8/24, indicated the resident was on oxygen therapy. Interventions included, but were not limited to, report signs of hypoxia and administer oxygen as ordered. A physician's order, dated 10/8/24, indicated the resident was to receive 2L of oxygen continuously. During an interview, on 10/30/24 at 2:24 p.m., CNA 2 indicated the resident's oxygen concentrator was set on 3L. She was unsure of the resident's ordered liter flow rate. During an interview, on 10/30/24 at 2:29 p.m., LPN 2 indicated the resident's ordered rate was for 2L. During an interview, on 11/4/24 at 9:58 a.m., the ADON (Assistant Director of Nursing) indicated the resident's order was for 2L and the resident's oxygen was set at 3L. 38872 2. During an observation, on 10/29/24 at 9:11 a.m., Resident 37 was observed sitting up in bed. She was receiving oxygen, through a nasal cannula, at 5 liters per minute. A physician's order, initiated on 7/16/24, indicated to provide oxygen at 2 liters per minute continuously via nasal cannula A care plan indicated the resident required oxygen therapy due to hypoxia (a condition which occurred when the body did not have enough oxygen). An intervention, with a start date of 3/6/24, indicated the resident would receive oxygen therapy per the physician's order. During an interview, on 10/29/24 at 9:15 a.m., the Director of Nursing reviewed the order for the resident's oxygen and indicated it was to be at two (2) liters per minute. The nurse was responsible to set the flow rate of the oxygen. During an interview, on 11/1/24 at 11:09 a.m., RN 10 indicated the nurse was to set the oxygen levels for the resident and check the setting throughout the day. A current facility document, titled OXYGEN ADMINISTRATION SKILLS VALIDATION, dated as revised on 3/4/24 and received from the Corporate Support Nurse on 11/01/24 at 2:00 p.m., indicated .Verify physician's order for the liter flow .prior to administering oxygen 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure the on-coming and off-going staff signed the narcotic count books each shift for 2 of 3 medication carts reviewed for drug reconciliation. (700-unit and 400-unit) Findings include: 1. During an observation, on 10/31/24 at 3:15 p.m., with Unit Manager 4 present, the October 2024 narcotic log count sheets for the 700-unit were observed. Book 1 was found to be missing 31 of 93 possible opportunities to sign the narcotic log sheet when staff were off-going and 28 of 93 possible opportunities to sign the narcotic log sheet when staff were on-coming. Book 2 was found to be missing 34 of 93 possible opportunities to sign the narcotic log sheet when staff were off-going and 33 of 93 possible opportunities to sign the narcotic log sheet when staff were on-coming. 2. During an observation, on 10/31/24 at 3:38 p.m., with LPN 19 present, the October 2024 narcotic log count sheets for the 400-unit were observed. The book was found to be missing 39 of 93 possible opportunities to sign the narcotic logs sheet when staff were off-going and 30 of 93 possible opportunities to sign the narcotic log sheet when staff were on-coming. During an interview, on 10/31/24 at 3:19 p.m., Unit Manager 4 indicated staff were supposed to sign on/off in the narcotic book. A current facility policy, titled Policy and Procedure for Scheduled Drugs, dated March 2015 and received from the Corporate Support Nurse on 11/01/24 at 2:00 p.m., indicated .At the beginning of an associate's shift they must count and account for all scheduled drugs .with the outgoing associate .At the end of an associate's shift they must count and account for all scheduled drugs .with the oncoming associate .At the conclusion of each shift the outgoing and oncoming licensed nurse should complete the Nurse's Narcotic Sign In/Sign Out sheet 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure medications and supplements were labeled and dated, expired medications were removed from the cart and medications were stored safe and secured away from residents for 3 of 3 units and 2 of 2 residents reviewed for medication storage. (500-unit, 800-unit, 700-unit, Resident 80 and Resident 45) Findings include: 1. During an observation, on 10/31/24 at 11:55 a.m., with LPN 16 present, the 500-unit medication cart was found to have an open Lantus insulin pen, dated 9/24/24, without a resident name on the pen. An anesthetic oral gel was opened and stored alongside an opened bottle of ear drops. There was also a 30-ounce bottle of liquid protein found open and without a resident's name on the bottle. During an interview, on 10/31/24 at 11:55 a.m., LPN 16 indicated the insulin was expired. The oral gel and eye drops were not to be stored together. The liquid protein was used for whoever needed it. 2. During an observation, on 10/31/24 at 2:53 p.m., with LPN 17 present, the 800-unit medication cart was found to have a 30-milliliter bottle of liquid protein, opened and without a resident's name on the bottle. The 800-unit medication room refrigerator had a bottle of aplisol (a solution used in tuberculosis testing) with the seal broke. There was no open date on the bottle or box. 3. During an observation, on 10/31/24 at 3:19 p.m., with Unit Manager 4 present, the 700-unit medication refrigerator had a bottle of aplisol with the seal broke and no open date. At that time, Unit Manager 4 indicated the solution was to be dated when it was opened. During an interview, on 11/1/24 at 2:00 p.m., the Corporate Support Nurse indicated it was the expectation open dates were placed on medications when they were opened. 48525 4. During an observation, on 10/28/24 at 10:23 a.m., Resident 80 had Diclofenac Sodium topical gel 1% (typically used for arthritis pain relief) on his bedside table. During an observation, on 10/29/24 at 9:26 a.m., Diclofenac Sodium topical gel 1% was still on his bedside table. The clinical record for Resident 80 was reviewed on 10/30/24 at 2:35 p.m. The diagnoses included, but were not limited to, other skin changes, chronic kidney disease, and vitamin d deficiency. The resident did not have a physician's order for Diclofenac Sodium topical gel 1%. During an interview, on 10/29/24 at 9:44 a.m., Unit Manager 4 indicated he should not have the gel in his room especially since he did not have an order for it. 5. During an observation, on 10/28/24 at 10:44 a.m., Resident 45 had Diclofenac Sodium topical gel 1% on a table in his room with a label on it. The label did not look like a facility label. During an observation and interview, on 10/29/24 at 9:38 a.m., the Diclofenac Sodium topical gel 1% was still on the table. Unit Manager 4 indicated they should not have the arthritis gel out in his room. The label on the tube did not look like it was from their pharmacy. The clinical record for Resident 45 was reviewed on 10/30/24 at 10:09 a.m. The diagnoses included, but were not limited to, unspecified edema, unspecified pain, and unspecified vitamin deficiency. A current facility policy, titled DRUG STORAGE, undated and received from the Corporate Support Nurse on 11/01/24 at 2:00 p.m., indicated .All expired .medications are removed from resident care areas and stored separately from medications available for administration .Drugs with different routes of administration should .be stored individually in separate compartments .Discontinued and expired medications should be removed from medication carts, refrigerators A current facility policy, titled BEDSIDE MEDICATIONS AND SELF-ADMINISTRATION OF MEDICATIONS, undated and received from the Director of Nursing (DON) on 11/4/24 at 1:40 p.m., indicated .The DON instructs all staff to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage. All staff will also be instructed to give the unauthorized medications to the DON for return to the family or responsible party when necessary 3.1-25(j) 3.1-25(m) 3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure a resident received dental services to repair or replace partial dentures for 1 of 1 resident reviewed for dental services. (Resident 122) Finding includes: During an observation, on 10/29/24 at 3:26 p.m., Resident 122 was well groomed with make-up on including lipstick with missing front teeth. During an observation, on 10/30/24 at 2:21 p.m., the resident was again well dressed, her hair was styled and make-up carefully applied. The clinical record for Resident 122 was reviewed on 10/30/24 at 11:11 a.m. The diagnoses included, but were not limited to, repeated falls, bipolar disorder, oral phase dysphagia, Alzheimer's dementia with behavioral disturbance, anxiety, depression, and impaired memory. An admission assessment, dated 2/2/24, indicated the resident had upper partial dentures. A physician's order, dated 2/2/24, indicated the resident may receive dentistry services as needed. A nursing progress note, dated 7/1/24 at 7:51 p.m., indicated the resident was found in her room holding two of her front teeth when the aid entered to assist with her bedtime rituals. They had apparently just fell out, both were completely rotten. The aid came out to the nurse's station to tell the nurse and when they had returned to the room, the resident had flushed both teeth down the toilet. A nursing progress note, dated 7/2/24 at 12:49 p.m., indicated the resident had no pain, infection, or bleeding noted in her mouth where the teeth had fallen out. A nurse practitioner note, dated 7/2/24, indicated per staff the resident's front teeth fell out with no incident. The unit manager was working on a dental consultation. A nursing progress note, dated 7/3/24 at 11:58 a.m., indicated the family was notified of the teeth falling out and the family wanted the resident to be seen by the in-house dentist. A speech therapy note, dated 7/8/24-8/6/24, indicated the resident had natural teeth but was missing a few upper teeth. A care plan, dated 8/26/24, indicated the resident desired to use the facility ancillary services, including dentistry. A speech therapy note, dated 10/26/24-11/24/24, indicated the resident had missing teeth. The electronic medical record did not include any dental visit notes or notes regarding any attempts at repairing or replacing the resident's partial upper dentures. During an interview, on 10/30/24 at 1:14 p.m., the Assistant Director of Nursing (ADON) indicated the teeth which fell out were partial dentures rather than natural teeth. The facility had contacted their dental provider to see if the dentures could be repaired but they had not heard back. During an interview, on 10/31/24 at 9:40 a.m., CNA 5 indicated the resident did not have her partial denture back. She thought they were getting fixed but had not heard anything about them in a long time. The resident was very put together, dressed very well, and always had her make-up and lipstick on. She did not think the resident would be comfortable not having all her front teeth if she did not have dementia. During an interview, on 10/31/24 at 10:00 a.m., Unit Manager 4 indicated the facility was working on getting her partial repaired or replaced, but he had not heard anything about them in a while. He did not know where things were in the process to get her partial dentures back. The resident had not had her dentures since the beginning of July. During an interview, on 10/31/24 at 1:45 p.m., the Administrator indicated the current social worker was new and the facility did not have any notes on any dental consult or dental visits for the resident. The facility could not provide any further notes regarding partial dentures or where things were in the process of getting them repaired or replaced. She thought the partial had been sent to the dentist but there was no documentation on where they were sent, when, or any further progress. The facility had no record of any dental visits arranged for the resident. She had no further paperwork to provide apart from the electronic medical record. A current facility policy, titled Dental Services Policy, dated 6/6/19 and received from the Clinical Support nurse on 11/4/24 at 12:10 p.m., indicated .will assist residents in making appointments .for routine .dental services and will refer residents with lost or damaged dentures for dental services within 3 days of said loss or damage .recognizing the importance of the dentures .to the resident self-esteem .When any member of the Community staff is informed that or notices that a resident's dentures are lost or damaged, that staff person will immediately complete the attached Lost or Damaged Dentures Report and submit the report to the Administrator .Within 3 business days of receiving the report, the Administrator or designee will ensure that the resident has been referred to the appropriate dental service provider for replacement or repair of the dentures. The Administrator or designee will also follow up to ensure that an appointment has been made 3.1-24(a)(3)

Based on observation, interview and record review, the facility failed to ensure food was served at a safe and appetizing temperature for 1 of 1 room tray tested for food temperatures. (200 hall) Finding includes: During an interview, on 10/28/24 at 10:49 a.m., Resident E indicated the food was cold. During an interview, on 10/28/24 at 11:29 a.m., Resident D indicated the food was sometimes cold. During an interview, on 10/28/24 at 3:09 p.m., Resident B indicated the food was cold. During an interview, on 10/29/24 at 11:15 a.m., Resident C indicated the food did not have good flavor and it was cold. During a resident council meeting, on 10/30/24 at 1:05 p.m., the resident council indicated the food was sometimes cold, especially the room trays. During an observation and interview, on 10/31/24 at 11:46 a.m., a lunch tray was chosen at random to obtain food temperatures. The country fried steak temped at 100 degrees, the peas temped at 101 degrees, and the glazed carrots temped at 105 degrees. The Assistant Dining Services Supervisor indicated the hot food should be served at least 120 degrees or higher and she would need to reheat the food prior to serving it to the resident. A current facility policy, titled Food Preparation and Safety Policy, dated 2020 and received from the Executive Director on 11/4/24 at 12:44 p.m., indicated .Trays are delivered promptly to ensure that food is served at a preferable temperature and to preserve the quality of the food .Hot food, that is not served at a preferrable temperature to the resident, will be re-heated, to an internal temperature of 165 F for 15 seconds, or replaced . This citation relates to Complaint IN00446463. 3.1-21(a)(2)

Based on interview and record review, the facility failed to ensure mail was delivered unopened for 1 of 1 resident reviewed for resident rights. (Resident 135) Finding includes: During a resident council interview, on 10/30/24 at 1:05 p.m., Resident 135 indicated an item of her mail from Medicaid had been opened by the facility prior to being delivered. She indicated she had not given permission and did not want anyone from the facility to open her mail. The clinical record for Resident 135 was reviewed on 10/30/24 at 3:08 p.m. The diagnoses included, but were not limited to, cerebral palsy, type 2 diabetes mellitus, chronic viral hepatitis, atherosclerotic heart disease, and noninfective gastroenteritis and colitis. Resident 135 signed a Permission & Acknowledgment form, on 9/30/24 at 7:20 p.m. She selected NO to I authorize community personnel and/or volunteers to open the resident's mail and read it to the resident at times the resident is unable to do so and NO to If the resident applies for Medicaid, I authorize the designated community personnel to open the resident's Medicaid mail each month to access the Medicaid number for billing purposes. Resident 135 had signed an Authorized Representative for Health Coverage form which named the facility as her representative. The form was not dated. During an interview, on 10/30/24 at 02:00 p.m., the Business Office Manager (BOM) indicated the facility opened Resident 135's Medicaid approval letter, made a copy of her new Medicaid card, and then delivered it to the resident. She had opened the Medicaid mail under the direction of the corporate office due to other sister facilities had checks delivered to residents which were supposed to go to the facility for payment. During an interview, on 10/31/24 at 9:26 a.m., the Executive Director (ED) indicated the facility did not have a policy pertaining to mail delivery or mail services. A current facility policy, titled Resident Rights, dated 6/6/19 and received from the ED on 10/31/24 at 9:26 a.m., indicated .Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .privacy and confidentiality .communicate in person and by mail .with privacy .The unauthorized release, access or disclosure of resident information is prohibited 3.1-3(s)(1)

Based on interview and record review, the facility failed to ensure pre-admission screening and resident reviews (PASARR) were accurate and updated for 2 of 3 residents reviewed for PASARR. (Residents 87 and D) Findings include: 1. The clinical record for Resident 87 was reviewed on 10/30/24 at 8:49 a.m. The diagnoses included, but were not limited to, depression, borderline personality disorder, and age-related physical debility. A notice of PASARR Level I, dated 8/2/24, indicated Resident 87 did not take any mental health medications. A physician's order, with a start date of 9/23/24, indicated the resident was on Amitriptyline (an antidepressant medication) 50 milligrams once a day. During an interview, on 10/30/24 at 2:10 p.m., the Clinical Support nurse indicated Resident 87 was on Amitriptyline on admission. She should have had the medication listed on her Level I PASARR. During an interview, on 11/01/24 at 11:37 a.m., Social Services 14 indicated the social service department was responsible for the PASARRs and were the ones who made sure the Level I and Level II were up to date. PASARRs should be updated when someone received a new mental health medication. 50901 2. The clinical record for Resident D was reviewed on 10/29/24 at 3:29 p.m. The diagnoses included, but were not limited to, major depressive disorder, anxiety, and bipolar disorder. Resident D was admitted to the facility with a diagnosis of bipolar disorder on 9/11/24. A PASARR Level I, dated 8/13/24, indicated Resident D did not have a serious mental health disability and it was determined no Level II screen was required. The mental health diagnoses listed on the Level I PASARR were anxiety and depression/depressive disorder. The diagnosis of bipolar disorder was present on Resident D's admission Minimum Data Set (MDS) assessment. During an interview, on 11/1/24 at 2:13 p.m., Social Services 14 indicated the social service department should review the resident's diagnoses upon admission and if the resident triggered for a Level II screen, they would initiate the Level II screening process. Resident D's bipolar diagnosis was missed, and a Level II screening should have been initiated. During an interview, on 11/1/24 at 2:04 p.m., the Clinical Support nurse indicated the facility did not have a policy for PASARR. The facility followed the resident assessment instructions (RAI). 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents reviewed who were at risk for falling (Resident B). Resident B had an unwitnessed fall on the day of his admission, requiring hospitalization where he was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Finding includes: Resident B's medical record was reviewed on 4/14/21 at 10:45 a.m. Diagnoses included, but were not limited to, end stage [CONDITION(S)], shortness of breath and spinal stenosis. Resident B's progress note, dated 04/10/21 at 3:30 p.m., entered by RN 1, reflected he arrived by EMS escorted by his family member. He was alert and oriented to self only. The note did not describe he was at risk for falls or interventions to prevent falls. Resident B's only other progress note, dated 4/10/21 at 8:09 p.m., was entered by RN 2. It documented the CNA reported to the nurse the resident had fallen out of bed. Nurse entered room found resident beside the bed on his left side, as nurse rounded the bed, I noticed a small amount of blood pooled on the floor where the resident head was resting .Resident was moved from floor to bed by Hoyer [mechanical] lift after assessment .Resident has a history of falls. The nurse documented he was alert and oriented times two, to self and touch. He had a laceration above his right eyebrow and a small skin tear to the same corner of the same eye. He was sent to the emergency room . Resident B's physician's orders, dated 4/10/21, included activity level: up as tolerated, non-weight bearing on right leg, and physical therapy and occupational therapy evaluation and treatment. His physician orders included the following medications for pain relief: [MEDICATION(S)]-acetaminophen, every 8 hours as needed for moderate pain, [MEDICATION(S)] every six hours as needed for mild to moderate pain. Residents B's Medication Administration Record (MAR) for 04/01/21 through 04/14/21, documented no medications were administered. Resident B's Point of Care History, dated 4/1/21 through 4/14/21, reflected CNA 3 documented on 04/10/21, Resident B required total dependence by one person to move in bed, total dependence by two people with a mechanical left to transfer, total dependence by one person for toileting and he was incontinent. Resident B's Admission Observation (assessment), dated 4/10/21, documented he had problems with memory, balance, bleeding and his heart. He had [CONDITION(S)] (blurred or no vision in the center of the visual field), an unsteady gait, a hip abductor and was oriented only to person (not time, place or situation). Resident B's Fall Risk Assessment, dated 04/10/21, documented he had cognitive deficit, a surgical site or wound to his lower extremity, was incontinent of urine and bowel and had a history of falls. Resident B's Event report, dated 4/10/21 at 8:08 p.m., and completed by RN 2, documented an unwitnessed fall which occurred on 4/10/21 at 7:05 p.m. The resident was lying within five feet of his bed immediately after the fall. When asked what happened, the form documented he was very confused and he just told staff to get the car ready and give him some clothes. Interventions initiated included one-on-one supervision and sending him to the ER due to a laceration. The facility's Incident Print, dated 4/12/21, documented: Type of injury added - 4/12/21 Laceration to left temple and reported subarachnoid hemorrhage. During an interview, on 4/14/21 at 3:14 p.m., the Director of Nurses (DON) indicated Clinical Liaisons from the facility's corporation, representing several facilities, visited residents in the hospital to do pre-admission assessments before the residents were discharged to the facility. When the resident was admitted during the weekday, the Clinical Liaison's completed Clinical Liaison Patient Assessment form was part of the admission packet which went to the facility's admission team for pre-planning. The admission packet was then given to the unit nurses prior to the resident's admission so the nurse could plan to receive the resident. Resident B's Clinical Liaison Patient Assessment, dated 4/09/21, documented he required fall interventions and hip protection. He was alert and oriented times three (to personal, place and time) and was pleasant and cooperative. It also documented he did not require restraints or a sitter, had no active behaviors, was not confused or impulsive, was not anxious, did not have poor safety awareness and was not exit seeking. Resident B's hospital Admission Note/History and Physical report, dated 4/04/21, reflected: Resident presented at ER [emergency room ] this morning because of right hip fracture. Apparently, patient suffered an accidental fall last night when he tried to get out of bed .He was found [to have a] right hip fracture in the emergency room . Patient's wife told me that patient had a small stroke half year ago and he has been struggling with gait instability and multiple falls at home recently. Resident B's hospital-generated Facility Transfer Report, dated 4/10/21, indicated the resident's primary diagnosis was right femur fracture and right hip open reduction and internal fixation (surgery to stabilize and heal right hip fracture). The form indicated he was a fall risk. It also documented he was not alert and oriented times three and had dementia and confusion. He required total hip precautions, maximum assistance by two people for activity and two people for transfers. The last medication he received for pain was [MEDICATION(S)], at 12:00 p.m. Resident B's Hospital Discharge Instructions for visit date 4/04/21, documented diagnoses of femur neck fracture, decreased activities of daily living, difficulty walking, and [CONDITION(S)]. It did not provide instructions for fall precautions. During an interview, on 4/14/21 at 2:20 p.m., the DON indicated Resident B had multiple falls at home resulting in a hip fracture and was admitted to the facility following the hip repair. His family member told them he was difficult to manage. She did not want him to fall again. She wanted him to have siderails at the facility and to be tied to the bed because that's what they did in the hospital. Both the weekend nurse supervisor, Registered Nurse (RN) 2, and his assigned unit nurse, RN 1, educated her on the risks for bedrails and explained they could not restrain him. Although Resident B's Clinical Liaison documented he was alert, oriented times three, pleasant and cooperative, he was not this way at admission. His family representative was able to be at his bedside when he was admitted , and he was calm when she was there, but fell shortly after she left. The DON indicated weekend/evening staff did not see hospital records or the Clinical Liaison Patient Assessment before a resident was admitted . They got the papers at admission, so the unit nurse and nursing supervisor were not aware Resident B was at risk of falling prior to his admission. Nurses did not put extra fall prevention interventions into place until they assessed the resident and determined what was needed. Residents identified as being at risk for falls were started with baseline interventions of low beds, skid-free socks/shoes and call lights within reach until it was determined more interventions were needed. Nurses were expected to do a full head-to-toe assessment including a fall risk assessment at admission, which RN 1 did. Standard interventions were in place for Resident B, for example, all beds had the capacity to be low beds and his call light was placed within reach. During an interview, on 4/15/21 at 11:30 a.m., the DON indicated interventions to prevent falls which could be implemented by nursing staff without a therapy evaluation or physician order included foam mat(s), gripper socks, gripper floor tape, signs to remind the residents to use their call light and bright-colored tape for the call lights. The nurses had access to a fall kit/tackle box(es) which contained nonskid floor strips, night lights, bright-colored tape, and signs. Grip bars, quarter or half bedrails required an assessment by the therapy department and must be installed by the Maintenance department. Scoop mattresses required a therapy assessment and must be ordered in advance from Central Supply. During a telephone interview, on 4/14/21 at 4:48 p.m., RN 2 indicated she was Resident B's nurse supervisor when he was admitted , on Saturday, 4/10/21 around 3:00 p.m. She did not see him brought in on a stretcher or before he fell . She was working on the other side of the building helping another nurse. She remembered letting Resident B's family member into that side of the building. The family member told her, the resident was very confused. She warned he might not know who they were. They should not be surprised if the resident told them to get the car and he wanted to go home, because he wanted to go home from the hospital. The spouse told RN 2 to just watch him. She could stay long enough to get him situated but had to leave right away. During an interview, on 04/15/21 at 9:30 a.m., RN 1 indicated Resident B arrived at the facility between 3:00 p.m. and 3:30 p.m., around shift change. The resident's spouse told him she wanted the resident to have siderails because there were siderails at the hospital. RN 1 educated her on the risk and indicated following up on it was on his to-do list. RN 1 indicated he had no ability to obtain bedrails or a grab bar because the resident had to be evaluated by therapy to receive a bedrail and the bedrails had to be installed by Maintenance. The resident was confused but was calm both before and after the spouse left. He had some upper body strength but could not stand unsupported following his hip surgery. He was not weight bearing, so the RN 1 did not anticipate he would get out of bed. The standard fall precautions a nurse could put into place without a doctor's order or evaluation by the therapy department included placing the bed in the low position and putting a foam mat(s) beside the bed. The resident did not have a have a foam mat, and RN 1 was not able to get one for him at the time. RN 1 indicated Resident B's bed was low, but not as low as it could go, prior to or at the time the resident fell . The frame was approximately 7 inches higher than its lowest position, or approximately 15 inches from the floor. RN 1 indicated he was in Resident B's room three times prior to his fall: to do his assessments when Resident B arrived; later to talk to his family and answer her questions; and then one more time about an hour before he fell . The spouse was at his bedside when he admitted , but left about an hour after he arrived, or approximately 4:30 p.m. The resident fell around 6:30 p.m. and was sent to the emergency room at 7:00 p.m. During an interview and observation, on 4/15/21 at 9:30 a.m. in Resident B's vacated room, RN 1 demonstrated his bed could be lowered with a remote and confirmed with a tape measurer the lowest position was 7 ½ inches from the floor. Observation of the room, at that time, revealed there was a call light near the bed. There were no bedrails or grip bars, scoop mattress, foam mat, gripper floor tape, signs to encourage using the call light, or other assistive devices related to fall prevention. When asked if he knew where to find additional tools nursing staff could use without a physician order, such as skid-free tape, RN 1 indicated he knew who to contact to find the items. During a telephone interview, on 04/15/21 at 11:00 a.m., Certified Nurse Aide (CNA) 3 indicated the paramedics left Resident B's bed in the high position when they transferred him from the stretcher to the bed. She lowered the bed, not all the way to the floor, but kind of low. He complained of pain when the lowered the head of the bed, so the head of the bed was up. He was very agitated after his spouse left and was trying to move his legs. He refused to take off his gown. When he was incontinent, she got another aide to help settle him down and provide incontinent care in bed. He needed total help to pivot or move in bed because he cried out about pain. She was in his room often, every 15 minutes, because he was yelling. The last time she was in his room, he was yelling every time they tried to move him and was not allowing them to touch him. She told him: Sir, try to calm down, so the nurse can look about you. He said okay, but he needed to get his legs settled down. She went to get the nurse and within just 10 to 15 seconds from the time she left the room, he was on the floor. When she found him, he was on his face, on the side of the bed away from the door. During an interview, on 04/14/21 at 11:20 a.m., with the Assistant Director of Nurses (ADON) and RN 4, RN 4 indicated she was the nurse assigned to Resident B's unit but did not meet him because he was admitted and discharged on the weekend. Regarding protocol/practice with new admissions, she immediately began a head-to-toe assessment within the hour, during which she made observations and asked questions related to fall risks. She also did a full fall risk assessment within the first hour. She could get interventions to prevent falls implemented quickly, in part because she usually had information from the hospital in advance of admission to know what interventions to have available. Possible interventions included non-skid shoes, bedrails for mobility if indicated and ordered, call lights within reach including soft-touch call lights if needed. They completed a Maintenance form if needed something like a soft-touch call light. They also did a medication review with the Nurse Practitioner or Physician to see if any medications which could potentially increase their fall risk could be discontinued. If bedrails were indicated, they discussed it with the unit manager, ADON and therapy staff at a daily meeting. During an interview, on 04/14/21 at 12:35 p.m., the Therapy Supervisor indicated they receive a physician's order to evaluate and then clarify physical, occupational and/or speech therapies for all new admissions. They evaluated their baseline for transfer ability, strength and fall risk within 24 to 48 hours after admission. If residents admitted during the weekend, they had contract and PRN (as needed) therapists which could evaluate them within 24 to 48 hours. They were not able to evaluate Resident B before he fell and was discharged . During an interview, on 4/15/21 at 11:38 a.m., Unit Manager 5 indicated when a resident was admitted on a weekday, the nurse/nurse manager had the admission packet to give to the unit nurses for advance information about the resident and how to set up the room. They did not set up the room for interventions to prevent falls, however, based on information from the hospital, because the hospital record may not be accurate or appropriate for the resident's skilled nursing setting. For example, the hospital records may reflect the resident was alert and oriented. But, the same resident may not be when he arrived at the facility because they sometimes became disoriented when moved to another environment. The nurse must do her own assessment. After the assessment, the nurse would typically start with a low bed and possibly place the bed against the wall. If the resident was alert and oriented, they could put bright tape on the call light to remind them to use the call light and signs that say, Call, don't fall. A current facility policy, titled Clinical - Fall Prevention Policy and Procedure, undated and provided by the DON on 4/15/21 at 11:15 a.m., indicated .Step One: Fall Risk Assessment .Each fall risk assessment will be individualized for every resident assessed. Every resident will be considered a high risk for falls during their stay and individualized interventions will be introduced as needed for these patients .Step Three: Strategies of Prevention. Strategies to prevent falls are unique for each community. Each fall risk factor is unique for every resident This Federal Tag relates to Complaint IN 524. 3.1-45(a)

Based on observation, interviews and record reviews, the facility failed to ensure a resident was being transferred following her Care Plan to prevent an accident for 1 of 3 resident reviewed for accidents (Resident C). This deficient practice resulted in Resident C being diagnosed with [REDACTED]. Finding includes: On 10/4/18 at 11:30 a.m., Resident C's record review was completed. [DIAGNOSES REDACTED]. mellitus, [MEDICAL CONDITION] unspecified affecting left nondominant side. The care plan dated 6/16/15, indicated the resident required assist with ADL's (Activities of Daily Living) secondary to ADL deficit related to [MEDICAL CONDITION] and dementia. Approaches indicated .5/19/17--Transfer resident using Hoyer lift The care plan dated 1/12/15, indicated the resident was at risk for falling and fall related injuries related to [MEDICAL CONDITIONS] and muscle weakness. Approaches indicated 5/19/17--Transfer using Hoyer lift A progress note, dated 9/23/18 at 5:46 p.m., indicated Resident noted to have swollen left knee and leg. Leg warm to touch and slight bruising noted. Right leg looks longer than left. No complaint of pain at hip area A Radiology Report dated 9/23/18 at 11:57 p.m., indicated Results: Nondisplaced fibula head fracture. Oblique, comminuted mildly malaligned tibial neck fracture. Conclusion: Acute tibial/fibula fracture. During an interview on 10/4/18 at 11:51 a.m., RN 2 indicated she came in on 9/24/18 and started the investigation of the injury of unknown origin of Resident C's fractured left fibula and tibial bones. She could not find the source of the fractures. She indicated she interviewed all the staff who provided care for Resident C from 9/21/18 to 9/24/18, and she pinpointed the time frame the LLE fractures would have occurred to after Sunday morning. RN 2 indicated she reviewed the resident's care plan and it indicated the resident was to be transferred with a Hoyer lift and the MDS (Minimum Data Set) assessment was coded a 4/3, which meant she required total dependence with physical assistance of two persons to transfer and that information matched up to the information the therapist told her. She indicated she was told by the therapist the resident was a maximum assist of two, which meant the resident required extensive assistance with physical assist of two people for transfers . RN 2 indicated during her investigation she determined the resident was transferred out of bed that morning with two people physically assisting her with a gait belt. During an interview 10/4/18 at 1:57 p.m., CNA 4 indicated she came into work at 7:00 a.m. on 9/23/18, and Resident C was sitting up in a wheelchair at the nurses station. She complained of pain in her left leg. CNA 4 notified LPN 3 of the resident's complaints of pain. Resident C went to breakfast and to lunch, then she was put to bed. CNA 4 indicated she transferred Resident C back to bed by herself using a gait belt after lunch. She indicated she was a two person transfer and she was not told she was a Hoyer lift transfer. CNA 4 indicated she transferred Resident C by herself that day because she used a gait belt. She indicated the resident was not able to bear weight. During an interview on 10/4/18 at 3:25 p.m., RN 2 was in attendance in Resident C's room at that time. Resident C had just returned from the hospital. RN 2 was observed raising this resident's bed blanket and a blue cast was observed on Resident C's left leg from mid thigh to right above her left toes. The resident was interviewed and she indicated she did not know what happened to her leg. During an interview with LPN 5 on 10/5/18 at 12:12 p.m., with RN 2 in attendance, LPN 5 indicated she was sitting at the nurses station on 9/23/18 between 5:00 and 5:30 p.m., when CNA 6 came to her and told her Resident C complained of her left leg hurt while giving her personal care. LPN 5 went to assess the resident's leg. She indicated when she looked at Resident C's left lower leg the shin portion of her leg was bow outward (her left foot was straight and the shin area was bowed outward) and the left leg was shorter than the right. It had faint bruising in the shin area and it was warm to touch in the shin area with 3+ [MEDICAL CONDITION] and was tight in the shin area. The resident indicated to LPN 5 at that time, her left leg was causing her pain. During an interview on 10/5/18 2:15 p.m., with RN 2 in attendance, CNA 6 indicated she and CNA 7 got the resident out of bed and dressed on 9/23/18 at approximately 5:30 a.m., with two physical assists and a gait belt. CNA 7 indicated this resident had been a two person assist since she had been working at the facility (approximately 1 year and 10 months). She indicated Resident C did not bear weight. She indicated she did not know the transfer status for the resident due to she did not have access to an assignment sheet. She usually got them out of the CNA assignment book and the unit managers made those available to the floor staff. No one told her Resident C's care plan indicated she was a hoyer lift. She indicated when she and CNA 7 got Resident C up the morning of 9/23/18, there was nothing abnormal about her left leg and no c/o of pain. When she came in that evening on 9/23/18, she and CNA 7 went to Resident C's room to get her up and when the two CNA's rolled her she screamed your hurting me she said my leg and she didn't know what was wrong. She looked at it, but she didn't know what happened. She indicated she did not use that leg because it was paralyzed, so she did not know what was wrong with her leg. She indicated the shin part of her leg was bowed outward and it felt warm. CNA 6 indicated she and CNA 7 transferred her by using a gait belt and both people had an arm under her arms and one hand on the gait belt and one person held her left leg around the thigh area because sometimes she will stick that leg straight out and it can it caught on the floor, so they hold her leg to protect it. A current policy titled Safe Lifting and Movement of Residents dated (MONTH) 2009, provided by the DON on 10/4/18 at 3:40 p.m., contained the following information, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . Policy Interpretation and Implementation: .2. Manual lifting of residents shall be eliminated when feasible A current policy title Locking Arms with the Resident dated (MONTH) 2004, provided by the DON on 10/4/18 at 3:40 p.m., contained the following, .General Guidelines: When moving a resident who cannot assist you, two (2) nursing assistants will be needed to lift the resident This Federal tag relates to Complaint IN 173. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident was not left outside without a method to contact staff for 1 of 3 residents reviewed for safety resulting in a potential for serious harm (Resident B). This deficient practice resulted in Immediate Jeopardy. The immediate jeopardy was identified on 8/3/18 and began on 8/1/18. The Regional Director of Operations, Executive Director, Assistant Health Facility Administrator, Corporate Compliance, Director of Nursing and Assistant Director of Nursing were notified of the Immediate Jeopardy on 8/3/18. The immediately jeopardy was removed on 8/6/18 but noncompliance remained a the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: The record for Resident B was reviewed on 8/3/18 at 9:00 a.m. [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview for Mental Status) score which indicated the resident had no cognitive impairment. The Care plan in place at the time of a fall, dated 2/23/18, obtained from the Director of Nursing (DON) on 8/3/18 at 1:34 p.m., indicated the resident was at risk for falling and fall related injuries related to history of falls, a [DIAGNOSES REDACTED]. Interventions in place at the time of the incident/fall included, encourage the resident to ask for assistance with transfers, assist with ADL (Activities of Daily Living) as needed to meet needs, cue/remind the resident to utilize call light to seek assist as needed for transfers related to a fall on 6/22/18, education given to ask for assistance with transferring related to a fall on 12/5/17, keep personal items and frequently used items within reach and report any noted functional changes. Current physician orders [REDACTED]. Insulin, 8 units was to be administered daily before bedtime. the Medication Administration Record [REDACTED] During an observation and interview with Resident B in the courtyard on 8/3/18 at 10:00 a.m., the resident was observed with a flaccid left arm . She indicated she could not use her left arm. She indicated that on 8/1/18, she was taken out to the courtyard around 7:00 p.m. by a Certified Nurse Aide (CNA). Resident B stated she overheard the CNA tell the Nurse on duty, she was outside. She was placed in a three person swing to the left of the door. After being outside for awhile, she tried to stand using the arm of the swing, lost her balance and fell to the concrete landing on her buttocks. She indicated, darkness was falling and the doors to enter the building were closed. She yelled for help and no staff came to her assistance. She laid on the concrete for 2-3 hours. She indicated she felt scared and upset. She laid on the concrete until a staff member heard her calling and two staff assisted her to her feet. She was placed in her wheelchair, which had been outside with her and it was cold and felt wet. She indicated she asked staff what time it was and she was informed it was 1 a.m. She did not get any medications, including her insulin while she was on the patio. During the interview, the courtyard area was observed to have no visible lighting around the door. The swing, (same swing as date of incident) where the resident was seated at the time of interview, was located approximately 10 feet to the left of the door on the concrete patio. A document titled, Event Report, dated 8/2/18, obtained from the DON on 8/3/18 at 1:34 p.m., indicated Resident B was outside of the building on facility grounds at 12:35 a.m. She was found sitting on buttocks. Environmental factor that may have contributed to the fall included a lack of light outside. A review of employee interviews conducted by facility staff on 8/2/18 at 9:36 a.m., CNA 4 indicated she took Resident B to the courtyard on (MONTH) 1, (YEAR) at 6:45 p.m., at her request. She transferred the resident onto the swing without difficulty. She then told the nurse on duty . every one is down and dry, but (name of Resident B) is still outside, I am out of here A review of employee interviews conducted by facility staff on 8/2/18, not timed, Qualified Medication Aide (QMA) 5, indicated .I looked for res (name of Resident B) again after dinner for medications and she was not on the unit . At 7:15 I notified other aide that (Name of CNA 4) had left for the night. I continued to pass meds (medications) and check off tasks. At around 8:15 p.m. (Name of another CNA) notified me she was going to break. (Name of Resident B) still not in her room. I continued passing medications and answering call lights . At 11 p.m., (Name of another CNA) leaves and I continue to cover call lights. (Name of Resident ) is still not in room. I figured that she was out with family since she goes out frequently. I realize around approx. (approximately) 11:30 that (Name of Resident B) is still not in room. I search activity room then it dawns on me, I opened patio doors and couldn't see her. I call out (Name of resident) and I hear her say Yes. (Name of Resident B) was found sitting on ground by swing with wheelchair cushion under her buttocks. I asked (Name of Resident B) why she did not yell out. (Name of Resident B) stated to me she did not want to wake anyone. I notified nurse immediately and waited for nurse to assess before getting her up. (Name of Resident B) did not seem to me to be crying or upset. Nurse took res (resident) vitals and I gave res medication at that time A review of employee interviews conducted by facility staff on 8/3/18, not timed, MDS Coordinator, indicated . 7 pm while doing evening rounds went to 500 courtyard saw (Name of Resident B) on swing without any signs of distress and looked comfortable. A review of employee interviews conducted by facility staff on 8/3/18, not timed, LPN 6 indicated . (name of QMA) called at 12:30 stating the resident was on the ground. Immediately went outside to assist and asked QMA to get the other nurse. Assessed (Name of Resident B) with (Name of second nurse) outside at 12:30 am. Resident was sitting on buttocks with her wheel chair cushion underneath her bottom, Resident stated she was brought outside and put in the swing while it was light out. Resident stated she was trying to transfer from the swing to her wheelchair when she fell During a telephone interview with CNA 4 on 8/6/18 at 1:18 p.m., she indicated about 6:45 on 8/1/18, she helped Resident B outside and helped her onto the swing, she told the nurse the resident was outside and left for the evening about 7:30 p.m. During an interview with the Executive Director on 8/3/18 at 12:26 p.m., she indicated resident checks are resident specific, if the resident is incontinent, checks are made every 2 hours or as needed. No Policy was available for resident checks. The immediate jeopardy that began on 8/3/18 was removed on 8/6/18 when the facility educated employees regarding sign out procedures to outdoor leisure location, including visual checks every 30 minutes. The facility designated an enclosed outdoor leisure area for residents. A lock and dawn to dusk lighting was installed on the leisure area. A two way communication would be provided to each cognitive resident and residents unable to utilize the communication device would have 1:1 supervision. A visual inspection of the courtyard area prior to locking doors at night would be required. Notification of cognitive intact residents and family members of cognitively impaired residents were notified of the facility leisure location safety practices. A policy was written outlining employee responsibilities as it applied to the outdoor leisure location. An audit process related to safety practices to ensure compliance with corporate oversight and reporting through Quality Assurance review. Noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was continuing the monitoring of the new policy and facility practice. This Federal tag relates to compliant IN 932. 3.1-45(1) 3.1-45(2)

Based on observation, interview and record review, the facility failed to prevent, identify, assess and treat pressure ulcers and DTI (Deep Tissue Injury) wounds for 4 of 5 residents observed and reviewed for pressure ulcers (Residents K, C, R and M). The Immediate Jeopardy began January 16, 2018, when the facility failed to implement prevention interventions to prevent the formation of new pressure ulcers and DTI's, failed to identify and assess the formation of pressure ulcers and DTI's, until the wounds were a Stage 3 up to Unstageable pressure ulcers while failing to obtain treatment orders from the Physician for these Pressure Ulcers and DTI's after they were identified. The Administrator, Director of Nursing (DON), Clinical Specialist, Director of Clinical Services and the Regional Director of Operations were notified of the Immediate Jeopardy on 1/23/18 at 1:20 p.m. The Immediate Jeopardy was removed on 1/24/18, but noncompliance remained at the lower scope and severity of pattern, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy Findings include: 1. On 1/19/18 at 12:45 p.m., during the facility tour with LPN 1 in attendance Resident K was observed sitting in his bed with his heels floated on pillows, no Prevalon boots were in place. His left foot was crossed over, laying on top of his right foot. When LPN 1 removed the left foot off the top of the right foot, there was a dime size indent in the blackened/purple area of the medial left heel. The top of the right foot, where the left heel was sitting, had a area at the bone protrusion. from the middle of his foot with a blackened scabbed area. The right medial heel had a bluish/purple area, which was closed. The left 5th metatarsal had a blister on it. The top middle area of his left foot had a dime sized black scabbed area to the area of the bone protrusion from his foot. No drainage was observed from any wound. LPN 1 indicated the resident's left foot should not have been crossed over onto the top of his right foot and the resident was unable to cross his own feet, so a staff member had to have crossed his feet. A record review was completed for Resident K on 1/22/18 at 3:55 p.m. [DIAGNOSES REDACTED]. A Physician order [REDACTED]. 10/19/16--Skin prep (topical medication when applied forms a protective film or barrier to heels daily before bedtime The following orders were received after the wound were identified on initial tour on 1/19/18. 1/20/18--Elevate heels on pillows every shift. 1/21/18--[MEDICATION NAME] Solution (potent topical antiseptic used to prevent or treat infections in minor wounds) (10%) topical solution moderate amount topical apply to unspecified lower leg every shift. (Order was unclear as to which area to apply the [MEDICATION NAME]) The resident had a Care Plan dated 10/19/16, which addressed the problem he was at risk for skin breakdown related to [MEDICAL CONDITION], incontinence, history of open areas, contractures with splint and palm protector use, HOB (head of bed) elevated at all times, decreased mobility and weakness. Goal: Reduce risk and prevent new wound/open area Target date 3/6/18. Approaches included, but were not limited to, .10/19/16--Offload heels when in bed, Pressure reducing surfaces: mattress, chair cushion . 10/19/16--Provide resident education on staff assist, Skin prep to heels The following change in condition reports were initiated after identification of the wounds on the initial tour on 1/19/18. A Change in Condition report dated 1/21/18 at 11:59 p.m., indicated a left heel blister was found on the resident. The wound measured 6.5 x 5.0 x 0.1 cm (Centimeters). The wound was classified as a blister. The Physician was notified on 1/19/18 at 3:00 p.m. and gave a new order for [MEDICATION NAME] every shift. The resident's (Family member) was notified of the new wound on 1/22/18 at 1:00 p.m. There was no further assessment of this wound in the resident's record or on this report. A Change in Condition report dated 1/21/18 at 11:59 p.m., indicated a right heel blister was found on the resident. The resident acquired a skin tear (1 cm x .1 cm) to right heel which was a formed blood blister, while being repositioned, moderate amt (amount) bleeding. Previous order skin prep to heels and off load while resting in bed. The wound started on 1/21/18 at 11:25 p.m. The wound was classified as a skin tear. It measured 1.0 x 0.1 x 0.1 cm. There was a moderate amount of bleeding from the wound. The family was notified of the new wound on 1/21/18 at 11:38 a.m. and the Physician was notified regarding the new wound on 1/21/18 at 11:58 a.m. The interventions were previous order skin prep to heels and off load while resting in the bed. There was no further assessment of this wound in the resident's record or on this report. A Change in Condition report dated 1/22/18 at 4:09 p.m., indicated the resident had open areas to his left foot on the 2nd, 3rd and 5th toes. There was no further assessment of this wound documented in the residents record or on this report. A Change of Condition report dated 1/22/18 at 4:09 p.m., indicated the resident had an open area to his left lateral foot. This wound started on 1/19/18 at 3:00 p.m. The wound was classified as an open area to the left lateral area. The wound measured 6.5 x 3.0 x 0.1 cm. The Physician was notified on 1/19/18 at 3:00 p.m. and the responsible family member was notified on 1/22/18 at 3:00 p.m. There was no further assessment of this wound documented in the resident's record. A Change of Condition report dated 1/22/18 at 4:10 p.m., indicated the resident had a blister to the top of his right foot. There was no further assessment of this wound documented in the resident's record. The bilateral feet wounds, which were assessed were lacking in assessments of wound beds, stages of wounds and measurements of wounds. On 1/23/18 at 12:17 p.m., with the DON, RN 2, LPN 3 and the Nursing Consultant present in Resident K's room, the pressure ulcers were observed. The resident's planter portion of his bilateral feet were flat up against the foot of the bed even though his heels were up on pillows, therefore his bilateral heels were touching the mattress, so there was no offloading of the bilateral heels. The following observations were made when his bilateral feet dressings were removed: 1. Left foot: a. The left lateral foot was a black/purplish color going down the foot towards the heel, with an open area and with white slough (Necrotic or avascular in the process of separating from viable tissue. Usually soft, moist and light in color; may be stringy) around the open area. Bright red blood was oozing down the side of his foot under the wound onto the towel under the resident's foot. The DON indicated this wound was a DTI (Deep Tissue Injury) (Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissues). b. The inner left heel was a dark black/purplish color with a small flap of skin pulled up away from the bottom of his heel with bright red bleeding dripping from the open area with the flap of skin. The DON indicated this wound would be a Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) when it opens, but was a DTI at that time. The dressing was stuck to the resident's heel and LPN 3 moistened it with Normal Saline prior to removing it, but as she removed the dressing bright red blood began to drip from the open area where the flap of skin was located. c. The middle of the left 4th and 5th digits (middle phalanges) had open areas. The DON indicated these wounds were Stage 3's. d. The top of the 5th digit (distal phalange) had a blackened hard eschar (thick, leathery necrotic (dead tissue) or devitalized tissue, frequently black or brown in color). The DON indicated this wound was an unstageable wound (Destruction of tissue or ulceration that extended under the skin edges, so that the pressure ulcer was larger at its base that at the skin surface). e. The top of the left foot had an area at bone protrusion, with a hardened black eschar covering the wound bed. The DON indicated this wound was unstageable. 2. Right foot: a. The medial side of the right heel was a bluish/purple color. The DON indicated the wound was a blood blister, which was a DTI. b. The lateral side of the right heel was a dark blackish/purple color. The DON indicated the wound was a blood blister, which was a DTI. At that time, RN 2 indicated she had measured both of these wounds as one wound when she assessed Resident K's right heel. There was a strip of brown colored skin observed between the medial and the lateral heel wounds, which divided these wounds into two wounds. c. The top of the right foot had an area where the bone protruding, with a hardened black eschar covering the wound bed. The DON indicated this wound was an unstageable. d. The middle of the right 3rd, 4th and 5th digits (middle phalanges) had scabbed wounds. The DON indicated these were open wounds, which were almost healed. e. The right great toe had a scabbed wound. The DON indicated this was an open wound, which was almost healed. f. The proximal area from the right great toe (around the 1st metatarsal) had an open area. The DON indicated this wound was a denuded blister at a Stage 3. The Wound Physician visited Resident K to assess his wounds to his bilateral feet on 1/24/18 at 8:00 a.m., and the following were observed: A Visit Note, dated 1/24/18 at 8:00 a.m., indicated the resident presented with multiple lower extremity ulcers. He had a pressure ulcer to the left heel, which had a start date of 1/19/18. The wound occurred from pressure and was aggravated by debility from a [MEDICAL CONDITION] and contractures in the lower extremities, which are worsening. The wound had minimal (Usually no more than 25% saturation to the wound dressing and the dressing was considered damp) sanguineous (Drainage primarily composed of blood. It is bright in color and thick in consistency. If the wound continues to drain after a few hours, it can indicate trauma to the wound) drainage. His feet were susceptible to injury and had ulcers to his toes from trauma when he first admitted to the facility. Several new ulcers to his bilateral feet and toes were noted on 1/19/18. The cause of the pressure wounds were having pressure into the footboard of the bed due to plantar contractures of his feet. The pressure to his medial bilateral heels was likely due coming in contact with each other due to external rotation of his hips. The pressure ulcers to his bilateral heels and feet were new problems and offloading was the most important part of the wound healing. He had a pillow between his legs and knees now to prevent contact. Resident K had a history of [REDACTED]. [MEDICAL CONDITION]. Left foot: Wound #1 was currently classified as an unstageable (Destruction of tissue or ulceration that extended under the skin edges, so that the pressure ulcer was larger at its base that at the skin surface) wound on the left medial (inside portion) calcaneous (Heel) caused by pressure. It measured 5.5 x 6.0 x 0.1 cm. There was a medium amount (25-75% saturation of dressing, which means the dressing was soaked) of sanguineous drainage noted. There was a small amount of (1-33%) red granulation (Pink-red moist tissue that fills an open wound when it begins to heal) in the wound bed and a large amount (67-100%) amount of necrotic tissue in the wound bed including eschar (thick, leathery necrotic (dead tissue) or devitalized tissue, frequently black or brown in color). Wound #2 was currently classified as an unstageable wound on the left lateral (outside portion) foot caused by pressure. The wound measured 11.0 x 3.0 x 0.1 cm. There was a small amount of serosanguineous (drainage composed primarily of blood and plasma, which was bright in color and thick in consistency and the runoff appeared pink. This drainage indicated damage to blood vessels and capillaries) drainage from the wound. There was a small amount (1-33%) of red granulation within the wound bed and a large (67-100 %) amount of necrotic tissue within the wound bed, which included eschar and adherent slough (Necrotic or avascular in the process of separating from viable tissue. Usually soft, moist and light in color; may be stringy). Wound #3 was currently classified as an unstageable wound on the left proximal (situated closer to the foot), distal (situated away from the foot) and dorsal (top surface of the foot) foot caused by pressure. The wound measured 0.8 x 0.6 x 0.1 cm. There was a large amount (67-100 %) of necrotic tissue within the wound bed, which included eschar. The surrounding skin color had [DIAGNOSES REDACTED] (redness and inflammation). Wound #4 was currently classified as an unstageable wound on the left dorsal, fourth toe caused by pressure. The wound measured 1.5 x 0.7 x 0.1 cm. There was a large amount (67-100%) of necrotic tissue within the wound bed, which included eschar. Wound #5 was currently classified as an unstageable wound on the left dorsal third toe caused by pressure. The wound measured 1.0 x 0.9 x 0 cm. The surrounding wound skin color had [DIAGNOSES REDACTED]. Wound #6 was currently classified as an unstageable wound on the left distal dorsal foot caused by pressure. The wound measured 1.0 x 0.9 x 0 cm. The surrounding wound skin color had [DIAGNOSES REDACTED]. General Note: DTI (Deep Tissue Injury) (Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissues). Right Foot: Wound #7 was currently classified as an unstageable wound on the right lateral calcaneous caused by pressure. The wound measured 5.0 x 2.7 x 0 cm. General Note: blood filled blister. Wound #8 was currently classified as an unstageable wound on the right medial calcaneous caused by pressure. The wound measured 4.0 x 3.5 x 0 cm. General Notes: DTI. Wound #9 was currently classified as an unstageable wound located on the right proximal dorsal foot caused by pressure. The wound measured 1.3 x 2.0 x 0.1 cm. The wound margin was fibrotic; thickened scar. Wound #10 was currently classified as an unstageable wound located on the right distal lateral foot caused by pressure. The wound measured 0.8 x 5.0 x 0 cm. General Notes: Possible DTI. Wound #11 was currently classified as an unstageable wound located on the right dorsal third toe caused by pressure. The wound measured 0.1 x 0.1 x 0.1 cm. There was a large amount (67-100%) of necrotic tissue within the wound bed, which included eschar. Wound #12 was currently classified as an unstageable wound located on the right dorsal fourth toe caused by pressure. The wound measured 0.1 x 0.3 x 0.1 cm. The wound had a small amount of serosanguineous drainage. There was a large amount (67-100%) red granulation within the wound bed. There was no necrotic tissue within the wound bed. General Notes: Now essentially a stage 2. Wound #13 was currently classified as an unstageable wound located on the right lateral fifth toe caused by pressure. The wound measured 2.5 x 1.2 x 0.1 cm. There is a small amount of serosanguineous drainage. There is a small amount (1-33%) red granulation within the wound bed and a small amount (1-33%) of necrotic tissue within the wound bed, which included eschar. During an interview, on 1/24/18 at 2:49 p.m., the DON indicated Resident K developed the pressure ulcers to the top of his bilateral tops of his toes and his lateral side of his left foot due to the footboard at the end of his bed. 2. On 1/19/18 at 11:22 a.m., during the facility tour with LPN 1 in attendance, Resident C was observed sitting in his Broda chair. LPN 1 indicated he had a pressure wound to his coccyx and a wound to his finger on his left hand. Unable to visualize the dressing to his finger due to the resident's contracture and he was having pain at that time. His bilateral thumb nails were long and the right fingernails were long. LPN 1 indicated at that time, his fingernails needed cut. On 1/19/18 at 11:27 a.m., CNA 6 and CNA 7 were observed transferring Resident C to bed with the Hoyer lift and giving pericare. The pressure ulcer dressing on his coccyx did not have a date on it. The bottom of the dressing had bowel movement on it and the dressing was open at the bottom due to no tape was applied to close it. During the pericare, CNA 6 removed the resident's coccyx dressing indicating she would notify the nurse she had removed the dressing and it needed to be reapplied. On 1/19/18 at 12:13 p.m., after the CNA's were finished with the resident, RN 8 was asked when she would be reapplying the dressing to his coccyx. She indicated she would have to wait until his pain medication arrived from the pharmacy. At this time during interview, LPN 1 indicated she heard the CNA inform RN 8 the resident needed his dressing replaced. During an interview on 1/19/18 at 1:30 p.m., RN 8 indicated when asked if she was going to place a dressing over the resident's coccyx to cover it until his pain medication arrived , she indicated she did not know his dressing was off his coccyx. RN 8 indicated the the CNA did not tell her the coccyx dressing had came off during the earlier personal care. On 1/19/18 at 1:42 p.m., RN 8 and LPN 1 completed the treatment to Resident C's coccyx. RN 8 indicated at that time, when she was packing the dressing into the coccyx wound, the resident had tunneling of the wound. During an interview on 1/22/18 at 10:04 a.m., a family member indicated she was visiting and bathing Resident C on 1/17/18, and she smelled something sour or yeasty. She indicated she realized the smell was coming from his left hand, so she notified his primary nurse. She indicated when the nurse removed the splint in his left hand two gnats flew out from his hand and there was a rotten smell when the nurse opened his hand. There was a wound on his index finger from his nail digging into his finger. She indicated she had begged someone to cut his nails for three months. She indicated she was told the CNA's did not cut his nails. During an interview on 1/22/18 at 12:08 p.m., RN 8 clarified Resident C had a wound to his left index finger. The record review for Resident C was completed on 1/22/18 at 3:37 p.m. [DIAGNOSES REDACTED]. The resident had a Care Plan dated 12/14/17, which addressed the problem he was admitted with a stage IV pressure ulcer to the coccyx. He was a poor surgical candidate and bone resection was contraindicated due to risk of bacteremia. Approaches included, but were not limited to, .5/10/17--Administer treatment as ordered The resident had a Care Plan dated 1/18/18, which addressed the problem he had a pressure ulcer to his left forefinger. Approaches included, .1/18/18--Administer treatment as ordered .1/18/18--Splint removed until wound healed. An EMAR (Electronic Medication Administration Record [REDACTED] 7/25/17--Monitor open area to left index finger weekly (the month of January the EMAR has been signed off as this order was completed) 1/17/18--Cleanse 2nd digit on left hand with soap and water. Apply Silver foam cover with dry dressing daily. (Discontinued 1/18/18) 1/18/18--Cleanse wound to left forefinger with NS, pat dry, apply skin prep to periwound, apply silver foam to wound bed and secure with dry dressing. Change daily. 7:00 a.m.-3:00 p.m. 1/18/18--Cleanse wound to left forefinger with NS, pat dry, apply skin prep to periwound, apply silver foam to wound bed and secure with dry dressing. Change as needed for soilage/displacement. 1/19/18--Wound C & S (Culture and Sensitivity) 3rd digit left hand one time. 1/20/18--Left fingers and left hand. X-ray 2nd digit to left hand to rule out osteomylitis stat A Progress note, dated 1/17/18 at 8:59 p.m., indicated Resident has wound to left hand, 2nd digit. Washed hand, flushed wound with NS, dried and wrapped with sterile guaze. [MEDICATION NAME] powder applied to palm and between fingers. Trimmed nails on left hand A Skin Condition Assessment Tool, dated 1/18/18 at 10:40 a.m., indicated the resident had an open area to the left 2nd finger. The wound measured 3.0 x 2.0 cm. Date of origin was 1/17/20. The wound was an acquired wound. There was a strong odor. There was no stage, wound bed description or depth measurement marked on the assessment document. During an interview, on 1/22/18 at 5:00 p.m., the Clinical Specialist indicated the wound on Resident C's left 2nd finger was a pressure ulcer from his fingernail. On 1/23/18 at 11:42 a.m., Resident C's left index finger was observed to have an open wound in the middle portion of his finger. The wound bed had white slough in it. His finger was swollen and was a darker color than his other digits on that particular hand. A Visit Note from the Wound Physician, dated 1/24/18 at 7:00 a.m., indicated the resident presented with an open area to his coccyx/sacrum area and a new area of pressure to his left index finger. Wound #1 was located to the resident's coccyx. The original cause of the wound was a pressure injury. The resident was admitted from the hospital in 2017 with this wound. The wound was currently classified as a Stage IV wound with the cause being pressure ulcer. The wound measured 4.0 x 2.5 x 0.3 cm. There was bone and fascia exposed with a medium amount of serosanguineous drainage on the dressing. The wound margin was well defined, but not attached to the wound base. There was a large amount (67-100%) red granulation within the wound bed and a small amount (1-33%) of necrotic tissue within the wound bed, which includes adherent slough. The wound was unchanged from the last assessment. Wound #2 was located to his left hand index finger. The current classification was a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) caused by pressure ulcer. The wound measured 0.1 x 0.1 x 0.1 cm with small amount of serosanguineous drainage on the dressing. There is a large (67-100%) pink, pale granulation within the wound bed. There was no necrotic tissue within the wound bed. General Notes: Based on history this will be a healing Stage 3 although looks more like a Stage 2 on my exam today. During an interview,on 1/24/18 at 5:25 p.m., the DON indicated Resident C's pressure ulcer was on his left index finger. The nurse who had documented Skin Assessment Tool and the progress note was counting his thumb as his first digit, then his index finger being his second digit. She indicated the nurses required education on wound assessments. 3. On 1/19/18 at 12:22 p.m., during the facility tour with LPN 1 indicated Resident R had a pressure ulcer to his coccyx and he was at lunch at that time. The record review for Resident R was completed on 1/23/18 at 10:00 a.m. [DIAGNOSES REDACTED]. A Change in Condition report, dated 1/16/18 at 5:16 p.m., indicated the resident had eschar on his left heel. The start date was 1/16/18 at 2:00 p.m. The wound classification was not documented on this report. The wound measured 2.0 x 2.0 x <0.1 cm (centimeters). The color of the wound was black. Interventions were to monitor the left heel. A progress note, dated 1/16/18 at 5:20 p.m., indicated, res (resident) noted to have open area on left heel wound bed is black in color, new orders for skin prep q (every) shift, wound team to eval (evaluate) and tx (treat) A Physician order [REDACTED]. 1/16/18--Prevalon boots while in bed 1/19/18--skin prep every shift to left heel There was no treatment ordered for Resident R's left heel wound from the date it was discovered on 1/16/18 until 1/19/18. On 1/23/18 at 10:04 a.m., Resident R's left heel wound was observed with the DON in attendance. His left heel wound had an approximate dime sized brown/black eschar area. At that time, the DON indicated the wound was a pressure ulcer and the resident wore tennis shoes when he was up, but he did not wear them now. A Visit Note report, from the Wound Physician dated 1/24/18 at 9:00 a.m., indicated the resident had a pressure ulcer to his left heel, which was discovered on 1/16/18 and the cause was pressure. Wound #1 was currently classified as an unstageable wound caused by a pressure ulcer located on the left posterior (back) Calcaneous (heel). The wound measured 1.2 x 1.4 x 0.1 cm. There was a large amount (67-100%) of necrotic tissue within the wound bed, which included eschar. The most important part of the wound healing was offloading his heels. 4. On 1/19/18 at 2:12 p.m., during the facility tour with LPN 1 in attendance, Resident M's pressure ulcer to her left inner heel was observed to have black eschar. The resident had her bilateral heels on the mattress and there were no Prevalon boots on her bilateral feet or in her room. LPN 1 indicated at that time, the resident was to have her Prevalon boots on both feet and she looked around her room for them, indicating there were none in her room. LPN 1 went to get LPN 11, who was her primary nurse, who also looked for the boots and indicated they were not in the room. LPN 11 indicated she did not know where she could get another pair for the resident. LPN 1 indicated to her where she could obtain the boots. The record review for Resident M was completed on 1/22/18 at 5:30 p.m. [DIAGNOSES REDACTED]. A Change of Condition dated 7/3/17 at 6:52 a.m., indicated the resident had a black area on her left heel. The wound started on 7/3/17 at 7:00 a.m. The wound classification was other skin--black area. The wound measured 4.0 x 5.0 cm and it was black colored. The treatment was [MEDICATION NAME] and the interventions put into place was Prevalon boots and a composure mattress. An EMAR dated January 2018, included, but were not limited to, the following orders: 2/2/17--Offload heels when in bed 2/2/17--Skin prep to heels 7/5/17--Prevalon boots on at all times The resident had a Care Plan dated 7/5/17, which addressaddressed the problem she had a pressure ulcer to plantar aspect of left foot due to fractured left knee resulting in decreased mobility, resident slept in bed with knees flexed and feet flat on bed surface. Approaches included, but were not limited to, .7/19/17--Prevalon boots at all times no shoes to be worn A Visit Note from the Wound Physician dated 1/24/18 at 7:00 a.m., indicated the resident had a pressure ulcer to her foot. Her pressure ulcer started on the planter surface of her foot on 7/2/18. The wound was stabilized with the treatment of [REDACTED]. She was offloading with Prevalon boots. Wound #2 was currently classified as an unstageable wound located to the left planter (bottom) calcaneous caused by pressure injury. The wound measured 3.5 x 3.0 x 0.1 cm. There is a large amount (67-100%) of necrotic tissue within the wound bed, which included eschar. The wound was unchanged from the last assessment. Plan: Continue diligent offloading. May need to debride eschar if it lifts anymore or starts to drain from underneath A current policy titled Wound management dated 2/15/17, provided by the Clinical Specialist on 1/22/18 at 1:15 p.m., contained the following, Purpose: To provide clinical guidance and best practices for the management of skin conditions within the (Name of Company) communities .Verification: Trust but verify: Each community will have a system in place to verify that skin conditions are being reported timely. It is the policy of (Name of company) that quarterly skin sweeps will be conducted on all residents in order to verify that all skin conditions are accounted for. The frequency of skin sweeps maybe increased to monthly by the nurse consultant when applicable. The wound team: Each wound will be visualized by the wound team to provide oversight of the care plan interventions and ensure that each resident's condition is accurately assessed in a timely manner. This list is not all inclusive but should serve as an example of skin conditions the wound team should evaluate: New wounds or open areas, Existing pressure and non-pressure open areas . IDT: The interdisciplinary team (IDT) will document the wound assessment in the medical record. The 'skin condition assessment tool' will be utilized and completed every seven (7) das on abnormal skin conditions by a member of the IDT wound team or designee The Immediate Jeopardy that began on 1/16/18 was removed on 1/24/18 when the facility completed facility wide skin assessments of all resident to ensure pressure ulcers were identified for intervention and treatment, completed inserving of staff on pressure ulcer prevention, assessment and treatment, and began the monitoring process to ensure on-going assessment of skin to prevent the development of pressure ulcers and to ensure implementation of current pressure ulcer prevention, intervention, assessment and treatments. The noncompliance remained a a lower scope and severity of pattern, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. This Federal tag relates to Complaint IN 490. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a pressure ulcer was assessed accurately, prevention interventions were implemented to prevent the worsening of the pressure ulcer and physician orders [REDACTED]. Resident C's pressure ulcer to the sacral region was discovered after admission as an unstageable wound, then deteriorated to necrotic bone being exposed. Finding includes: Resident C's record was reviewed on 12/27/16 at 12:00 p.m. [DIAGNOSES REDACTED]. A Hospital patient transfer report dated 7/15/16, indicated .Pressure Ulcer present on admission to hospital . location: left foot 2nd metatarsal . appearance: reddened intact Resident C's care plan dated 7/17/16, which addressed the problem she was at risk for skin breakdown related to incontinence, current open areas, dementia, decreased mobility, and weakness. Interventions included, but were not limited to, 7/17/16--Offload heels when in bed check every shift, Pressure reducing surfaces: mattress/chair cushion, Provide resident education on staff assist, Skin prep to heels before bed, Head of bed elevated no more than 30 degrees when in bed unless clinically contraindicated check every shift, Skin protectant/barrier cream, Turn and reposition every shift A change in condition form dated 7/20/16 at 2:53 p.m., indicated .description: open area to coccyx . 3 cm (centimeter) x 2.5 cm x 0 cm . Interventions: Dermaseptine (a skin protectant moisture barrier cream) . to be monitored via wound team No description of the wound or staging of the wound was located. The facility's MDS (Minimum Data Set) admission assessment for Resident C dated 7/24/16, indicated she was at risk of developing a pressure ulcer and did not have a Stage I or higher pressure ulcer upon admission to the facility. A skin condition assessment dated [DATE] at 5:13 p.m., indicated Resident C had an acquired (facility grown) pressure sore to her coccyx which measured 4 cm by 2.7 cm by 0.2 cm. The date of origin was 7/20/16. It was .unstageable with 75% slough (yellow, green, gray, nonviable tissue) and 25% [MEDICATION NAME] (deep pink to pearly pink) with no odor Resident C's care plan dated 7/28/16, which addressed the problem she presents with an unstageable pressure area to her coccyx related to immobility, weakness, infection, and cognition. Interventions included, but were not limited to, .7/28/16--Record location and size of wound, Wound care center to evaluate and treat, Monitor and report any signs of localized infection (swelling, redness, pain or tenderness) . 8/4/16--Low air loss mattress with a setting of 5- check function every shift, Administer medications as ordered Physician orders [REDACTED]. Wound Center note dated 8/2/16, indicated .I was asked to see this resident for a pressure ulcer found on her sacrum/coccyx by the nursing staff on 7/20/16 . Now with a new pressure on her right buttocks found today . Coccyx is unstageable . measurements are 3.3 cm x 4.5 cm x 0.4 cm . Wound bed is 76-100% slough, 1-25% granulation .Right buttocks is a Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough at be present but does not obscure the depth of tissue loss. May include undermining and tunneling) pressure injury . measurements are 3.8 cm x 2.8 cm x 0.1 cm .Coccyx- cleanse wound bed with normal saline. Pat dry. Apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze, then cover with dry gauze and secure daily . Right buttocks- Cleanse wound area with mild soap and water. Rinse thoroughly. Dry. Apply [MEDICATION NAME], or equivalent, to the wound bed area once a shift . Upgrade mattress to Low air loss mattress. Upgrade wheelchair cushion to ROHO or equivalent. Turn every 2 hours A Physician order [REDACTED]. No documentation for turning and repositioning every two hours, an order for [REDACTED]. Wound Center note dated 8/9/16, indicated .Coccyx measurements are 3.5 cm x 5 cm x 0.4 cm . Wound bed is 76-100% slough, 1-25% pink granulation. The wound is deteriorating .Patient currently has appropriate offloading wheelchair cushion: No Wound Center note dated 8/16/16, indicated .Coccyx measurements are 3.5 cm x 3.7 cm x 0.4 cm . Wound bed is 76-100% slough, 1-25% pink granulation . Patient currently has appropriate offloading wheelchair cushion: No . A skin condition assessment dated [DATE] at 1:37 p.m., indicated Resident C had a pressure sore to her coccyx which measured 3.8 cm by 3.0 cm by 1.2. The date of origin was 7/20/16 and was developed in house. It was .unstageable with 50% slough (yellow, green, gray, nonviable tissue) and 50% [MEDICATION NAME] (deep pink to pearly pink) with strong odor and the wound edge was macerated/soft A skin condition assessment dated [DATE] at 4:26 p.m., indicated Resident C had a pressure sore to her coccyx which measured 3.8 cm by 2.7 cm by 1.2 with undermining (Destruction of the tissue or ulceration, which extended under the skin edges, so the pressure ulcer was larger at the base of the wound than at the skin surface) . The date of origin was 7/20/16 and was developed in house. It was .unstageable with 50% slough (yellow, green, gray, nonviable tissue) and 50% [MEDICATION NAME] (deep pink to pearly pink) with strong odor and the wound edge was macerated/soft Wound Center note dated 9/6/16, indicated .Coccyx measurements are 4 cm x 2.8 cm x 1.2 cm . Undermining has been noted at 8:00 and ends at 2:00 with a maximum distance of 1.9 cm .Wound bed is 26-50% slough, 51-75% pink granulation. The wound is deteriorating . Patient currently has appropriate offloading wheelchair cushion: No . No Wound Center notes or skin assessment with the wound measurements were located for the week of September 13th. A skin condition assessment dated [DATE] at 12:15 p.m., indicated Resident C had a pressure sore to her coccyx which measured 3.2 cm by 2.0 cm by 1.0 cm. The date of origin was 7/20/16 and was developed in house. It was .unstageable with 25% slough (yellow, green, gray, nonviable tissue) and 75% [MEDICATION NAME] (deep pink to pearly pink) Wound Center note dated 9/27/16, indicated .Coccyx is a Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle) measurements are 3.5 cm x 1.8 cm x 1.2 cm . Bone is exposed . Undermining has been noted at 10:00 and ends at 2:00 with a maximum distance of 1.8 cm .Wound bed is 1-25% slough, 76-100% pink granulation . Patient currently has appropriate offloading wheelchair cushion: No . Wound Center note dated 10/4/16, indicated .Coccyx is a Stage 4 measurements are 3.5 cm x 2 cm x 1.2 cm . Necrotic bone is exposed . Undermining has been noted at 9:00 and ends at 2:00 with a maximum distance of 3 cm. There is a moderate amount of yellow drainage noted which has no odor. The patient reports a wound pain of 4/10. The wound margin is thickened and rolled under. Wound bed is 1-25% slough, 76-100% pink granulation. The wound is deteriorating . Patient currently has appropriate offloading wheelchair cushion: No . Make sure has ROHO cushion if up in wheelchair During an interview on 12/28/16 at 8:39 a.m., a family member of Resident C indicated when she arrived for a visit, the resident's door was always closed and Resident C was in isolation for [MEDICAL CONDITION]. She indicated during her visits, she did not observe staff turning and repositioning her family member. During an interview on 12/28/16 at 2:30 p.m., the Director of Nursing (DON) indicated she could not find documentation or a physician order [REDACTED]. During an interview on 12/28/16 at 4:09 p.m., the DON indicated the [MEDICATION NAME] order for Resident C's right buttocks was not transcribed correctly and an order was not found. She indicated the staff nurses were not allowed to stage the wounds when they were discovered. A member of the Interdisciplinary Team (IDT) or the wound doctor were the ones who staged the wounds. A current policy titled Wound Management dated 3/2015, provided by the Director of Nursing on 12/28/16 at 3:45 p.m., indicated Purpose: To provide clinical guidance and best practices for the management of skin conditions .Skin condition worsened .Review of the care plan/ MD order(s)/ nurse aide sheet .Can any new interventions be added to further reduce pressure to the affected site This Federal tag relates to Complaint IN 457 and IN 760. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview the facility failed to ensure a resident with a recent removal of a nasogastric (NG) tube was assessed and interventions implemented to prevent dehydration for 1 of 3 residents sampled for hydration (Resident B). This deficient practice resulted in the resident transported and admitted to the local area hospital for a change in mental status and dehydration which required physician interventions to include intravenous fluids. (Resident B). Findings include: The record for Resident B was reviewed on 09-21-15 at 12:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. At the time of admission, the resident weighed 179 lbs (pounds), and was admitted to the facility with a NG (naso-gastric) feeding tube in place for nutrition. A physician order dated 08-16-15, instructed the nursing staff to weigh the resident daily. The order included a notation which instructed the nursing staff to notify MD (Medical Doctor) of a weight gain of 2 lbs. (pounds) in one day or 5 lbs. in a week. The Dietitian's Nutrition assessment, dated 07-31-15, indicated the resident received nothing by mouth, had physician orders included Glucerna 1.2 at 65 ml; (milliliters) over 24 hours and estimated fluid needs of 2025 ml. A review of the record indicated the nursing staff received physician orders to remove the feeding tube on 09-01-15. The record further indicated the resident had physician orders to receive a pureed diet with honey thickened liquids for nutrition and hydration and required dependent assist with feeding. The resident also had physician orders for Speech Therapy related to the appropriate diet and the resident's chewing and swallowing abilities. A review of the fluid consumption documentation indicated the following fluid intake after the NG feeding tube had been removed: 09-01-15 1710 c.c., 09-02-15 1200 c.c . 09-04-15 1500 c.c., 09-05-15 1680 c.c . 09-07-15 1940 c.c., 09-08-15 1320 c.c., 09-09-15 1680 c.c. A review of the Speech Therapist treatment notations, once the resident's NG feeding tube had been removed and began to consume liquid by mouth indicated the following: 09-01-15 - Patient lethargic and fatigued on this date. Patient with significant delay in swallow . Signs and symptoms of aspiration throughout PO (by mouth) trials . delayed coughing times 10, throat clearing times 2, and labored breathing times 1. 09-02-15 Aid staff feeding pt. (patient) when SLP began therapy session. Pt. presented with running nose and running eyes. SLP educated aid on s/s (signs and symptoms) of aspiration and (sic) 'dry swallow, double swallow and max cueing to swallow. Pt. with increase lethargy throughout PO intake. Pt. with wet vocal quality times 2 with HTL (honey thickened liquid) consumption. SLP cued pt to cough. Pt. did not respond to cueing and did not cough. SLP completed dry swallow with spoon. 09-03-15 Pt with consumption of puree and HTL in dining room during meal. Pt. with intermittent wet vocal quality throughout meal consumption. 09-07-15 Pt being fed by an aid. Pt with increased lethargy and distraction throughout meal consumption. Pt with 10% meal consumption. 09-09-15 Pt. wife reported pt did not eat AM meal due to increased lethargy. Pt with increased lethargy this date throughout therapy session and less verbalization than typical. Pt warranted max verbal cueing to swallow bolus. 09-10-15 Pt has demonstrated increased difficulty over the past several sessions. Pt has been less responsive and required an increased amount of cueing, especially for swallowing. Pt's wife and staff educated on current concerns due to increased need for cuing (sic), increased delay in or lack of swallow, and possible dehydration. Staff and family demonstrated understanding at this time and wife reported possible need for Pt. to go to the hospital. His consumption has been poor, which mean (sic) .hydration have likely not been satisfactory. A review of the physician progress notes [REDACTED]. 09-03-15 Patient denies any complaints, still with significant L (left) side [MEDICAL CONDITION]. Tolerating NG feeds; however NG tube got clogged and nothing worked in regards to attempts at unclogging it. Will trial a PO diet and monitor intake. Speech Therapy. Apparently was not a candidate for a PEG (Percutaneous endoscopic gastrostomy feeding tube) tube in hospital. If problems with dysphagia or PO intake poor, will consider PEG tube. 09-08-15 L side [MEDICAL CONDITION] unchanged. Swallow function improved and NG removed, has poor PO intake. 09-10-15 (Spouse) at bedside with many concerns regarding his overnight care and also states minimal PO intake past 2 days. She insists on sending him to ED (Emergency Department) despite multiple attempts to offer immediate IV (intravenous) placement . Pt is more lethargic than baseline. The resident was transported to the local hospital on 09-10-15, through the emergency room Department and admitted to the hospital. The record indicated at the time the resident presented to the emergency room , the resident was drooling and somulent. The Hospital record indicated, Impression: [MEDICAL CONDITION], Acute [MEDICAL CONDITIONS] Fibrillation and Dysphagia. The resident was started on Intravenous fluids in the emergency room to correct the [MEDICAL CONDITION]. The record indicated the resident originally presented with altered mental status and clear dehydration. The record further indicated a laboratory test for a BUN (blood urea nitrogen level) of 52 (normal range of 8 - 26) and a serum sodium level of 169 (normal range of 136 - 145). The Hospital emergency room Nursing notations indicated the resident was dehydrated with scant urine, oliguria. During an interview on 09-23-15 at 12:30 p.m., the facility Dietitian indicated she had not been informed the resident's nutrition had been changed from a tube feeding to a mechanical altered diet. The Dietitian further indicated she would have needed to reassess the resident for his nutrition and hydration status, and the total amount of fluids needed. The Dietitian indicated that when a resident was on a pureed diet and thickened liquids they were at risk for dehydration. A review of the facility policy on 09-23-15 at 12:00 p.m., titled Clinical Signs of Dehydration, and Risk Factors that my lead to Dehydration, dated March 2015, indicated the following: Dehydration - Rapid decrease in weight, elevated serum sodium > (greater than 148) and/or BUN and or BUN:Creatinine > (greater than 25:1, diminished urine output, postural [MEDICAL CONDITION] and/or weak rapid pulse. This Federal tag relates to Complaint IN 272. 3.1-46(b)

Based on record review and interview the facility failed to ensure a resident with a recent removal of a nasogastric (NG) tube was assessed and interventions implemented to prevent a significant weight loss of 17 lbs. (pounds) in 9 days for 1 of 3 residents sampled for weight loss. (Resident B). This deficient practice resulted in the resident transported to the local area hospital and admitted for a change in mental status, weight loss and dehydration which required physician interventions to include intravenous fluids. (Resident B). Findings include: The record for Resident B was reviewed on 09-21-15 at 12:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. At the time of admission, the resident weighed 179 lbs, and was admitted to the facility with a NG (naso-gastric) feeding tube in place for nutrition and hydration A physician order dated 08-16-15, instructed the nursing staff to weigh the resident daily. The order included a notation which instructed the nursing staff to notify MD (Medical Doctor) of a weight gain of 2 lbs. (pounds) in one day or 5 lbs. in a week. A review of the record indicated the nursing staff received physician orders to remove the feeding tube on 09-01-15. The record further indicated the resident had physician orders to receive a pureed diet with honey thickened liquids for nutrition and hydration and also required dependent assist with feeding. The resident also had physician orders for Speech Therapy related to the appropriate diet and the resident's chewing and swallowing abilities. Further review of the resident's record lacked a plan of care to reflect a change in nutrition for the resident from receiving nutrition through a NG tube to a mechanically altered diet. A review of the Speech Therapist treatment notations, once the resident's NG feeding tube had been removed and began to consume food and liquids by mouth indicated the following: 09-01-15 - Patient lethargic and fatigued on this date. NG tube removed by nursing while SLP (Speech Language Pathologist) present during afternoon session. Patient with significant delay in swallow . Signs and symptoms of aspiration throughout PO (by mouth) trials . delayed coughing times 10, throat clearing times 2, and labored breathing times 1. 09-02-15 Aid staff feeding pt. (patient) when SLP began therapy session. Pt. presented with running nose and running eyes. SLP educated aid on s/s (signs and symptoms) of aspiration and (sic) 'dry swallow, double swallow and max cueing to swallow.' Pt. with increase lethargy throughout PO intake. Pt. warranted max cues throughout meal consumption to swallow. Pt. with wet vocal quality times 2 with HTL (honey thickened liquid) consumption. SLP cued pt to cough. Pt. did not respond to cueing and did not cough. SLP completed dry swallow with spoon. Pt. with meal consumption about 50 % SLP discussed with nsg. (nursing) staff to order pt. Ensure (a supplement) and thicken to a appropriate viscosity due to increase lethargy during meal consumption; resulting in reduced consumption amount. There was no physician order for [REDACTED]. 09-03-15 Pt with consumption of puree and HTL in dining room during meal. Pt. with intermittent wet vocal quality throughout meal consumption. Pt warranted mod (moderate) - max (maximum) verbal/tactile cueing to swallow and complete double swallow. Pt. discussed with nsg. staff to check pt lungs periodically throughout day due to upgraded diet. 09-04-15 . Pt pocketing food in oral cavity. Max cues to not talk with food in oral cavity. Pt with overt s/s of aspiration times 6 in form of cough and times 4 wet vocal quality. Average hold during oral phase was about 15 seconds . Pt reported being full after about 10 % meal consumption. 09-07-15 Pt being fed by an aid. Pt with increased lethargy and distraction throughout meal consumption. Pt with oral phase hold of an average of about 15 seconds. Pt began spitting out food and refusing meal. Pt with 10% meal consumption. 09-09-15 Pt seen bedside this date during lunch. Pt (spouse) present during therapy session and reported pt did not sleep all night. Pt (spouse) reported pt was coughing and moaning in pain. Pt. wife reported pt did not eat AM meal due to increased lethargy. Pt with increased lethargy this date throughout therapy session and less verbalization than typical. Pt warranted max verbal cueing to swallow bolus. Oral phase average time 12 - 15 seconds with puree consumption . Pt with reduced hyolargyneal excursion and increased weakness . Nsg. staff gave pt medication with HOB (head of bed) lowered. SLP educated on importance of raising HOB when providing medication in bed. A review of the meal consumption documentation indicated the following: 09-01-15 Dinner 1 - 25% consumed, 09-02-15 No documentation for Breakfast or the lunch meal, Dinner 26 - 50 % consumed, 09-03-15 Breakfast 1 - 25% consumed, Lunch 26 - 50 % consumed, Dinner 1- 25 % consumed, 09-04-15 Breakfast 1 - 25 % consumed, Lunch 1 - 25 % consumed, Dinner 76 - 100 % consumed., 09-05-15 Breakfast 26 - 50 % consumed, 51 - 75 % consumed, 51 - 75 % consumed, 09-06-15 No documentation for the Breakfast or Lunch meal, Dinner 26 - 50 % consumed, 09-07-15 No documentation for the Breakfast or Lunch meal, Dinner 76 - 100 % consumed, 09-08-15 No documentation for the Breakfast or Lunch meal, Dinner 1 - 25 % consumed, 09-09-15 Breakfast 'None' consumed, Lunch 'None' consumed, Dinner 26 - 50 % consumed. A review of the resident's daily weights, from the time the NG feeding tube was removed until 09-10-15 when the resident was transported to the local area hospital indicated the following: 09-01-15 178 lbs., 09-02-15 178.7 lbs., 09-03-15 178 lbs., 09-04-15 no documentation, 09-05-15 178.9 lbs., 09-06-15 161.6 lbs., 09-07-15 177.2 lbs, 09-08-15 169.8 lbs., 09-10-15 161.2 lbs. A review of the physician progress notes [REDACTED]. 09-10-15 (Spouse) at bedside with many concerns regarding his overnight care and also states minimal PO intake past 2 days. She insists on sending him to ED (Emergency Department) despite multiple attempts to offer immediate IV (intravenous) placement . Pt is more lethargic than baseline. At the time the resident presented to the local hospital on 09-10-15, the emergency room record indicated the resident was drooling, somulent and had an actual weight of 162 lbs. The resident was admitted to the hospital with [REDACTED]. The record lacked documentation the physician or dietitian were notified of the weight loss as documented in the clinical record and a change in the mental alertness of the resident. A review of the facility policy on 09-23-15 at 12:00 p.m., titled Clinical Signs of Dehydration, and Risk Factors that may lead to Dehydration, dated March 2015, indicated the following: Risk Factors - Weight loss - rapid loss is attributed mostly to loss of fluid, not foods, ADL (Activities of Daily Living) decline; dependence on staff for fluid intake; dysphagia and/or refusing liquids, limited fluid intake or decreased thirst sensation, medications such as diuretics, laxatives, Diagnosis: [REDACTED]. Intake Assessment: If fluid needs are not being met, determine the root cause by examining risk factors as above. A review of the facility Weight Management Policy, on 09-23-15 at 1:00 p.m., and dated 02-17-2015, indicated the following: Policy Statement: Purpose - This policy is meant to provide guidance to the community on obtaining weights and addressing significant weight changes. It is considered to be a best practice for each community to develop a weight team that will ensure weights are obtained in the same manner for each resident by the same staff members to ensure accuracy. If the resident has a previous weight n the medical record that weight will be compared to the current weight being obtained to ensure that a reweight is done immediately if there is a significant change in weight. If the resident weighs 101 lbs. r more and there is a weight change from the previous weight of +/- (plus or minus) 5 lbs., then he/she will be reweighed. Significant weight loss/gain protocol (for weekly admission weights and routine monthly weight monitoring and any other weight change the IDT (Interdisciplinary Team) determines to be at risk) - Family/physician/RD (Registered Dietitian) notification will be documented in the medical record. The RD will be notified to assess/review the resident for recommendations on his/her next visit. Initiate or update care plan to include: .expected weight changes, risks affecting weight changes, RD consult and recommendations, Resident compliance, intake records for fluid and fluids, nurse aide communication matches the care plan interventions when applicable. Weight loss worsens: Notify MD (Medical Doctor), family and staff, Review of the care plan/MD order(s)/nurse aide sheet to ensure they reflect current interventions and status. This Federal tag relates to Complaint IN 272. 3.1-46(a)(2)

Based on observation, interview and record review the facility failed to ensure the necessary care for a resident with an indwelling catheter, in that when Resident "A" had an indwelling catheter placed due to [MEDICAL CONDITION], the nursing staff failed to ensure the resident's urinary output was sufficient. This deficit practice resulted in the resident with a change in condition, which prompted the nursing staff to alert the Emergency Medical System to transport the resident to the local area hospital with a [DIAGNOSES REDACTED]. (Resident's "A", "G", "B", "C", "D", "E", and "F"). Findings include: 1. The record for Resident "A" was reviewed on 02-02-15 at 9:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had recently returned to the facility form a hospitalization for urinary tract infection and dehydration. The resident had physician orders, dated 01-20-15 for [MEDICATION NAME] (an irrigation solution for obstruction in urinary catheters), 100 ml (millimeters) - "Special instructions: Instill 100 ml into Foley/bladder, clamp and let dwell for 10 minutes, unclamp and let solution drain into Foley bag. Once an Evening on Tuesday and Saturday 3:00 p.m. - 11:00 p.m." An additional physician order, dated 01-20-15, instructed the nursing staff to "Change urinary catheter and drainage bag PRN (as needed) occlusion/dislodgement. Document the procedure in the progress notes to include: ml. (milliliters) removed from the existing Foley bulb, the ml. placed in the new bulb, any drainage from the meatus, characteristics of the peri care, urinary return and the residents tolerance of this procedure as needed. Special instructions: Unmanageable [MEDICAL CONDITION] cannot be treated or corrected medically or surgically for which alternative therapy is not feasible and is characterized by: (1) documented PVR (post void residual) > (greater than) 200 ml (2) inability to manage retention/incontinence with I & O (intake and output) catherization." A review of the Nurses Progress Notes, dated 01-21-15 at 7:58 a.m., indicated, "Resident had some retention on prior shift and cath. (catheter) place <sic> with desired results. MD (Medical Doctor) notified with no new order given." "01-21-15 at 3:15 p.m. 500 c.c. (cubic centimeters) yellow urine emptied from res. (resident) catheter today. No c/o (complaints of) pain or discomfort. Fluids encouraged." "01-21-15 11:08 p.m. LATE ENTRY - During evening bath aide alerted writer that resident had blood in his undergarment . Assessed resident and cleaned him up. Resident stated he was in no pain. No signs of trauma or swelling. Reassessed resident during bed check and no further signs of bleeding or trauma. Will continued to monitor." The record lacked any additional information related to the resident's catheter or further bleeding until 01-24-15 at 6:00 p.m. when the licensed nurse employee # 9 documented, "Aide was in resident's room attempting to dress him for dinner. Aide was unable to stand resident up on her own, which is unusual, so aide went to find this nurse. This nurse immediately began to ask resident yes and no questions, but resident was unable to respond. This nurse took resident's vitals (159/75, 138 bpm (beats per minute), 101.7 degrees (temperature) and 94 % (oxygen saturation level)) and called the on call NP (nurse practitioner). Resident was sent to the hospital. Family has been notified." A review of the Hospital record on 02-02-15 at 11:00 a.m., indicated the resident was transported to local area hospital (#1) on 01-24-15. The emergency room documentation indicated the resident was + (positive) for fever, shock, dehydration, pneumonia and urinary tract infection - makes sounds like crying but no tears. HR (heart rate) 115 -[MEDICAL CONDITION] with fever. Giving IV (intravenous) fluids has indwelling Foley too." The emergency room nursing documentation indicated the resident's "abd. (abdomen) was firm - bladder scanned for 999 ml (millimeters). The catheter apparently plugged and unable to irrigate it." The resident's catheter was changed and a urine specimen was obtained. The nurse documented the urine was "cloudy and odorous." "Nursing Note; 1000 ml returned from catheter, then catheter clamped for about 30 min. (minutes), then reopened. A total of 1900 ml drained from bladder. Abd. now soft." The urinalysis indicated the resident had "abnormalities" in the urine which included "occult blood, large leukocyte esterase, cloudy in appearance, white blood cells > 100 in the urine, packed bacteria and mucus." The family requested the resident to be transferred to the hospital (#2) where the resident had previously been hospitalized . The transfer papers indicated the resident had a "UTI (urinary tract infection) and Foley malfunction." A hospital Consultation notation dated 01-25-15, indicated, "I was asked to see the patient for [MEDICAL CONDITION], UTI in a chronic Foley Catheterized patient. He had worsening mental status at the SNF (skilled nursing facility) and fever up to 101 and [MEDICAL CONDITION] his Foley catheter was exchanged on admission to emergency room because it was clogged with mucus and non-draining." The facility clinical record was reviewed for fluid intake and urinary output from the date the catheter was noted to be obstructed on 01-21-15 until the time the resident was transferred to the local area hospital due to a change in mental status. The following was noted: 01-21-15 Fluid Intake - 2200 ml. Urinary Output at 6:54 a.m. 225 ml, 8:07 a.m. 225 ml, 2:42 p.m. "Large," 11:43 p.m. 600 ml. 01-22-15 Fluid Intake - 1320 ml. Urinary Output at 6:18 a.m. 200 ml, 10:02 a.m. "Large," 11:00 p.m. Large/650 ml. 01-23-15 Fluid Intake 840 ml. Urinary Output at 7:52 a.m. 950 ml, 6:13 p.m. "Large." 01-24-15 Fluid Intake 940 ml. Urinary Output 1:36 a.m. "Medium"/700 ml, 1:34 p.m. "Large." The Nursing staff failed to measure and document the exact amount of output in milliters and the record lacked documentation of the resident's urinary output for each shift. The record lacked the amount of urinary output on the evening shift 01-22-15, the night shift on 01-23-15 and evening shift on 01-24-15. The resident remained at the hospital until the time of discharge. The Discharge Summary indicated the resident had been admitted with "[MEDICAL CONDITION] secondary to complicated UTI secondary to ESBL (Extended spectrum beat-lactamase) E.coli (Escheria coli) - which was resolved, and toxic metabolic [MEDICAL CONDITION]." 2. The record for Resident "G" was reviewed on 02-03-15 at 2:30 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had an indwelling catheter. A review of the resident's current plan of care dated 10-29-14 prompted the nursing staff with the following interventions in regard to the catheter. "Assess the drainage of SPC (suprapubic catheter) every shift. Record amount, type, color, odor. Observe for leakage. Avoid obstruction in draining." A review of the Nurses Progress notes dated 01-7-15 indicated the super <sic> pubic catheter changed "per sterile tech. (technique)...yellow urine return. A review of the Intake and Output Report indicated the resident had zero output on 01-04-15, 01-05-15, 01-07-15, 01-10-15, 01-11-15, 01-15-15, 01-19-15, 01-20-15, 01-21-15, 01-22-15, 01-24-15, 01-26-15, 01-27-15 and 01-28-15. The Urinary Output detailed report from 01-04-15 through 02-01-15 the Certified Nurses Aides documented the output in "Details" as "Large" or "Medium," with no value or mls recorded. The Nursing staff failed to measure and document the exact amount of output in milliliters and the record lacked documentation of the resident's urinary output daily and for each nursing shift. 3. The record for Resident "B was reviewed on 02-02-15 at 11:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the CNA assignment sheet indicated "In and Out catheter per nurse. Record Output." The resident had physician orders, dated 01-18-15 for In and Out catheterization every 6 hours. A review of the Nurses Progress Notes indicated the following: "01-17-15 at 11:40 p.m. - resident had c/o fullness and inability to urinate, contacted MD and got order for in and out cath times 1. In and out cath, per sterile procedure, tolerated well by resident 650 ml dark amber urine retrieved." "01-18-15 at 1:36 a.m. Order for In & Out cath. (catheter) every 6 hours obtained from (name of physician) due to patient [MEDICAL CONDITION]." "01-20-15 at 12:15 a.m. In et (and) out cath via sterile technique for 150 dark yellow urine. Encourage to drink." "01-20-15 at 5:05 a.m. In et out cath via sterile technique for 210 dark amber urine. Pt. (patient) tolerated procedure well." "01-21-15 at 12:15 a.m. In et out cath via sterile technique for 200 dark yellow urine. Encouraged to drink." "01-21-15 at 6:10 a.m. In et out cath via sterile technique for 150 dark yellow urine. Encouraged to drink." "01-26-15 I/O (in and out) catheter per MD order. 240 ml of dark amber urine. Resident tolerated procedure well with no discomfort noted." "01-29-15 at 12:45 a.m. In et out cath for 100 ml dark amber urine. Pt. tolerated procedure well." "01-29-15 at 7:40 a.m. In et out cath done 250 ml return dark amber urine. Pt. tolerated procedure well." The facility nursing staff were monitoring the resident's urinary output in addition to the frequent catheterization. A review of the fluid intake and urinary output from 01-16-15 through 02-01-15 indicated the resident had either "large, medium or small urinary outputs" with no specific measurements or documentation the exact amount of the resident's urinary output in milliliters. The Nursing staff failed to measure and document the exact amount of urinary output in milliliters for each shift. During an interview on 02-02-15 at 3:30 p.m., Administrative staff verified there was no facility policy which instructed the staff to document "large, medium or small" in regard to urinary output. 4. The record for Resident "C" was reviewed on 02-02-15 at 1:05 p.m. [DIAGNOSES REDACTED]. The resident had an indwelling catheter. A review of the CNA assignment sheets prompted the nursing staff "resident has Foley catheter. Empty after each shift record output." The resident had a physician order dated 01-20-15, which indicated: "Special instructions: Unmanageable [MEDICAL CONDITION] cannot be treated or corrected medically or surgically for which alternative therapy is not feasible and is characterized by: (1) documented PVR (post void residual) > (greater than) 200 ml (2) inability to manage retention/incontinence with I & O (intake and output) catherization." A review of the Fluid Intake and Urinary Output report indicated the following: 01-20-15 Fluid Intake 2640 mls. Urinary Output 1085 mls. 01-21-15 Fluid Intake 2280 mls. Urinary Output - no documentation related to mls. 01-22-15 Fluid Intake 2680 mls. Urinary Output 1020 mls. 01-23-15 Fluid Intake 2520 mls. Urinary Output "Medium - no documentation related to amount of mls." 01-24-15 Fluid Intake 2700 mls. Urinary Output "Large" - no documentation related to amount of mls, and "Medium 900 mls." 01-25-15 Fluid Intake 3060 mls. Urinary Output 600 mls. 01-26-15 Fluid Intake 2480 mls. Urinary Output 900 mls. 01-27-15 Fluid Intake 2500 mls. Urinary Output 2625 mls. 01-28-15 Fluid Intake 2520 mls. Urinary Output - no documentation related to mls. 01-29-15 Fluid Intake 2900 mls. Urinary Output "Medium 640 mls/ Large 1200 mls." 01-30-15 Fluid Intake 2650 mls. Urinary Output "Medium - no documentation related to the amount, Medium 200 mls." 01-31-15 Fluid Intake 1380 mls. Urinary Output 1100 mls, "Medium 440 mls." 02-01-15 Fluid Intake 2580 mls. Urinary Output 900 mls. 02-02-15 Fluid Intake 1680 mls. Urinary Output "Large 1200 mls, and 600 mls. The Nursing staff failed to measure and document the exact amount of output for each shift. 5. The record for Resident "D" was reviewed on 02-02-15 at 1:50 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had an indwelling urinary catheter. A review of the CNA assignment sheets instructed the nursing staff "Foley catheter empty each shift - record output." A review of the Nurses Progress notes lacked documentation related to the resident's urinary catheter or ongoing assessment for [MEDICAL CONDITION]. A review of the Fluid Intake and Urinary Output report indicated the following: 01-25-15 Fluid Intake 1434 mls. Urinary Output. No documentation for day shift or night shift. Evening shift - Large/Medium 1600 mls. 01-26-15 Fluid Intake 1637 mls. Urinary Output. No documentation for day shift. Evening shift and night shift only. Large - 1600 mls. 01-27-15 Fluid Intake 1197 mls. Urinary Output. No documentation for day shift or night shift. Evening shift - Large/Medium 1650 mls. 01-28-15 Fluid Intake 1591 mls. Urinary Output. No documentation for night shift. Day shift and evening shift Large 1900 mls. 01-29-15 Fluid Intake 1591 mls. Urinary Output. No documentation for day shift. Night shift and evening shift - Large no documentation of mls. obtained and a subsequent entry - Medium 250 mls. 01-30-15 Fluid Intake 3171 mls. Urinary Output. No documentation for day shift or night shift. Evening shift only - Large no documentation of mls. large 900 mls. 01-31-15 Fluid Intake 2754 mls. Urinary Output. No documentation for day shift or night shift. Evening shift - Medium 350 mls. 02-01-15 Fluid Intake 1911 mls. Urinary Output. No documentation for day shift or night shift. Evening shift - Large no documentation of mls. obtained, and a subsequent entry - Large 2525 mls. The Nursing staff failed to measure and document the exact amount of output in milliliters and the record lacked documentation of the resident's urinary output for each shift. 6. The record for Resident "E" was reviewed on 02-02-15 at 2:40 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the CNA assignment sheet prompted the nursing staff to "empty Catheter bag every shift - report amount." During an observation on 02-03-15 at 10:00 a.m., the resident was seated in his wheelchair and the urinary drainage bag was suspended from the arm of the wheelchair. A review of the resident's current plan of care, dated 09-24-14 indicated interventions for the catheter included, "assess the drainage every shift. record the amount, type color, odor and observe for leakage." The record indicated the resident's catheter was changed during a recent appointment at the Urologist office. A current physician order instructed the nursing staff to record the output from the drainage bag every shift. A review of the Fluid Intake and Urinary Output report indicated the following where the output was less than the intake amount: 01-02-15 Fluid Intake 2640 mls. Output 1800 mls. 01-03-15 Fluid Intake 1880 mls. Output 890 mls. 01-05-15 Fluid Intake 1080 mls. Output 500 mls. 01-06-15 Fluid Intake 1440 mls. Output "0." 01-07-15 Fluid Intake 2680 mls. Output 1700 mls. 01-09-15 Fluid Intake 1100 mls. Output 600 mls. 01-15-15 Fluid Intake 2680 mls. Output 1250 mls. 01-17-15 Fluid Intake 2320 mls. Output 1050 mls. 01-18-15 Fluid Intake 600 mls. Output 375 mls. 01-19-15 Fluid Intake 1100 mls. Output 650 mls. 01-20-15 Fluid Intake 640 mls. Output 450 mls. 01-21-15 Fluid Intake 2417 mls. Output 1650 mls. 01-23-15 Fluid Intake 1110 mls. Output 820 mls. 01-28-15 Fluid Intake 2440 mls. Output 700 mls. 01-30-15 Fluid Intake 7360 mls. Output 700 mls. 01-31-15 Fluid Intake 960 mls. Output 350 mls. 02-01-15 Fluid Intake 1480 mls. Output 750 mls. 02-02-15 Fluid Intake 1150 mls. Output 975 mls. In addition, the Nurses Progress Notes lacked documentation or assessment of the drainage, color, odor of urine or leakage. 7. The record for Resident "F" was reviewed on 02-02-15 at 3:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had an indwelling urinary catheter. A review of the CNA assignment sheet did not identify this resident with a catheter. A review of the resident's current plan of care, dated 01-28-15, indicated the resident had the indwelling catheter related to bladder outlet syndrome and [MEDICAL CONDITION]. A physician order dated 01-27-15 instructed the nursing staff to "Flush f/c (Foley catheter) with 300 c.c. saline PRN, sluggishness/non-patency as needed." The resident had a physician order dated 02-02-15 which indicated, "Special instructions: Unmanageable [MEDICAL CONDITION] cannot be treated or corrected medically or surgically for which alternative therapy is not feasible and is characterized by: (1) documented PVR (post void residual) > (greater than) 200 ml (2) inability to manage retention/incontinence with I & O (intake and output) catherization." A review of the nurses progress notes indicated the following: "01-16-15 at 6:49 a.m. - Res. co <sic> [MEDICAL CONDITION], requesting I & O cath. states urinary frequency with scant o/p (output). I & O preformed <sic>. cath met resistance - res. states he has an enlarged prostate. resident tolerated procedure well - small amt. (amount) of blood to the end of cath when removed. 400 c.c. o/p res also stated he had a hx (history) with (name of physician). NP notified. n.o. (new order) reced (received) for appt. (appointment) to be made with (name of physician)." "01-20-15 at 10:00 p.m. Resident also c/a <sic> not able to urinate enough. NP notified. This writer I/O cath. resident, 750 ml output. Resident tolerated well." "01-22-15 at 11:59 p.m. Resident came to the nursing station c/o not able to urinate. this write reassessed bladder for distention, tenderness was observed. PRN I/O cath. performed, 600 c.c. clear yellow urine received. Resident tolerated procedure well." "01-24-15 at 3:56 p.m. Res. c/o not urinating all day, resident catherized and returned 400 c.c. of clear yellow urine." "01-25-15 4:50 a.m. Res. was catherized at 0100 (1:00 a.m.) for urine retention, 400 c.c. were obtained. Will continue to monitor." "01-25-15 at 12:33 p.m. Resident was I & O cath this a.m. 300 mls received, resident expressed now that he wants to be cath again, original <sic> order states every 8 hours, NP notified, states to follow original <sic> order, resident notified." "01-25-15 at 11:22 p.m. Resident I & O cathed at approx. (approximately) 1600 (4:00 p.m.) per sterile technique, with 400 mls cl. (clear) yellow urine out at this time." "01-26-15 at 1:27 a.m. This writer I/O cath. Resident, per his request for [MEDICAL CONDITION]. 200 c.c. urinary output of clear yellow urine." "01-26-15 1:37 a.m. Resident continues c/o not able to urinate per usual, requesting to be cath frequently NP aware. Resident has an appointment with Urologist on Tuesday." "01-27-15 at 1:29 a.m. Res. co (complained of) [MEDICAL CONDITION]. noted abdominal distention. I & O cath per PRN order. O/P 500 c.c. clear yellow urine. Expressed relief when completed." The record indicated the resident returned from the Urologist appointment 01-27-15 with recommendation for I & O cath every 4 - 6- hours. States urologist discussed other options such as chronic Foley vs. (versus) SP (supra pubic) tube. New DX. (diagnosis) bladder outlet obstruction and [MEDICAL CONDITION]. NP notified...received order to anchor Foley cath. for DX bladder outlet syndrome, flush and f/c (Foley catheter) change orders...catheter placed at 1330 (1:30 p.m.). Res. tolerated well...immediate return of 350 c.c. clear/yellow urine." A review of the Nurse Practitioner note dated 01-31-15, indicated: "Plan" bladder outlet obstruction and [MEDICAL CONDITION]: Resident seen by Urology, given the option for Foley catheter vs. I/O cath. 6 times a day. Resident requesting staff to I/O cath 3 - 4 times during an 8 hour shift. Therefore Foley catheter was placed. Unable to bladder scan...." During an interview on 02-03-15 at 10:40 a.m. the resident indicated, "I don't like it (in regard to the indwelling catheter) but they told me I have to have it. Sometimes it gets kinked and the urine doesn't flow. The nurses don't seem worried about it." A review of the Fluid Intake and Output Report from 01-27-15 indicated the following: 01-27-15 Fluid intake 1360 mls. Output 350 mls. 01-28-15 Fluid intake 1920 mls. Output 900 mls. 01-29-15 Fluid intake 1460 mls. Output 800 mls. 01-31-15 Fluid intake 1720 mls. Output 420 mls. 02-01-15 Fluid intake 2080 mls. Output 450 mls. 02-02-15 Fluid intake 720 mls. Output 500 mls. Further review of the Urinary Output documentation indicated the certified nurses aide documented the following: 01-27-15 at 1:49 a.m. "Medium", 12:05 p.m. "Large." 01-29-15 at 1:19 a.m. "Large." 02-01-15 4:00 a.m. "Medium," 2:31 p.m. "Large." 02-02-15 12:04 p.m. "Large." The Nursing staff failed to measure and document the exact amount of output in milliliters and urinary output for each shift. 8. During interviews on 02-03-15 the following information was obtained in regard to the documentation, observation and responsibilities of the nursing staff in regard to indwelling catheters. CNA #5 - The CNA's record if the amount is "large, medium or small. Then we report the amount to the nurses and they put that in the nurses computer." CNA #6 - "I look at the bag and do it in thirds for large medium or small. I chart the amount of mls - the nurses don't do it because I saw it." LPN #7 - "The CNA's don't mess with the catheter bags only the nurses can do that - we empty it and document the amount." LPN #8 - "Only the nurses can do the catheters especially if a resident is on a fluid restriction. I guess if the resident is not on a fluid restriction anyone can do it." During an interview on 02-02-15 at 3:30 p.m., the Administrator indicated the facility did not have a device to scan the resident's bladder as in a post void residual amounts. 9. Review of the facility policies in regard to resident's with catheters, or who required catheterization indicated the following: 9a. A review of the nursing skills check list on 02-02-15 at 12:15 p.m., titled "In & Out Cath. (catheter) procedure," undated - "measure and dispose of urine (observe characteristics of urine.)" 9b. A review of the facility policy on 02-02-15 at 1:00 p.m., titled "Catheter Irrigation, Open System, dated as revised October 2010, indicated the following: "Purpose - The purpose of this procedure is to maintain patency of the catheter... General Guidelines: ... 3. Check the urine for unusual appearance. Record findings... 6. Maintain an accurate record of the resident's daily fluid intake and output if indicated...Documentation The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed... 3. The amount of solution used to irrigate, the amount returned as drainage, and the amount of urine drained. 4. The character and color of urine/drainage. 5. Any observation of obstruction: evidence of blood, pus; presence of sediment, change in output, amount or color; patency of catheter, etc." 9c. A review of the facility policy on 02-03-15 at 9:45 a.m., titled "Catheterization, Residual," dated as revised October 2010, indicated the following: "Purpose: The purpose of this procedure is to assess the amount of urine left in the bladder after a resident voids." "Documentation: The following information should be recorded in the resident's medical record: 6. The amount of residual urine obtained. 7. The character (i.e. color, clarity, etc.) of the residual urine obtained." 9d. A review of the facility policy on 02-03-15 at 9:45 a.m., titled "Emptying a Urinary Drainage Bag," dated as revised October 2010, indicated the following: "Purpose: The purpose of this procedure are to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain a sterile specimen." "General Guidelines: 1. Empty the urinary drainage bag at least every eight (8) hours or more often if needed to keep the bag from becoming full... 5. Observe the character of the urine such as color (straw-colored, dark, or red), clarity (Cloudy, solid particles, or blood), and odor." "Steps in the Procedure: 7. Open the drainage bag and let the urine flow into the measuring container." "Reporting: 2. Notify the physician of the amount of residual urine,if any, and if there are any abnormalities in the character of the urine." 9e. A review of the faciity policy on 02-02-15 at 1:00 p.m., titled "Catheterization, Intermittent," dated as revised October 2010, indicated the following: "Purpose: The purpose of this procedure is to provide guidelines for the aseptic insertion of an intermittent catheter." "Documentation: The following information should be recorded in the resident's medical record: 3. The amount of urine drained. 4. The character, clarity and color of urine. 5. Any observation of obstruction: evidence of blood, pus etc. 6. Any change in the resident's condition (e.g. swelling, discomfort etc... 9. All assessment data obtained during the procedure." "Reporting: 2. Notify the physician of any abnormalities (i.e. urine output greater than 800 mls, obstruction of catheter, etc." This Federal tag relates to Complaint IN 721. 3.1-37(a)

Based on record review and interview the facility failed to ensure the hydration needs of a resident, in that when a resident's condition began to decline, the facility nursing staff failed to assess hydration needs and provide sufficient fluids to meet hydration needs for 1 of 3 residents sampled for urinary tract infections and hydration needs in a sample of 5. (Resident A) This deficient practice resulted the resident transported to the local area hospital for a change in mental status and required intravenous fluids. Findings include: 1. The record for Resident A was reviewed on 01-20-15 at 12:50 p.m. [DIAGNOSES REDACTED]. The resident had an indwelling catheter. These [DIAGNOSES REDACTED]. Fluids needs for this resident as formulated by the Registered Dietitian on 07-09-14 were 2000 - 2400 c.c. daily. A review of the nursing progress notes indicated the following: 12-25-14 at 2:22 p.m., indicated res. (Resident) (family member) was in to see res. earlier and stated res. urine looked cloudy, and would like a UA (urinalysis) done on res. Writer assessed res. urine. 500 c.c. (cubic centimeters) yellow urine in bag, mucous noted in tubing. Urine did not appear cloudy. NP (Nurse Practitioner) notified. UA per family request. Res. (spouse) notified. Changed catheter with 18 fr (french) coude cath. (catheter), and new drainage bag, unable to obtain enough urine now for sample. Will cont. (continue) to check and obtain sample for UA to be sent tomorrow d/t (due to) lab close <sic> today for holiday. 12-25-14 at 7:05 p.m. Urine obtained, golden yellow in color, no visible particles, slight odor noted. Lab (laboratory) faxed specimen ready for pick up. 12-30-14 at 12:18 p.m. Res. sitting at table in dining room. Res. not eating, not responding to verbal stimuli in room. Res. asked direct questions by writer. Res. right eye open and would move toward direction of writer. Left eye closed. Responds to sternal rub. B/P (blood pressure) 114/63, pulse 118. Res. with food in mouth, unable to get res. to swallow food. Res. assisted to bed per two staff. Page out to NP. 12-30-14 at 1:00 p.m. NP returned call with orders to send res. to ER (emergency room ). A review of the resident's daily fluid intake from the time the urinalysis was obtained and the resident had a change in condition on 12-30-14 were as follows: 12-25-14 = 1940 c.c. 12-26-14 = 600 c.c. 12-27-14 = 1200 c.c. 12-28-14 = 840 c.c. 12-29-14 = 1100 c.c. 12-30-14 = 360 c.c. The resident was transported to a local area hospital due to a change in condition where it was determined the resident had elevated electrolytes due to dehydration which required intravenous fluids to be administered. The emergency room documentation dated 12-30-14, indicated the resident had previous admission's to the local area hospital for acute [MEDICAL CONDITION] due to dehydration and obstruction. The local area hospital comprehensive metabolic profile indicated that at the time the resident presented at the Emergency Department on 12-30-14, the BUN (blood urea nitrogen) level was 26 - H (high) (normal range 8 - 21). The Hospital admission notes indicated, Current present illness was severe at onset, associated fever, dysuria, and dry mucous membranes. Toxic/metabolic [MEDICAL CONDITION] in the setting [MEDICAL CONDITION] from complicated UTI (urinary tract infection). The Differential [DIAGNOSES REDACTED]. Neurological: slow, lethargic and stuporous with a white blood cell count of 14,000 and mild to moderate pyuria. Mental status change is likely related to urinary tract infection and underlying [MEDICAL CONDITION] and comorbidities. The resident was started on intravenous fluids for acute [MEDICAL CONDITION] and dehydration. During an interview on 01-20-15 at 1:45 p.m., a concerned family member voiced frustration that the nursing staff did not assess the continued hydration needs of the resident, when the resident had a history of [REDACTED]. 2. A review of the facility policy on 01-21-15 at 8:15 a.m., dated as revised 11/12, titled Hydration Monitoring, indicated the following: Purpose To aid each resident in receiving sufficient fluid intake to maintain hydration in accordance with calculated fluid needs. Policy: It is the policy of this facility to monitor the resident's fluid balance in accordance assessed needs or problems. Examples of resident problems or needs which may (underscored) require hydration monitoring: 1. Significant weight variances or identified nutritional risk. 2. diagnosed with [REDACTED]. 3. Functional impairments which prevent independent access to fluids. 5. Signs and symptoms of dehydration: weight loss, unusually dry skin, dry mucous membranes, dry cracked tongue, cracked lips, poor skin turgor, excessive thirst, fever, malaise, abnormal lab values (elevated Hbg (hemoglobin), K+ (potassium), Cl (chloride), Na+ (sodium), [MEDICATION NAME], transferrin, BUN (blood urea nitrogen) or urine specific gravity), abnormally low urinary output, highly concentrated urine. Procedure: Fluids needs will be calculated by the Dietary manager or the Registered Dietician. Fluids will be provided on meal trays, with between meal nourishments, medication administration, during activities programming, and offered frequently during care and resident contact. A minimum of 60% of the residents daily fluid needs will be provided on the resident's meal trays within a 24 hour period. A dehydration assessment will be completed upon admission and with significant changes in condition to assist in identifying risk factors and development of the plan of care. A plan of care shell be developed to address any hydration concerns. This plan of care will be developed utilizing the clinical conditions and risk factors identified, taking into account the estimated fluid needs of the resident. When indicated, shift and 24 hour fluid intake totals shall be calculated and analyzed by a licensed nurse.The attending physician shall be notified of significant hydration concerns. This Federal tag relates to Complaint IN 069. 3.1-46(b)

Based on observation, interview and record review, the facility failed to accurately monitor fluid intake for 1 of 1 resident on a fluid restriction being reviewed for monitoring of fluid intake amounts. (Resident #226) Resident #226's Sodium level was 130 mmol / L (millimol / Liter) upon discharge from the hospital, 128 mmol / L on 7/21/14 after admission to the facility and 117 mmol / L on 8/10/14 which was critically low. Findings include: Resident #226's record was reviewed on 8/11/14 at 8:06 A.M. [DIAGNOSES REDACTED]. An Admission History and Physical dated 7/18/14, indicated the resident was brought to the emergency room for a decreased level of consciousness. He was found to have a Sodium level of 118 mmol / L (millimol / Liter) and was later hospitalized . The normal Sodium level should have been 135-145 mmol / L. He was treated with Intravenous fluids and Sodium level was corrected to 130 mmol / L. He was released to a facility for rehabilitation. The Physician indicated he had prior issues with [MEDICAL CONDITION] approximately one year ago and was hospitalized and underwent rehabilitation at the same facility and was released to an apartment. The physician indicated he was confused, which had worsened with his present illness and the past medical history included, but was not limited to, [MEDICAL CONDITION] and dementia. The resident had a Care Plan dated 7/18/14, that addressed the problem "Resident is at risk for fluid imbalance and weight changes related to diuretic use and CKD ([MEDICAL CONDITION]) and fluid restriction." Intervention indicated, "...8/1/14--Hold [MEDICATION NAME] per order, Maintain fluid restriction per current order...7/18/14--Encourage fluid intake...." The resident's record lacked a Care Plan for non compliance with fluid restrictions. During an observation on 8/4/14 at 2:42 P.M., the resident had a clear 8 ounce plastic glass sitting on his bedside table with a clear fluid in it. At this time, during an interview the resident indicated he was on a fluid restriction. The Medication Administration Record (MAR) dated August 2014, indicated the resident's physician's orders [REDACTED]. 07/18/14--Fluid restriction 1000 cc (cubic centimeters) daily. Discontinued on 8/6/14. Diagnosis: [REDACTED]. Days: 400 cc every shift Evenings: 400 cc every shift Nights: 200 cc every shift The vital sign area of the computer indicated the resident had consumed the following amount of fluids on the following dates and times. The fluids were not totaled on the computerized form. The abbreviation ml (milliliters) was the equivalent to cc (cubic centimeters) while referring to amount of fluid intakes. 7/18/14 at 3:04 P.M.--1000 ml and 8:45 P.M.--720 ml ( Oral fluids totaled 1720 ml for the 24 hours). 7/20/14 at 12:31 P.M.--480 ml, 3:10 P.M.--360 ml and 10:36 P.M.--500 ml (Oral fluids totaled 1340 ml for the 24 hours). 7/29/14 at 2:49 P.M.--960 ml and 9:05 P.M.--725 ml (Oral fluids totaled 1685 ml for the 24 hours). 8/2/14 at 7:11 P.M.--1400 ml (Oral fluids totaled 1400 ml for the 24 hours). 8/3/14 at 9:57 A.M.--720 ml and 7:43 P.M.--720 ml (Oral fluids totaled 1440 ml for the 24 hours). 8/4/14 at 11:36 A.M.--1420 ml and 9:58 P.M.--180 ml (Oral fluids totaled 1600 ml for the 24 hours). The Progress notes on these dates and times indicated the following: 7/26/14 at 11:10 A.M., the resident had fluids within his reach. 7/26/14 at 11:16 A.M., the resident had fluid within his reach. The Medication Administration Record (MAR) dated August 2014, indicated the resident's physician's orders [REDACTED]. 08/06/14--Fluid restriction 1800 cc daily. Discontinued on 8/8/14. Diagnosis: [REDACTED]. Days: 700 cc every shift Evenings: 700 cc every shift Nights: 400 cc every shift The vital sign area of the computer indicated the resident had consumed the following amount of fluids on the following dates and times. The fluids were not totaled on the computerized form. 8/7/14 at 12:35 A.M.--400 ml, 11:52 A.M.--700 ml, 2:40 P.M.--780 ml, 4:20 P.M.--700 ml and 7:37 P.M.--1060 ml (Oral fluids totaled 3640 ml for the 24 hours). 8/8/14 at 3:34 A.M.--400 ml, 9:26 A.M.--700 ml, 4:50 P.M.--500 ml, 6:28 P.M.--120 ml and 11:55 P.M.--200 ml (Oral fluids totaled 1920 ml for the 24 hours). The Medication Administration Record (MAR) dated August 2014, indicated the resident's physician's orders [REDACTED]. 08/08/14--Fluid restriction 1000 cc daily. Diagnosis: [REDACTED]. Days: 500 cc every shift Evenings: 300 cc every shift Nights: 200 cc every shift The vital sign area of the computer indicated the resident had consumed the following amount of fluids on the following dates and times. The fluids were not totaled on the computerized form. 8/9/14--10:08 A.M.--1840 ml, 1:36 P.M.--500 ml, 4:44 P.M.--300 ml and 8:48 P.M.--360 ml (Oral fluids totaled 3000 cc for the 24 hours) 8/10/14 at 5:53 A.M.--120 ml, 10:08 A.M.--360 ml, 11:10 A.M.--500 ml, 2:25 P.M.--360 ml, 4:33 P.M.--300 ml and 6:52 P.M.--1060 ml (Oral fluids totaled 2700 ml for the 24 hours) The July and August 2014, MAR indicated by nurse's signature, the resident received the ordered amount of fluids. Progress Notes lacked documentation that the resident was noncompliant with his fluid restriction order. The record indicated Basic Metabolic Panel (BMP) (Laboratory test that measures the amount of electrolytes) was completed on the listed dates with these results: 7/21/14: Sodium level=128 low Normal-135-145 mmol / L 7/28/14: Sodium level=130 low 8/04/14: Sodium level=125 low A BMP laboratory test was ordered for Friday. 8/06/14: Sodium level=126 low A Repeat BMP laboratory test was ordered for Friday and the resident was placed on an 1800 cc fluid restriction. 8/08/14: Sodium level=123 low 8/9/14 at at 9:50 P.M., "During med round noticed resident slumped in chair. Assessed him and found his speech to be slurred and resident acting restless. Resident was alert not oriented. Vitals were wnl (within normal limits). Called MD (Medical Doctor) and stat labs were ordered and IV (Intravenous) fluids. Labs were returned and MD notified. IV infiltrated, MD notified. PICC (Peripherally Inserted Central Catheter) line now being placed, per MD, this evening, when IV team arrives. Resident being monitored, family aware." A 1000 cc fluid restriction was ordered and a Stat (Immediately) BMP laboratory test was ordered on [DATE]. 8/09/14: Sodium level=120 critically low 8/10/14: Sodium level=117 critically low, IV therapy at 75 cc / hour continues. 8/11/14: Sodium level=122 low, IV therapy at 75 cc / hour continues. During an observation on 8/11/14 at 5:10 P.M., the resident had a white styrofoam cup with a lid and a straw in the lid that had a clear fluid in it that was three-fourths full. At this time, during an interview the resident indicated the cup was his glass with water. During an interview on 8/11/14 at 5:15 P.M., LPN #6 indicated the resident was on a fluid restriction and he was not suppose to have water sitting at his bedside. 8/11/14 at 6:18 P.M., "Resident sitting up in chair next to bed/table, some audible congestion noted, no wheezing, O2 on per n/c (nasal canula), nurse asked to provide nebulizer treatment prn (as needed). Resident able to answer questions asked appropriately, +2 [MEDICAL CONDITION] in bilateral lower extremities. 0.9% IV fluids running...." During an interview on 8/12/14 at 10:02 A.M., LPN #8 indicated she documented the amount of fluids the resident received in the computer. She indicated she determined the amount of fluid he received by the amount of fluid the computer order indicated he was allowed to receive. She indicated his daughter brought him in drinks and he was able to walk around and was able to obtain water himself, but not lately since he has been sick. She indicated the CNA's were not suppose to give the resident extra fluids. During an interview on 8/12/14 at 10:10 A.M., CNA #9 indicated she documented the amount of fluids she gave the resident in the computer. She indicated she knew the amount of fluids he could received by the assignment sheet. She indicated he should receive 500 cc for dayshift. She indicated she did not give him extra fluids. During an interview on 8/12/14 at 10:00 A.M., the DoN indicated the nursing staff gave the resident his fluids on his meal trays. She indicated the Dietary services would not have known how many fluids to give him since they did not place the fluids on the residents tray during meal service. During an interview on 8/12/14 at 11:08 A.M., the Director of Nursing (DoN) nodded that she agreed if the nurses initials were in the box on the MAR for the shift worked for the fluid restriction order indicated the resident received the full amount of fluids ordered for that shift. She indicated the night shift nurse was responsible for totaling the 24 hour fluid intake and ensuring the resident was not exceeding his allotted amount of fluids for the 24 hour period. The DoN indicated if the resident had gone over his allotted fluid restriction amount, the resident's Physician was to be notified. The DoN indicated she could not determine if the fluid amounts from the MAR and the vital sign area of the computer had been totaled together at the end of the 24 hours to determine if the resident had stayed within his allotted fluid restriction amount. During an interview on 8/12/14 at 11:12 A.M., the Administrator indicated that RN #4 would have to educate the resident's daughter not to bring drinks into him to drink and she felt she would understand the education the first time she was educated. She indicated the facility had realized they had a problem with the fluid restriction and resident's intakes and they had started addressing that issue yesterday after it was brought to their attention. She indicated the last time the resident's Sodium was low while he was hospitalized , he was treated with IV fluids. During an observation on 8/12/14 at 12:45 P.M., the resident had 2+ bilateral lower extremity [MEDICAL CONDITION]. During an interview on 8/12/14 at 11:20 A.M., the Assistant Director of Nursing indicated the resident had a new order for nebulizer treatments for every four hours as of today to treat the congestion. A current policy titled "Hydration Monitoring" dated 11/12, provided by the DoN on 8/12/14 at 10:00 A.M., indicated, "...Policy: It is the policy of this facility to monitor the resident's fluid balance in accordance assessed needs or problems. Examples of resident problems or needs which may require hydration monitoring: ...4. medical need for exact measuring of fluid intake and output; i.e. fluid restrictions, force fluids or enteral feedings...Procedure: ...A plan of care shall be developed to address any hydration concerns. This plan of care will be developed utilizing the clinical conditions and risk factors identified, taking into account the estimated fluid needs of the resident. When indicated, shift and 24-hour fluid intake totals shall be calculated and analyzed by a licensed nurse...." A current policy titled "Fluid Restriction" undated, provided by the DoN on 8/12/14 at 11:45 A.M., indicated "Policy: Residents are place on restricted fluid intake when ordered by the physician. Procedure: ...3. It is the responsibility of the charge nurse and the Dining Services Director to determine the best method to meet the fluid restrictions based upon the resident's fluid intake history, number of medications and medication passes, etc....8. Fluid restrictions are noted on the care plan." 3.1-37(a)

Based on record review and interview the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable physical well being, in that when a resident had a history of [REDACTED]. This deficient practice resulted in a resident's condition to decline and 911 had to be notified for transport to the local area hospital for 1 of 3 sampled residents. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 06-04-14 at 10:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was discharged from a local area hospital and admitted to the facility the same date, 05-02-14. A review of the "discharge summary" received on 05-02-14, indicated the resident had physician orders [REDACTED]. A review of the Interdisciplinary Progress notes indicated the following from 05-05-14 thru 05-09-14: "05-06-14 8:03 a.m. - Suctioned for thick secretions with a yankers." "05-08-14 3:27 p.m. - Suctioned times 1, rec'd (received) thick white secretions." "05-09-14 8:28 a.m. - Neb. (nebulizer) tx. (treatment) done per order. Resident with noted increased congestion to right upper lobe. Suctioned times 4 small amount of thick whitish sputum obtained." A review of the Medication Administration History from 05-05-14 through 05-09-14 indicated the following: "05-05-14 6:00 p.m. "Lung sounds before treatment - coarse. Lung sounds after treatment - coarse." "05-06-14 12:00 a.m. "Lung sounds before treatment - coarse. Lung sounds after treatment - slightly coarse." "05-06-14 6:00 a.m. "Lung sounds before treatment - coarse. Lung sounds after treatment - slightly coarse." "05-06-14 6:00 p.m. "Lung sounds before treatment - coarse. Lung sounds after treatment - coarse." "05-07-14 12:00 a.m. "Lung sounds before treatment - diminished. Lung sounds after treatment - diminished." "05-07-14 6:00 a.m. "Lung sounds before treatment - diminished. Lung sounds after treatment - diminished." "05-07-14 6:00 p.m. "Lung sounds before treatment - coarse. Lung sounds after treatment - coarse." "05-08-14 12:00 a.m. "Lung sounds before treatment - congested. Lung sounds after treatment - congested." "05-08-14 6:00 a.m. "Lung sounds before treatment - congested. Lung sounds after treatment - diminished." "05-08-14 12:00 p.m. "Lung sounds before treatment - congested. Lung sounds after treatment - clear." "05-08-14 6:00 p.m. "Lung sounds before treatment - wheezing. Lung sounds after treatment - wheezing." A review of the Medication Administration History for May 2014 lacked any documentation the resident received the PRN (as needed) treatments for shortness of breath or wheezing. On 05-09-14 the resident had a significant change in condition which required 911 emergency to be activated and the resident transported to the local hospital emergency room . The EMS (emergency medical services) 911 documentation was reviewed and noted as follows: "Unresponsive, diaphoresis - hot, retraction of accessory muscles, left upper and lower lobe wheezing, right upper and lower lobe wheezing. [MEDICAL CONDITION] (Continuous Positive Airway Pressure) applied with a flow rate of 25 liters per minute." At the time the resident arrived at the local area hospital emergency room , the resident was examined by the emergency room physician who indicated, "the patient presents with difficulty breathing and respiratory problem. Degree at onset moderate. Degree at present severe. Heart rate 130 bpm (beats per minute) HI, respiratory rate 22 HI, Oxygen saturation level 79 %." The "respirations are tachypneic, respiratory distress severe, labored, with breath sounds bilateral diminished, rhonchi present retractions severe." "Upon presentation to the emergency department, patient was impending [MEDICAL CONDITION]. Patient had elective intubation done by myself. Pneumonia was likely on chest x-ray. The patient is currently sedated and on the vent. (ventilator)." A review of the IP (Inpatient) Admission Note H & P (History and Physical) indicated "acute [MEDICAL CONDITION]: hypoxic in ED (emergency department) in setting of septic shock, intubated." The clinical record lacked documentation of any additional interventions in regard to administering the PRN breathing treatments to the resident. The physician was not notified of the change in the resident's chest congestion during suctioning or routine breathing treatments from 05-05-14 thru 05-09-14 when the resident was found with "skin warm and clammy, resp. (respirations) increased and labored. Resident noted gripping sheets. BP (blood pressure) WNL (within normal limits), HR (heart rate) 140, Temp. (temperature) 103.4 at this time, cold clothes <sic> applied to pulse points. O2 (oxygen) saturation) 79 %, neb. treatment given at this time. UN (unit manager), ADON (assistant director of nurses) notified. MD (Medical Doctor) paged at this time." This Federal tag relates to Complaint IN 439. 3.1-37(a)

Based on record review and interview the facility failed to ensure a resident with an indwelling catheter received treatment to ensure/prevent infections, in that when a resident was admitted to the facility with an indwelling catheter, the nursing staff failed to follow the hospital physician discharge orders for the maintenance of the catheter to aid in the prevention of a urinary tract infection for 1 of 3 sampled resident. (Resident "A"). The resident was sent to the hopsital and admitted for Urinary Tract Infection [MEDICAL CONDITION]. Findings include: The record for Resident "A" was reviewed on 06-04-14 at 10:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was discharged from a local area hospital and admitted to the facility the same date, 05-02-14. A review of the "discharge orders" received on 05-02-14, indicated the resident required "Oxychlorosene sodium (a topical antiseptic for treating localized infections) 0.2 % intra BLADDER IRRIGATION," every week. Start 05-01-14 10:00 a.m." In addition the Hospital Discharge Summary, dated 05-02-14, indicated the resident "will have a weekly (every Monday) bladder irrigation with [MEDICATION NAME] 0.2 % concentration, 200 ml instilled with a dwell time of 5 minutes and then evacuated. This is for UTI (urinary tract infection) [MEDICATION NAME]." Further review of the "Discharge Instructions prompted the nursing staff "weekly (every Monday), bladder irrigations as ordered. Oxychlorosene sodium 0.2% intra-bladder. Dose = 4 times 50 ml syringes - total dose of 200 ml. Dwell time: 5 minutes." A review of the facility physician orders, transcribed and entered into the computer by licensed nurse #6 lacked this treatment for [REDACTED]. (milliliters) or _______for _______as needed." The areas were blank and therefore lacked instruction to the nursing staff for this treatment." The facility also had physician orders [REDACTED]. The "verified results" of the WBC (white blood cell count) was 8.4 (normal range of 4.00 - 10.50). A review of the Progress Notes indicated the following: "05-06-14 11:13 p.m. FC (foley catheter) drained for 375 c.c. (cubic centimeters) of clear yellow urine with some sediment noted." The record lacked any documentation the resident received the physician ordered irrigation. The irrigation should have been completed on Monday 05-05-14. On 05-09-14 the resident had a change in condition with noted wheezing, labored breathing, increased heart rate (140 beats per minute) and an elevated temperature of 103.4 Fahrenheit. The resident was transported to the local area hospital for evaluation and treatment via 911 emergency. A review of the local area hospital record on 06-04-14 at 2:00 p.m., indicated the following: The resident arrived at the hospital at 10:35 a.m., on 5/9/14, to the emergency room . At the time the resident arrived he was unresponsive. The resident's "heart rate was 130 bpm (beats per minute), respiratory rate of 22, oxygen saturation level at 79 % and blood pressure 76/57." Laboratory testing was completed in the emergency room , and the resident was found to have a WBC (white blood cell count) of 15.1 "H" (high)." A review of the "Critical Care Staff Initial Consult," dated 05-09-14, indicated "Impression and Plan - * Urinary Tract Infection -[MEDICAL CONDITION]." The results of the "Urine culture - Microbiology indicated the resident had > (greater than) cfu (colony forming units)/ml Gram Negative Road, and > 100,000 cfu/ml [MEDICATION NAME] species." The "Impression and Plan" indicated Shock unspecified and urinary tract infection -[MEDICAL CONDITION]." A review of the "IP (In Patient) Note H & P (History and Physical),"Final Report," indicated, "[MEDICAL CONDITION] <sic> septic shock likely due to UTI..." During an interview on 06-05-14 at 11:00 a.m., the Administrator verified the resident did not receive the physician ordered treatments to aid in the prevention of urinary tract infections and further indicated the licensed nurse failed to transcribe the physician orders [REDACTED]. This Federal tag relates to Complaint IN 439. 3.1- 41(a)(2)

Based on record review and interview the facility failed to ensure the hydration needs of a dependent resident, in that when a resident required the facility nursing staff to provide sufficient fluids to meet hydration needs the facility failed to ensure adequate hydration which resulted in the resident transported to the local area hospital with a [DIAGNOSES REDACTED]. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 06-04-14 at 10:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was discharged from a local area hospital and admitted to the facility the same date, 05-02-14. A review of the "discharge orders" received on 05-02-14, indicated the resident required "Adult non Fiber Formula," to be infused at 70 c.c. (cubic centimeters) continuously" through the feeding tube, with the addition of "125 ml (milliliters) water bolus every three hours." This water bolus would calculate to be 1000 c.c. over a 24 hour period. A review of the facility physician orders, transcribed and entered into the computer by licensed nurse #6 indicated "Water flush 150 c.c. Special Instruction: Give additional 150 c.c. of water flush QID (four times a day) 8:00 a.m., 2:00 p.m., 4:00 p.m. and 10:00 a.m." A review of the Nursing Admission Assessment, dated 05-02-14 indicated the resident was "at risk for dehydration." The resident had physician orders at the time of admission for a "General Chemistry" which was drawn on 05-06-14. The resident results were reported to the facility on [DATE], and the resident's Sodium was 146 "H" (high) (normal range 135 - 145) and BUN (blood urea nitrogen) "H" at 26 (normal range 8 - 21). During an interview on 06-04-14 at 11:20 a.m., the Registered Dietician indicated she had not reviewed this residents chart or the orders for the feeding tube with the water flushes prior to the resident being discharged back to the local area hospital, but "he would need 600 c.c. flushes per day." A review of the "fluids and supplements" section of the resident record, indicated the resident received the following hydration: "05-03-14 560 c.c., 05-04-14 - no documentation, 05-05-14 480 c.c. and 560 c.c., 05-06-14 560 c.c., 05-07-14 400 c.c. and 560 c.c., 05-08-14 960 c.c." On 05-09-14 the resident had a change in condition and was transported to the local area hospital for evaluation and treatment via 911 emergency. A review of the local area hospital record on 06-04-14 at 2:00 p.m., indicated the following: The resident arrived at the hospital at 10:35 a.m. to the emergency room . At the time the resident arrived he was unresponsive. The resident's "heart rate was 130 bpm (beats per minute), respiratory rate of 22, oxygen saturation level at 79 % and blood pressure 76/57." Laboratory testing was completed in the emergency room , and the resident was found to have a BUN of 71 "H", and a Sodium level of 153 "HI." The emergency room Physician Notes dated 05-09-14 indicated "Patient with [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and hypertension. Patient was given multiple IV (intravenous) fluids boluses in emergency department." The record further indicated the resident received "6155 c.c. of fluids within the first 24 hours of hospitalization to rehydrate the resident." A review of the "Critical Care Staff Initial Consult," dated 05-09-14, indicated "Impression and Plan - * Shock. Plan fluid administration. Oliguria (diminished urine secretion in relation to fluid intake) and anuria (complete suppression of urine formation by the kidney) - Plan: Hydration metabolic corrections." The IP (Inpatient) Critical Care Staff Progress Note indicated the resident had "[MEDICAL CONDITION]/dehydration." The resident was transferred from the emergency room to the Adult Intensive Care Unit "for [MEDICAL CONDITION]/septic shock likely due to UTI (urinary tract infection), [MEDICAL CONDITION], AKI (acute kidney injury), dehydration and acute [MEDICAL CONDITION]." During an interview on 06-06-14 at 11:00 a.m., the Administrator and the Corporate Nurse verified the resident did not receive the hydration needs aws indicated in the physician orders. A review of the facility policy on 06-04-14 at 12:35 p.m., dated as "revised 2008," indicated the following: "Policy Statement - This facility will endeavor to provide adequate hydration and to prevent and treat dehydration." "Policy Interpretation and Implementation - 1. The Dietician will assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need. The Dietitian, nursing staff and the physician will assess factors that may be contributing to inadequate fluid intake." This Federal tag relates to Complaint IN 439. 3.1-46(b)

Based on record review and interview the facility failed to ensure the special needs of a resident in regard to hydration and enteral feedings, in that when the resident had specific physician orders [REDACTED]. This deficient practice effected 1 of 3 resident's reviewed for hydration and enteral feeding and resulted in the resident' being transported via 911 to the local area hospital with a [DIAGNOSES REDACTED]. Findings include: The record for Resident "A" was reviewed on 06-04-14 at 10:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was discharged from a local area hospital and admitted to the facility the same date, 05-02-14. A review of the "discharge orders" received on 05-02-14, indicated the resident required "Adult non Fiber Formula," to be infused at 70 c.c. (cubic centimeters) continuously" through the feeding tube, with the addition of "125 ml (milliliters) water bolus every three hours." This water bolus would calculate to be 1000 c.c. over a 24 hour period. A review of the facility physician orders, transcribed and entered into the computer by licensed nurse #6 indicated "Water flush 150 c.c. Special Instruction: Give additional 150 c.c. of water flush QID (four times a day) 8:00 a.m., 2:00 p.m., 4:00 p.m. and 10:00 a.m." This amount of fluid recorded allowed only 600 c.c. of the 1000 c.c. needed by the resident. The resident had physician orders [REDACTED]. The resident's laboratory results were reported to the facility and the resident's Sodium was 146 "H" (high) (normal range 135 - 145) and BUN (blood urea nitrogen) "H" at 26 (normal range 8 - 21). During an interview on 06-04-14 at 11:20 a.m., the Registered Dietician indicated she had not reviewed this residents chart or the orders for the feeding tube with the water flushes prior to his discharge to the hospital, but according to the orders "he would need 600 c.c. flushes per day." A review of the "fluids and supplements" section of the resident record, indicated the resident received the following hydration: "05-03-14 560 c.c., 05-04-14 - no documentation, 05-05-14 480 c.c. and 560 c.c., 05-06-14 560 c.c., 05-07-14 400 c.c. and 560 c.c., 05-08-14 960 c.c." On 05-09-14 the resident had a change in condition and was transported to the local area hospital for evaluation and treatment via 911 emergency. A review of the local area hospital record on 06-04-14 at 2:00 p.m., indicated the following: The resident arrived at the hospital at 10:35 a.m. to the emergency room . At the time the resident "arrived he was unresponsive." The resident's "heart rate was 130 bpm (beats per minute), respiratory rate of 22, oxygen saturation level at 79 % and blood pressure 76/57." Laboratory testing was completed in the emergency room , and the resident was found to have a BUN of 71 "H", and a Sodium level of 153 "HI." The emergency room Physician Notes dated 05-09-14 indicated, "Patient with [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and hypertension. Patient was given multiple IV (intravenous) fluids boluses in emergency department." The record further indicated the resident received "6155 c.c. of fluids/hydration with in the first 24 hours of hospitalization ." A review of the "Critical Care Staff Initial Consult," dated 05-09-14, indicated "Impression and Plan - * Shock. Plan fluid administration. Oliguria (diminished urine secretion in relation to fluid intake) and anuria (complete suppression of urine formation by the kidney) - Plan: Hydration metabolic corrections." The resident was transferred from the emergency room to the Adult Intensive Care Unit "for [MEDICAL CONDITION]/septic shock likely due to UTI (urinary tract infection), [MEDICAL CONDITION], AKI (acute kidney injury), dehydration and acute [MEDICAL CONDITION]." This Federal tag relates to Complaint IN 439. 3.1-47(a)(2)

Based on observation, record review and interview the facility failed to ensure a resident who was identified with a pressure area, received appropriate treatment and services. This deficient practice involved the lack of nursing assessment, failure to follow the physicians orders, and resulted in a delay in the appropriate treatment for [REDACTED]. (Resident "B"). Findings include: The record for Resident "B" was reviewed on 06-12-13 at 8:40 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was recently re-admitted to the facility on [DATE] after a hospitalization . A review of the resident's current plan of care, dated 05-21-13 indicated the resident "is at risk for pressure ulcers, due to very limited mobility and fragile coccyx." Approaches to this "problem" indicated "Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences, report any signs of skin breakdown (sore, tender, red, or broken areas)." Review of the physician orders, dated 05-21-13 instructed the nursing staff to "apply dermaseptin to area on coccyx two times a day. Resident should be seen by wound doctor on next visit per MD (medical doctor)." A review of the nursing progress notes lacked documentation related to the resident's ulcerated area during treatment changes or weekly as indicated in the plan of care. A physician progress notes [REDACTED]. Problems since her latest return include continued abd. (abdominal) pain, tho (though) she states this has improved a little, and LE (lower extremity) [MEDICAL CONDITION]. She also has early skin breakdown on her coccyx, which is very painful. Imp (impression)/Plan: Painful pressure area on sacral bony prominence, will apply [MEDICATION NAME] foam for cushioning and ask wound team to see." A subsequent physician order, dated 06-06-13 indicated "[MEDICATION NAME] foam to sacral bony prominence - change every 48 hours - please ask wound team to see for wound." Observation on 06-12-13 at 9:30 a.m., with licensed nurse employee #3 in attendance, the resident was seated on the side of the bed, bent over holding her stomach. When interviewed the resident indicated "I didn't sleep at all last night the pain was so bad. I don't know if I can take this anymore." When interviewed about the pain, the resident indicated her coccyx area. During this observation the resident stood up with the assistance of licensed nurse employee #3, and the resident's coccyx area was observed. The area did not have a dressing and there was an opened area to the resident's coccyx area. Interview on 06-12-13 at 11:20 a.m., the Administrator and Director of Nurses verified, the resident had not been assessed for her pressure ulcer, the nursing progress notes, lacked documentation of the area, and the resident had not been evaluated or assessed by the local wound care team as ordered by the physician. At 12:10 p.m. on 06-12-13 the Director of Nurses provided the assessment of the resident's pressure ulcer and included the measurements of the area and were documented as follows: "Date of onset: 05-21-13, Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough), length 1.8 centimeters by 0.4 centimeters in width and a depth of 0.1 centimeters. Pale granulation tissue with no drainage." During the Exit Conference on 06-12-13 at 12:36 p.m., the Director of Nurses and the Administrator indicated the local Wound Care team come to the facility "weekly - on Monday's." Approximately 3 weeks had passed since the physician instructed the nursing staff to have the resident evaluated and treated by the Wound Care team. This Federal tag relates to Complaint IN 811 3.1-40(a)(2)

Based on observation, record review and interview the facility failed to ensure physician orders [REDACTED]. (Resident "B"). Findings include: The record for Resident "B" was reviewed on 06-12-13 at 8:40 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was recently re-admitted to the facility on [DATE] after a hospitalization . A review of the resident's current plan of care, dated 05-21-13 indicated the resident "is at risk for pressure ulcers, due to very limited mobility and fragile coccyx." Approaches to this "problem" indicated, "Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences, report any signs of skin breakdown (sore, tender, red, or broken areas)." Review of the physician orders, dated 05-21-13 instructed the nursing staff to "apply dermaseptin to area on coccyx two times a day. Resident should be seen by wound doctor on next visit per MD (medical doctor)." A physician progress notes [REDACTED]. Problems since her latest return include continued abd. (abdominal) pain, tho (though) she states this has improved a little, and LE (lower extremity) [MEDICAL CONDITION]. She also has early skin breakdown on her coccyx, which is very painful. Imp (impression)/Plan: Painful pressure area on sacral bony prominence, will apply [MEDICATION NAME] foam for cushioning and ask wound team to see." A subsequent physician order, dated 06-06-13 indicated "[MEDICATION NAME] foam to sacral bony prominence - change every 48 hours - please ask wound team to see for wound." Observation on 06-12-13 at 9:30 a.m., with licensed nurse employee #3 in attendance, the resident was seated on the side of the bed, bent over holding her stomach. When interviewed the resident indicated "I didn't sleep at all last night the pain was so bad. I don't know if I can take this anymore." When interviewed about the pain, the resident indicated her coccyx area. During this observation the resident stood up with the assistance of licensed nurse employee #3, and the resident's coccyx area was observed. The area did not have a dressing, and there was an opened area to the resident's coccyx area." Interview on 06-12-13 at 11:20 a.m., the Administrator and Director of Nurses verified, the resident had not been assessed by the nursing staff for her pressure ulcer, the nursing progress notes lacked documentation of the area, without documentation of improvement or deterioration of the wound, and that the resident had not been evaluated or assessed by the local wound care team. This Federal tag relates to Complaint IN 811 3.1-35(g)(2)

Based on record review, interview, and observation, the facility failed to assess for elopement risk, develop interventions to prevent elopement and provide adequate supervision of a cognitively impaired resident with a known elopement attempt, resulting in the resident sustaining a fractured arm when the resident was let out of the building by a facility staff member. This affected 1 of 4 residents reviewed for wandering behavior/elopements in the sample of 24 (Resident # 134). In addition, the facility failed to thoroughly investigate an elopement and develop interventions for prevention of future elopements for 1 of 6 residents reviewed for wandering behaviors/elopement in the supplement sample of 6. (Resident # 136). The facility failed to identify and correct a non-functional exit door (employee entrance door). This deficient practice had the potential to affect 3 of 4 residents reviewed for wandering behavior/elopements in the sample of 24 (Residents #51, 44, and 43) and 4 of 6 residents reviewed for wandering behaviors/elopement in the supplemental sample of 6 (Residents #136, 31, 52, and 34). The Immediate Jeopardy began on 5/20/12 when the facility failed to assess for elopement risk, develop interventions to prevent elopement and provide adequate supervision of a cognitively impaired resident with a known elopement attempt, resulting in the resident sustaining a fractured arm when the resident was let out of the building by a facility staff member. The facility Administrator, Associate Administrator, 3 Corporate Clinical Specialists (Registered Nurse), and the Corporate Vice President were notified of the Immediate Jeopardy on 7/13/12 at 4:15 P.M. The Immediate Jeopardy was removed on 7/16/2012, but the facility remained at the lowered scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings Include: Review on 7/9/12 at 9:00 A.M. of the facility reported incident included, but was not limited to, "Date received 5/22/12... Resident/Patient/Clients: (Resident #134)... Intake Detail: Date of Alleged: 5/20/12 at 2:10 P.M.... Brief Description of Incident: Staff member (Dietary Aide #1) let resident (Resident #134) out key coded door... Staff member (Dietary Aide #1) thought resident was a visitor... Staff member (Dietary Aide #1) walked to other side of the building, upon returning staff member observed she (Resident #134) had fallen... Staff member (Dietary Aide #1) notified nursing personnel immediately... Type of Injury/Injuries: Received 3 minor abrasions... Immediate Action Taken: Head to toe assessment completed... Physician and family notified... One on one (supervision) initiated... Preventive Measures Taken: Supervisor (Registered Dietician #2) immediately inserviced staff member Dietary Aide #1)..." The facility failed to include in the report the resident's injury of fractured humerus. On 7/12/12 at 3:30 P.M., Resident #134's closed record was reviewed. [DIAGNOSES REDACTED]. Resident #134 was admitted to the facility on [DATE] and discharged to local hospital on [DATE]. An "Admission /Readmission Nursing Assessment," dated 2/23/12 at 2:21 P.M., included, but was not limited to, "Resident (Resident #134) alert and oriented to person... Right hip fracture... Resident high fall risk and bed and chair alarms applied..." There was no documentation of an elopement assessment completed on admission. A "Fall Care Plan," dated 2/23/12, included, but was not limited to, "Problem: Resident (#134) is at risk for falls related to hip fracture... Goal: Resident will remain free from injury related to falls... Approach: Assist with ADLs (Activities of Daily Living) as needed... Bed and chair alarms... Cue/remind resident to use call lights to seek assistance as needed... Keep call light in reach at all times... Keep personal items and frequently used items within reach..." An admission "Minimum Data Set, assessment, dated 3/1/12, included, but was not limited to, "Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment)... Transfer: 3/2 (extensive assistance requiring one person)... Ambulation of unit: 4/2 (total dependence requiring one person)...." There were no other "Minimum Data Set" assessments completed on Resident #134 to signify a change in condition. An "Impaired Decision Making Care Plan," dated 4/19/12, included, but was not limited to, "Problem:(Resident #134) has had episodes of impaired decision making ability... Goal: (Resident #134) will have no negative effects from her impaired decisions related to falls/injuries... Approach: Communicate routinely with MD, family, resident... Educate resident on potential negative effects from impaired decisions... Encourage (Resident #134) to participate in all aspects of her care... Encourage to utilize call light for assistance instead of trying to transfer independently... Praise for being compliant...." A "Nurse's Progress Notes," dated 4/19/12 at 11:49 A.M., included, but was not limited to, "Writer spoke with her (Resident #134) (daughter) via telephone today to answer the questions that (Resident #134) was unable to answer because of her cognitive dysfunction... (Resident #134) is going to (local facility's) secured unit on or around 6/1/12... will continue to work with (Resident #134) and her family on appropriate discharge planning..." A "Nurse's Progress Notes" dated 4/24/12 at 4:28 A.M., included, but was not limited to, "(Resident #134) up ad lib... continues with alarms to wheelchair... is reminded several times to remain seated in wheelchair due to resident's attempting to self transfer and has a risk of falls..." A "Nurse's Progress Notes," dated 5/11/12 at 1:12 A.M., included, but was not limited to, "Patient (Resident #134) continues to ambulate without staff spotting her... Patient has been educated multiple times regarding need for staff to be present while ambulating to relieve fall risk..." A "Nurse's Progress Notes" dated 5/11/12 at 10:48 P.M., included, but was not limited to, "Requires a lot of verbal redirection due to multiple unassisted transfers and unsteady gait... Personal safety alarm on and functioning...." A "Nurse's Progress Notes," dated 5/14/12 at 10:48 P.M., included, but was not limited to, "Patient (Resident #134) has not attempted to elope this shift... In report, it was reported that she had attempted in the A.M. (to elope)... Patient has been cooperative with nursing care... Patient able to ambulate well..." There was no documentation of immediate interventions placed after the attempted elopement on 5/14/12 and there was no documentation of a completed elopement assessment on 5/14/12. There was no documentation of notification of social service personnel regarding the attempted elopement on 5/14/12. A "Nurse's Progress Notes," dated 5/18/12 at 2:44 P.M., included, but was not limited to, "(Resident #134) continues to have severe cognitive deficit and her needs have to be anticipated and provided by nursing staff and family when they are available..." A "Nurse's Progress Notes," dated 5/20/12 at 12:19 P.M., included, but was not limited to, "Resident was witnessed by therapy walking out of main entrance into the parking lot... Resident was let out of the front door by a visiting delivery service... Therapy notified writer (Registered Nurse #3) and we approached resident in parking lot she had her walker and all personal belongings draped on top of the walker... Resident stated she was going to walk home... Resident was alert and oriented x 3 new (sic) her name where she was and time... Escorted resident back into the building... upset and resistant... placed on 15 minute checks... called daughter, paged MD, and notified weekend supervisor... Received order to (sic) motion censor (sic) resident room along with 15 minute checks..." A "15 Minute Monitoring Record," dated May 20, 2012, included, but was not limited to, "12:30 P.M. to 1:45 P.M.: Lounge... 2:00 P.M. to 2:15 P.M.: Resident Room... 2:30 P.M.: No documentation noted... 2:45 P.M. to 11:00 P.M.: Started 1 on 1..." A "Nurse's Progress Notes," dated 5/20/12 at 2:10 P.M., included, but was not limited to, "(Dietary Aide #1) came down the hall and stated that a resident (Resident #134) was standing at the front door when she (Dietary Aide #1) went to clock out and that she let her (Resident #134) outside alone... when she (Dietary Aide #1) returned from clocking out she spotted the resident down in the parking lot... she (Dietary Aide #1) went back into the building to find the closest nursing station and sent to assist her... (Resident #134) had minor abrasions on knees and was guarding right arm... order obtained for x-ray... notified daughter... (daughter) sending daughter to sit with resident... resident placed immediately on 1 on 1 supervision..." An 'Elopement Assessment," dated 5/20/12 at 2:30 P.M., included, but was not limited to, "Does the resident have a pertinent Diagnosis: [REDACTED]. plan and CNA (Certified Nursing Assistant) assignment sheet: (the boxes marked) Personal safety alarm device, frequent monitoring: 1 on 1 supervision, and motion sensor alarm to room door..." A "Nurse's Progress Notes," dated 5/20/12 at 10:41 P.M., included, but was not limited to, "X-ray results received and reported... Received new order to send (Resident #134) to (local hospital) emergency room ... Daughter informed of x-ray results and order to send to hospital... Resident has been resting in bed calmly with CNA (Certified Nursing Assistant) at bedside... Neurological checks and vitals within normal limits... Norco (pain medication) given x 2 this shift... Right upper extremity immobilized... Noted blood pooling under skin with notable bruising to right shoulder..." On 7/12/12 at 5:30 P.M., the facility investigation of Resident #134's elopement on 5/20/12 was requested from the facility Administrator. On 7/13/12 at 9:30 A.M., the facility Administrator provided the investigation of the elopement on 5/20/12. The facility investigation included, but was not limited to: A "Radiology Report" dated 5/20/12, no time, included, but was not limited to, "(Resident #134)... Exam: Shoulder, 1 View, Right... Conclusion: Acute fracture and dislocation..." A written statement from Registered Dietician #2, dated 5/20/12, no time, included, but was not limited to, "(Dietary Aide #1) approached myself and stated she did something wrong... she knew she would get into trouble for and wanted to fess up now... She (Dietary Aide #1) stated she opened the front door to allow a resident (Resident #134) to go outside... (Dietary Aide #1) stated the resident was carrying several clothing items and she didn't know she was a resident... (Dietary Aide #1) was then notified that the resident fell outside, which is when she approached me (Registered Dietician #2)... After I (Registered Dietician #2) checked with the nursing supervisor and staff, I spoke with (Dietary Aide #1) one on one and told her under no circumstances should she allow a resident to go outside without a staff member... (Dietary Aide #1) received a copy of the elopement policy... She voiced understanding of the policy and received verbal counseling by myself for the incident...." A written statement from Dietary Aide #1, no date or time, included, but was not limited to, "On date of May 20, 2012 a resident (Resident #134) was at the door with a few of her shirts on hangers... not knowing I was not supposed to open the doors for residents, I had opened the door... I let her (Resident #134) out and finished walking across the parking lot to the dish room... It was around 2:40 P.M. when I had gotten in the other doorway by the time clock... another resident's family member came and had asked for help... a resident was down in the parking lot... I ran for help... it was barely a 3 minute lapse from the time I opened the door..." There were no other interviews provided in the elopement investigation. A "Staff Development" program attendance record, dated 5/21/12 through 5/26/12, included signatures of dietary staff for the program titled, "Elopement" with the policy and procedure for "Elopements" attached. On 7/16/12 at 12:25 P.M., in an interview, the facility Administrator indicated the only other staff inserviced were those that were present in the facility on 5/22/12. He indicated he did not have further documentation regarding other staff being inserviced on elopement. At that time, the facility Administrator provided a document titled, "Sign in Sheet: Topics Discussed: Employee Morale, employees breakroom remodel, new team members, parking, elopement, resident abuse, questions and concerns..." The sign in sheet included, but was not limited to, signatures from administration, nursing, and housekeeping. On 7/13/12 at 1:15 P.M., in an interview with the facility Administrator, all information regarding Resident #134's elopement interventions and facility interventions placed after the 5/20/12 incident were requested. On 7/13/12 at 2:30 P.M., in an interview, the facility Administrator indicated there were no other documents to provide regarding the attempted elopement of Resident #134 on 5/14/12 and elopement of Resident #134 on 5/20/12. 2. On 7/16/12 at 12:30 P.M., the clinical record for Resident #136 was reviewed. [DIAGNOSES REDACTED]. Resident #136 was admitted to the facility on [DATE]. An elopement risk assessment, dated 1/19/2012, indicated Resident #136 was not an elopement risk. A quarterly elopement risk assessment, dated 7/3/2012, indicated Resident #136 was not an elopement risk. A quarterly "Minimum Data Set" assessment, dated 7/3/12, included, but was not limited to, "Brief Interview Mental Status: 1 (severe cognitive impairment)... " A "Progress Note," dated 7/3/12 at 1:31 P.M., included, but was not limited to, "(Resident #136) continues to prefer own routine... sister visits daily for several hours and will take him for walks outside and around the building..." There was no documentation of an attempted elopement prior to 7/5/12. A "Progress Note," dated 7/5/2012, at 1:00 P.M., included, but was not limited to, "(Resident #136) observed by staff in parking lot... Assessed, skin dry and intact with no signs or symptoms of perspiration, redness, or injuries..." A "Progress Note," dated 7/5/12 at 5:07 P.M., included, but was not limited to, "Resident placed in elopement book... it appears that a visitor may have held door for resident to enter the (Assisted Living) apartments as he was wandering this date and when he entered the area he then opened the door on the apartment side and was in the parking area (staff parking area)... he has not attempted to go near doors again... educated him on need for staff/family to be with him outdoors... currently on 15 minute checks... elopement care plan completed... MD notified... notified sister with care plan meeting to be held on 7/6/12 to discuss possibly memory care unit... she (sister) hopes facility will be able to continue placement..." Unable to locate documentation regarding Resident #136's previous wandering as described in the above progress note. An updated elopement risk assessment completed at 2:12 P.M., on 7/5/2012, indicated Resident #136 was at risk for elopement. On 7/16/12, at 12:20 P.M., the Director of Nursing (DON) provided the investigation of the incident. This included , but was not limited to the following information: A document titled, "Indiana State Department of Health Incident Report Form," dated 7/5/2012, included, but was not limited to the following: "Brief Description of Incident: Elopement. Nurse saw resident in parking lot outside Station 2 and brought back inside." "Immediate Action Taken: Assessed resident..." "Preventive measures taken: Started 15 minute checks on resident. Notified MD and family. Checked door at Station 2 to ensure locks appropriately. Elopement assessment updated. Care planned. Added picture of resident to Elopement Book." One staff interview indicated, "Resident spotted by writer in the parking lot 7-5-12 @ 1300 (1:00 P.M.). Resident alone propelling himself in the wheelchair. Nurse assisted the resident back into the facility and notified unit manager." This statement was signed by LPN #7. During an interview on 7/16/2012 at 2:30 P.M., Clinical Specialist (RN) #8 indicated the facility had not implemented any interventions because they were not certain how the resident exited the facility. Clinical Specialist #8 indicated there should be a sign on the independent living door informing visitors not to allow residents through the door. 3. The facility "Elopements" policy and procedures, dated 8/05, included, but was not limited to, "Policy: Nursing personnel must report and investigate all reports of missing residents... Procedures: Elopement risk Assessment: It is the policy of this facility to assess all residents upon admission, quarterly, and with significant changes for their elopement risk. Residents identified as being high risk for elopement will have a plan of care that identifies the risk and appropriate interventions..." 4. On 7/14/2012 at 10:15 A.M., a tour of the facility to evaluate exit doors was initiated. The door at the employee entrance was observed. Next to the door was a functioning keypad. Social Services #9 indicated the door was only supposed to open when the correct code was entered on the keypad inside or on the keypad outside. The door contained a push-bar, but the door would not latch and therefore could not be closed tightly. At the top of the door was a magnetic closing device. Upon testing the door, it opened freely without depressing the push-bar or entering a code on the keypad. The magnetic closing device appeared to be hanging loosely from the doorframe. The Maintenance Director was notified. He indicated the door was not in that condition an hour ago and that he would fix it again. On 7/15/2012, at 2:15 P.M., this exit door was observed to still not latch. The door could be pushed open without depressing the push-bar or entering a code on the keypad. On 7/15/2012, at 2: 30 P.M. this exit door was observed. The door still was not latched but was securely held closed by the magnetic closing device. On 7/16/12 at 12:30 P.M., the facility Administrator provided a document titled, "Listing Of Residents That Are Potentially At Risk For Elopement," no date included on the document. In an interview, at that time, the facility Administrator indicated the document was a current list of residents at risk for elopement. The residents included on the list were Residents #136, 31, 52, 51, 34, 44, 43, 66, and 130. The residents who had access to the employee entrance door were Residents #136, 31, 52, 51, 34, 44, and 43. The Immediate Jeopardy that began on 5/20/12 was removed on 7/16/12 after the facility inserviced facility employees in all departments on the facility elopement policy, doors were observed alarmed or secured, residents identified as an elopement risk were added to the elopement book and Certified Nursing Assistant assignment sheets, new policies and procedures were put in place for residents who are actively exit seeking, signs to alert visitors to refrain from assisting a resident have been enlarged, and maintenance ensured and will continue to ensure that the doors are functioning properly, but non-compliance remained at the lowered scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to provide effective and timely treatment, services, and interventions to promote healing of facility acquired pressure ulcers for 2 residents whose Stage II pressure ulcers increased in size and became unstageable due to slough and eschar. This deficiency impacted 2 of 8 residents reviewed for pressure sores in a sample of 24 residents. (Resident #47 and #94) Findings include: 1. In an interview during the initial orientation tour on 7/9/12 at 11:32 A.M., L.P.N. #4 indicated Resident #47 was totally dependent on staff for all care, received nutrition through a continuous gastrostomy tube feeding, required a mechanical lift for all transfers in and out of bed, and used a low air loss mattress. The nurse also indicated the resident had a Stage II pressure sore of the coccyx that was acquired in the facility, and a healed pressure sore area on one foot. The resident was observed at that time sitting in a semi-reclined geri-chair in the T.V. lounge area. The clinical record for Resident #47 was reviewed on 7/9/12 at 1:52 P.M. [DIAGNOSES REDACTED]. A Significant Change M.D.S. (Minimum Data Set) assessment, completed on 8/19/11, indicated the resident had no speech, was rarely able to understand others and rarely was understood by others, was determined to have moderately impaired cognitive skills for daily decision-making by staff assessment, was totally physically dependent on 2 staff for all daily care, was always incontinent of both bowel and bladder, and had one Stage 4 unhealed pressure sore (the site was not identified). The most current Quarterly M.D.S. assessment, completed on 4/26/12, indicated no changes except the resident now had severe impairment in cognitive skills for daily decision-making, and had no unhealed pressure sores. The "Observations" section of the facility's electronic records included, but was not limited to, the following information: "5/1/12--No skin issues. Slight redness on bottom. Turn and re-position, pressure reduction mattress, chair cushion. 6/5/12--Onset 5/31/12; coccyx. Acquired in-house. Stage II, 4.0 (length) by 6.2 (width) cm. (centimeters), no depth. Small amount serosanguinous exudate. Pressure reducing device for chair, pressure reducing device for bed, turning and repositioning program, heel protectors. 6/25/12--Stage II coccyx, 5.0 by 7.0 cm., no depth. Small amount serosanguinous exudate. Wound bed yellow. Santyl and dry dressing. Pressure reducing device for bed, turning and repositioning program, Dietary/Nutritional supplements, elevate [MEDICAL CONDITION]/affected area, heel protectors. 7/2/12--Coccyx/unstageable, 5.0 by 6.5 by 0.2 (depth) cm. Small amount serosanguinous exudate, wound bed yellow. Pressure reducing device for bed, turning and repositioning program. A "Resident Care Record" form, identified by the Director of Nurses as the C.N.A. assignment sheet, was provided for Resident #47 on 7/12/12. The form indicated the resident required total ADL (Activity of Daily Living) care, was incontinent of bowel and bladder, was to be given incontinence care every 2 hours, was to be turned every 2 hours, was on a low air loss mattress, was to have feet and ankles "floated" (positioned off of surfaces), and to use small pillow/blanket at pressure points. A Care Plan entry, updated 4/26/12, addressed a problem of "At risk for skin breakdown due to incontinence and need for assist with bed mobility." The interventions included, but were not limited to the following: "12/20/10--Avoid shearing resident's skin during positioning, transferring, and turning. 12/20/10--Float left ankle. 12/20/10--Keep bony prominences from direct contact with one another with pillows, foam wedges, etc. 12/20/10--Keep clean and dry as possible. Minimize skin exposure to moisture. 12/20/10--Keep linen clean, dry, and wrinkle free. 12/20/10--Provide incontinence care after each incontinent episode. 12/20/10--Turn and reposition every 2 hours. 12/20/10--Use pressure reducing mattress for pressure reduction when in bed." A Care Plan entry, updated 4/26/12, addressed a problem of "At risk for pressure ulcers due to complete incontinence and need for staff to provide mobility." The interventions included the ones listed in the previous Care Plan entry, but were updated with a "Start Date" of 8/22/11. An additional approach was added for: "Use low air loss mattress for pressure reduction when resident in bed." A Care Plan entry, updated 4/26/12, addressed a problem of "Completely incontinent of both her bladder and bowel functions." The interventions included, but were not limited to, the following: "8/22/11--Staff will check before/after meal times, at bedtime, and every 2 hours at night providing incontinent care and brief changes as needed." The July, 2012 physician order [REDACTED]. 6/6/12--ProStat 64 Liquid 30 ml. (milliliters) daily. 6/6/12--Vitamin C 500 mg. (milligrams) one daily. 6/6/12--Vitamin E 400 mg. one daily for 60 days. 6/6/12--Zinc 220 mg. one daily On 7/11/12 at 8:30 A.M., the resident was observed sitting in a semi-reclined geri-chair in her room. From 9:15 to 11:20 A.M., the resident was continuously observed sitting in the semi-reclined geri-chair in her room. During that time period, the resident was not "off-loaded" (raised up off of her buttocks and coccyx for at least 5 minutes to relieve pressure on that area) at any time. On 7/11/12 at 11:20 A.M., L.P.N. #4 and an unidentified C.N.A. went into the resident's room. The L.P.N. said "We're just readjusting her--she has been on her booty for ...." The C.N.A. placed a small soft stuffed animal under the resident's left upper arm, and another under her right ankle. The resident's right foot was observed to have been resting directly on the surface of the foot rest with no space between the heel skin and the foot rest. After placing the stuffed animal under the resident's foot, the heel was raised 1 inch above the surface. After completing this adjustment, the resident was wheeled in her geri-chair out to the T.V. lounge. At no time was the resident's bottom off-loaded from the seat of the geri-chair. In an interview on 7/11/12 at 9:30 A.M., L.P.N. #4 indicated Resident # 47 only had an open area of the coccyx, and two places on the right foot were healed. She indicated the resident "stays up (in the geri-chair) until after lunch," and then is transferred back into bed to be given incontinence and wound care. On 7/11/12 at 2:10 P.M., R.N. #6 and L.P.N. #5 were observed while giving wound care treatment to Resident #47. Upon entrance to the room, the resident was observed to be laying on her right side, with the head of the bed raised 35-40 degrees. There was a folded "draw" sheet under the resident, placed so the top was at the resident's waist area, and the bottom was at her upper thigh area. The sheet extended out to both sides of the bed. The dressing over the pressure sore was crumpled and damp. When R.N. #6 removed the dressing, the tape holding the dressing was observed to be stuck to the peri-wound area. The open area was approximately 3 centimeters in circumference with irregular edges, with a loss of the upper dermis/skin. The wound bed was clean, without slough, and red in color. There was a 1 inch peri-wound area around the whole circumference of the wound that was reddened, and appeared to be macerated (a softening or breaking down of tissue from constant dampness, which can be caused by exposure to anything wet). The tape of the dressing had been stuck to this area. The resident's buttocks and perineum was shiny and wet, with reddened and macerated areas over the vulva and in the creases between the bilateral lower buttocks and upper thigh area. The right heel was observed to have intact skin, but had bright red to blue coloration throughout the entire heel skin area. After removing the dressing, R.N. #6 went into the bathroom to wash her hands. As L.P.N. #5 was assisting to hold the resident on her right side, the resident urinated a large amount of urine, which ran down across her perineal area and left buttock and buttock crease areas. The resident also began to strain to have a bowel movement, and a hard, formed stool was observed at the rectal opening. R.N. #6 returned to the bedside, prepared clean gauze with some normal saline, and dabbed at the wound bed. When she turned to obtain the Santyl ointment to place on the wound bed, the resident strained with the bowel movement, and urinated a large amount again. L.P.N. #5 continued to hold the resident to the right side, and had a direct view of the area. Using a Q-tip applicator, R.N. #6 applied the Santyl ointment to the wound bed. As she did so, the R.N. remarked "The orders say to apply the Santyl to the yellow (slough) areas, but there isn't any." Following the Santyl, the R.N. obtained another Q-tip applicator, placed some Dermaseptine on the end, and applied the cream to the peri-wound area. There was a glob of cream unevenly applied to the 3-6 o'clock peri-wound area, with only small amounts of the cream applied to the remainder of the peri-wound areas. The resident continued to strain to have a bowel movement, and a small round marble size piece of stool dropped to the sheet. R.N. #6 then placed a large (ABD) dressing over the wound, and taped it in place. One piece of tape was applied down the middle of the dressing, so that both the bottom of the dressing and tape covered the resident's rectal area. After applying the dressing, R.N. #6 picked up the small piece of stool with a gloved hand and discarded into a trash bag. No incontinence care was provided. The two nurses used the draw sheet to scoot the resident back up to the top of the bed, and repositioned her on her back. The draw sheet, which was wet with urine, was not changed. In an interview on 7/12/12 at 10:05 A.M., L.P.N. #4 indicated as the Unit Manager she only occasionally does direct observations of nursing staff performing dressing changes and other care. In an interview on 7/12/12 at 10:05 A.M., the Director of Nursing indicated she had been in the position of D.O.N. for a couple of months. She indicated the Staff Development Coordinator would have done observations of staff providing care, but the facility had not had anyone in that job position for the last 6-8 months. Someone had been hired to fill that job position 4 weeks ago. She indicated she felt the return demonstrations of care has been something that was lacking. The 2008 A.M.D.A. (American Medical Directors Association) "Pressure Ulcers in the Long-Term Care Setting, Clinical Practice Guidelines" manual defines a Stage II pressure ulcer as "Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink ulcer bed, without slough (necrotic or avascular tissue in the process of separating from viable tissue. Usually soft, moist, and light in color; may be stringy)." An "Unstageable" ulcer is defined as "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (thick, leathery, necrotic or devitalized tissue, frequently black or brown in color; skin that has lost its usual physical properties and biological activity; may be loose or may be firmly adhered to the wound.) in the wound bed." 2. On 7/10/12 at 10:30 A.M., Resident #94's record was reviewed. [DIAGNOSES REDACTED]. Resident #94 was admitted to the facility on [DATE] without any sign or symptom of pressure wounds. An "At risk for skin breakdown" care plan, dated 7/11/11, included, but was not limited to, "Problem: Start date: 7/13/11... (Resident #94) is at risk for skin breakdown due to incontinence and need for assist with bed mobility... Goal: Resident's skin will remain intact... Approach (with approach start date of 7/13/11): Avoid shearing resident's skin during positioning, transferring, and turning... Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominence's... Encourage fluids... Keep clean and dry as possible. Minimize skin exposure to moisture... Maintain head of bed at the lowest degree of elevation possible... Use pressure reducing cushion for pressure reduction when resident in chair... Use pressure reducing mattress for pressure reduction when resident in bed..." A quarterly "Minimum Data Set" assessment, dated 12/27/11, included, but was not limited to, "Brief Interview Mental Status (BIMS)" 7 (moderate cognitive impairment)... Transfer: 3/2 (extensive assistance of 1 staff person)... " There was no documentation of Resident #94 having a pressure area on the quarterly MDS completed on 12/27/11. Resident #94 was coded as yes to risk for pressure areas with the following treatments marked as used: pressure reducing devices for chair and bed and application of ointments. A "Resident Progress Notes," dated 3/8/12 at 5:00 P.M., included, but was not limited to, "OA (open area) noted to right sacral area. 2 x 1 x 0.2. Nurse Practitioner notified... N.O. (new order) received for thick layer of Dermaseptine (skin barrier), cover with Biatin foam dressing BID(2 times per day) and PRN (as needed) for soilage. D/C (discontinue) when healed... son notified...." No documentation was found of new interventions implemented after the area opened. Only new intervention was the ordered dressing change. A "Skin - Pressure Ulcer Evaluation," dated 3/8/12 at 5:00 P.M., included, but was not limited to, "OA to right sacral area... 2 x 1 x 0.2... Where acquired: In-House... Stage of ulcer: Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough)... Plan of Care: (No new interventions added)." A "Skin - Weekly Skin Inspection," dated 3/13/12 at 10:56 P.M., included, but was not limited to, "Treatment to sacral area... showing improvement... no other concerns (no measurements or description given)." A "Skin - Weekly Skin Inspection," dated 3/20/12 at 11:00 P.M., included, but was not limited to, "Risk factors (marked as risk): Impaired Mobility, refusal of some aspects of care and treatment, cognitive impairment, exposure of skin to urinary and fecal incontinence, inability to respond meaningfully... No assessment of the wound was provided...." A "Resident Progress Notes," dated 3/24/12 at 9:00 A.M., included, but was not limited to, "Certified Nursing Assistant (CNA) stated while transferring resident from bed to wheelchair CNA's foot got tangled in phone cord... caused CNA's and resident's leg to tangle... resident taken by stretcher to hospital...." A "Resident Progress Notes," dated 3/29/12 at 5:29 P.M., included, but was not limited to, "Resident arrived by ambulance from (local hospital)... Resident has four surgical incisions to left leg... 2 centimeter pressure sore on coccyx (same pressure area resident had prior to admission to the local hospital) Resident #94 was in a local hospital for 5 days. The measurements of the pressure area remained the same on re-admission. A "Skin - Pressure Ulcer Evaluation" dated 3/29/12 at 9:22 P.M., included, but was not limited to, "Description: Admission: Where (Pressure) Acquired: Hospital (the pressure area was the same area being treated prior to discharge to hospital)... Location: Coccyx... Stage of Ulcer: Stage II... Length and Width: 2 centimeters... Skin and Ulcer Treatments (marked interventions): Turning and repositioning program... Pressure ulcer care..." A "Open Area" care plan, dated, 3/30/12, included, but was not limited to, "Problem start date: 3/30/12... Resident has OA to coccyx... admitted with (resident had prior to 5 day stay at hospital)... Goal: OA to remain free of infection... Approach (with start date of 3/30/12: Apply treatment as ordered... Low air loss mattress... Supplements as ordered... Turn and reposition... Weekly skin inspections... (with start date of 5/9/12) Physical Therapy for estim (electrical stimulation treatment) as ordered..." The skin assessments on the "Skin - Pressure Ulcer Evaluation" for the dates of 4/2/12 at 12:25 P.M. and 4/9/12 at 5:31 P.M., showed improvement with measurements in centimeters of 1.0 x 1.2 on 4/2/12 and 1.2 x 1.5 on 4/9/12 as compared with the 3/29/12 measurement at 2 centimeters. However, the skin assessment on 4/16/12 at 11:20 A.M., showed an increase. A 'Resident Progress Notes" dated 4/12/12 at 4:02 P.M., indicated Resident #94 was started on antibiotic therapy for a urinary tract infection and placed on contact isolation for vancomyicin resistant [MEDICATION NAME] in the urine. A "Skin - Pressure Ulcer Evaluation," dated 4/16/12 at 11:20 A.M., included, but was not limited to, "Length and width in centimeters: 2.0 x 2.5... Skin and Ulcer Treatments (marked): Pressure reducing device for chair, pressure reducing device for bed, turning and repositioning, nutrition or hydration intervention to manage skin problems, and pressure ulcer care... Plan of Care (marked): Continue current plan of care..." No documentation of physician notification regarding the increase in size of pressure wound was located in Resident #94's clinical record. There was no documentation of a skin assessment on 4/23/12 and 4/24/12; however, the following notes indicated the physician was notified and orders received on 4/24/12 (8 days after a noted increase in wound size). A "Resident Progress Notes," dated 4/24/12 at 4:55 P.M., included, but was not limited to, "New orders received for (wound team Nurse Practitioner) to evaluate stage II pressure ulcer on coccyx that resident was admitted with (Resident #94 had the pressure prior to her 5 day stay in the hospital and returned with the same measurements)... New wound care orders..." A "Wound, Ostomy, Continence Center Initial Evaluation," dated 5/1/12, no time, included, but was not limited to, "Subjective: (Resident #94) is a patient that is new to me... Objective: Upon assessment today, the left superior ischial tuberosity or the superior ischium, she does have a wound that measures 3.2 centimeters long x 3.15 centimeters wide x less than 0.1 centimeters deep... However, the wound base is necrotic... Today the wound base is 40% black, 40% yellow and 20% red... Assessment: Unstageable pressure ulcer left superior ischium... Plan: Discontinue foam dressing to her left buttocks... pre-[MEDICATION NAME] level... pillow placed between her knees and legs and no skin to skin contact... apply Santyl periwound for protection and cover with a dry dressing and change daily... anchor Foley... the patient is incontinent and there is no way that her wound is going to get better with her incontinence..." Resident #94's ulcer opened on 3/8/12 with a Stage II pressure wound measuring 2 centimeters that resulted in an unstageable pressure wound on 5/1/12 measuring in centimeters 3.2 long x 3.15 width x 0.1 deep. On 7/13/12 at 11:15 A.M., RN #25 was observed providing wound care to Resident #94. The right coccyx area was not measured at that time; however, the wound appeared round with a small amount of yellow colored tissue noted on the left upper side with surrounding pink tissue. There was no odor noted or drainage of the wound. RN #25 cleansed the area with a 4 x 4 gauze at which time the resident cried and moaned in pain. On 7/13/12 at 1:00 P.M., the facility Clinical Specialist #27 indicated she did not have any further documentation to provide for Resident #94. She aware of the concerns regarding Resident #94 developing a pressure area that worsened, the lack of care plan development, and no physician notification for 8 days. 3. On 7/16/12 at 12:19 P.M., the Administrator provided a Policy/Procedure titled "Skin Care and Pressure/Non-Pressure Ulcer Management Program," and dated as revised April, 2011. Information included, but was not limited to, the following: "INTRODUCTION... Managing a skin prevention program is dependent upon many factors. There are certain clinical conditions along with limited mobility that may contribute to the development of pressure ulcers. These conditions may include, but are not limited to the following: 1. Urinary incontinence... 3. Diabetes 4. [MEDICAL CONDITION] 12. [MEDICAL CONDITION]/dehydration.... There are also certain treatments that may contribute to pressure ulcer development. These treatments may include, but are not limited to, the following: ... 5. Head of be elevated majority of the day due to medical necessity.... RISK INTERVENTIONS... 2. Turn and reposition on an every two hour schedule or per individual plan of care... 4. Use pillows or adequate positioning devices to avoid skin to skin contact... 6. Heel and elbow protectors may be utilized as appropriate to reduce friction. 7. Utilize measures to reduce pressure on heels. 8. Adequate cleansing, moisturizing, and protection of skin.... SKIN CARE AND EARLY TREATMENT-- Cleanse: ... Cleanse skin after each episode of incontinence... Activity: Use proper positioning, transferring and turning techniques...." 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure physician's orders were followed which caused which caused residents to have anxiety and mental anguish worrying about the possibility of having an adverse reaction without ordered medications 3 of 8 residents reviewed for physicians's orders being followed in a sample of 14 residents (Resident P) (Resident Q) (Resident O). Findings include: 1. The record for Resident P was reviewed on 2/16/2012 at 10:30 A.M. Resident P was admitted on [DATE] at 3:30 P.M. and had current [DIAGNOSES REDACTED]., depression, irritable bladder, difficulty in walking, post laminectomy [MEDICATION NAME]-T11, T12 vertebralplasty, weakness, muscles, chronic pain, and [MEDICAL CONDITION]. Admission physician orders dated 2/3/2012 indicated Resident P had physician orders for: [MEDICATION NAME] 50 milligram (mg) tab PO (by mouth) every 12 hours, [MEDICATION NAME] 20 mg po daily, [MEDICATION NAME] 75 mg twice daily, [MEDICATION NAME] 16 units sub q (subcutaneous injection) daily each evening, [MEDICATION NAME] 250 mg po four times a day for two weeks, [MEDICATION NAME] 300 mg cap po three times a day, [MEDICATION NAME] 200 mcg (micro grams) tab po daily, [MEDICATION NAME] 10 mg po three times a day before meals, Amlodopine 7.5 mg po daily, [MEDICATION NAME] 40 mg po twice a day, [MEDICATION NAME] 5 mg po daily, [MEDICATION NAME] 100 mg tab po daily, [MEDICATION NAME] 120 mg twice a day, [MEDICATION NAME] 325 mg three times daily, Requip 2 mg tab po three times daily. Resident P's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] syndrome), [MEDICATION NAME] (anti-reflux), and [MEDICATION NAME] (irritable bowel). Resident P's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 9:00 A.M.. dose (high blood pressure), [MEDICATION NAME] 8:00 A.M. dose (blood thinner), [MEDICATION NAME] 9:00 A.M. dose (anti-[DIAGNOSES REDACTED]), [MEDICATION NAME] 9:00 A.M. and 1:00 P.M. doses (anti- [MEDICAL CONDITION]), [MEDICATION NAME] 8:00 A.M. dose (anti-[MEDICAL CONDITION]), [MEDICATION NAME] (insulin), [MEDICATION NAME] 9:00 A.M. and 1:00 P.M. doses (antibiotic), [MEDICATION NAME] 6:00 A.M. dose ([MEDICAL CONDITION]), [MEDICATION NAME] (anti-[MEDICAL CONDITION]), [MEDICATION NAME] 9:00 P.M. dose (anti-reflux), [MEDICATION NAME] 8:00 A.M., 11:00 A.M., and 4:00 P.M. doses (iron supplement), Requip 9:00 AM. and 1:00 P.M. doses (anti-tremor/restless leg syndrome). A doctor's progress note dated 2/3/12, 2145 (9:45 P.M.), indicated Resident P had complaints of diarrhea-suspected [MEDICAL CONDITION]. Start [MEDICATION NAME]. UTI (urinary tract infection), [MEDICAL CONDITIONS] and Ext (extremities) 1-2 + [MEDICAL CONDITION]. A care plan dated 2/3/2012 indicated Resident P was at risk for the following: oxygen desaturation related to pneumonia and [MEDICAL CONDITION], potential for acute episode related to hypertension diagnoses, and a potential for either hyper or hypo glycemic episode related to diabetes mellitus. All problems had approaches to prevent complications which included administering medications as ordered. During an interview on 2/15/2012 at 915 A.M., LPN #1 and LPN #2 indicated Resident P was alert and oriented and able to answer questions accurately. A Minimum Data Set (assessment tool) dated 2/10/2012, indicated Resident P was alert and oriented. During an interview with Resident P on 2/15/2012 at 9:30 A.M., Resident P stated, "Pharmacy is terrible. I was admitted last week. Didn't get meds for 2 days." During an interview on 2/16/12 at 3:50 P.M., The DON (Director of Nursing) and Administrator where asked to provide information regarding Resident P's medication not being given the first two days of admission. During an interview on 2/17/2012 at 1:20 P.M., Resident P stated, "I finally went to sleep. Went to sleep praying. Prayed a lot I wouldn't have a grand mal [MEDICAL CONDITION]. You can't stop your [MEDICAL CONDITION] medication cold turkey. I told the nurse if I had a [MEDICAL CONDITION] I would fall out of this bed and if I fell out of this bed and fractured something someone would pay. I told the nurse if they couldn't get my medicine I would call my pharmacy and get them. She said they should be in but they didn't come. I have had [MEDICAL CONDITION] for [AGE] years. In 1981 or 82 I had a [MEDICAL CONDITION] and fractured my back at T12. I have had lots of fractures. My last grand mal [MEDICAL CONDITION] was September 2010. I came in with [MEDICAL CONDITIONS]. My lungs filled up at the hospital and I was on a lot of [MEDICATION NAME]. I didn't get my [MEDICATION NAME] for two days here. Insulin either. A friend of mine went down and told the nurse to call him when the meds arrived. Thank the Lord that nothing has happened yet. The last time I was here in February last year the same thing happened. During an interview on 2/17/2012 at 1:50 P.M., The DON and Administrator indicated no further documentation was available to explain why resident #P did not get the ordered medication. 2. The record for Resident Q was reviewed on 2/15/12 at 1:30 P.M.. Resident Q was admitted on [DATE] with [DIAGNOSES REDACTED]. Nursing notes dated 2/9, 2/10, and 2/12/2012 indicated Resident Q was alert and oriented. During an interview on 2/15/2012 at 0915 A.M., LPN #1 and LPN #2 indicated Resident #Q was alert and oriented and able to answer questions accurately. During an interview on 2/15/2012 at 1300, Resident Q stated, "I was a DON (Director of Nursing) for twenty-one years. I was admitted last Thursday. Did not get insulin 2 nights in a row. Both nights I told the Aide (they call them something different here). She said she would check with the nurse. Both nights I fell asleep and did not get insulin. Third day I asked my nurse if the order had been changed. She said no, I should have got my insulin and didn't." A physician's order dated 2/9/2012, indicated Resident Q had a order for [MEDICATION NAME] 16 units Sub Q (subcutaneous injection) every evening. Review of Resident Q's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 2/16/12 at 3:50 P.M., The DON (Director of Nursing) and Administrator where asked to provide information regarding Resident Q's insulin not being given the first two days of admission as ordered. During an interview on 2/17/2012 at 1:50 P.M., The DON and Administrator indicated no further documentation was available to explain why Resident Q did not get the ordered insulin. 3. The record for Resident O was reviewed on 2/15/12 at 10:00 A.M. Resident O was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident O's MDS (minimum data set-assessment tool) dated 1/27/2012, indicated Resident O was alert and oriented. During an interview on 2/15/2012 at 0915 A.M., LPN #1 and LPN #2 indicated Resident O was alert and oriented and able to answer questions accurately. During an interview on 2/15/2012 at 1:30 P.M., Resident O stated, "I go to [MEDICAL TREATMENT] so I am not here for my 9:00 A.M. meds. When I get back some of the nurses will not bring me my 9:00 A.M. meds. I have to ask for them and explain why it is ok for me to take my 9:00 A.M. meds even if it is not 9:00 A.M. I especially have to have my [MEDICATION NAME] or my legs go crazy." Resident O indicated some nurses will bring them but some refuse. A Physician's order dated 12/21/11, indicated Resident O had an order for [REDACTED]. Resident O's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., on 2/2/12, 9:00 P.M. on 2/2/12, and 9:00 A.M. on 2/3/2012. During an interview on 2/16/12 at 3:50 P.M., The DON (Director of Nursing) and Administrator where asked to provide information regarding Resident O's [MEDICATION NAME] not being given as ordered. During an interview on 2/17/2012 at 1:50 P.M., The DON and Administrator indicated no further documentation was available to explain why resident O did not get the ordered [MEDICATION NAME]. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure residents were free of significant medications errors which caused residents to have anxiety and mental anguish worrying about the possibility of having an adverse reaction without ordered medications for 3 of 8 residents reviewed for medication errors in a sample of 14 residents (Resident P) (Resident Q) (Resident O). Findings include: 1. The record for Resident P was reviewed on 2/16/2012 at 10:30 A.M. Resident P was admitted on [DATE] at 3:30 P.M. and had current [DIAGNOSES REDACTED]., depression, irritable bladder, difficulty in walking, post laminectomy [MEDICATION NAME]-T11, T12 vertebralplasty, weakness, muscles, chronic pain, and [MEDICAL CONDITION]. Admission physician orders [REDACTED]. day before meals, Amlodopine 7.5 mg po daily, [MEDICATION NAME] 40 mg po twice a day, [MEDICATION NAME] 5 mg po daily, [MEDICATION NAME] 100 mg tab po daily, [MEDICATION NAME] 120 mg twice a day, [MEDICATION NAME] 325 mg three times daily, Requip 2 mg tab po three times daily. Resident P's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] syndrome), [MEDICATION NAME] (anti-reflux), and [MEDICATION NAME] (irritable bowel). Resident P's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 9:00 A.M.. dose (high blood pressure), [MEDICATION NAME] 8:00 A.M. dose (blood thinner), [MEDICATION NAME] 9:00 A.M. dose (anti-[DIAGNOSES REDACTED]), [MEDICATION NAME] 9:00 A.M. and 1:00 P.M. doses (anti- [MEDICAL CONDITION]), [MEDICATION NAME] 8:00 A.M. dose (anti-[MEDICAL CONDITION]), [MEDICATION NAME] (insulin), [MEDICATION NAME] 9:00 A.M. and 1:00 P.M. doses (antibiotic), [MEDICATION NAME] 6:00 A.M. dose ([MEDICAL CONDITION]), [MEDICATION NAME] (anti-[MEDICAL CONDITION]), [MEDICATION NAME] 9:00 P.M. dose (anti-reflux), [MEDICATION NAME] 8:00 A.M., 11:00 A.M., and 4:00 P.M. doses (iron supplement), Requip 9:00 AM. and 1:00 P.M. doses (anti-tremor/restless leg syndrome). A doctor's progress note dated 2/3/12, 2145 (9:45 P.M.), indicated Resident P had complaints of diarrhea-suspected [MEDICAL CONDITION]. Start [MEDICATION NAME]. UTI (urinary tract infection), [MEDICAL CONDITIONS] and Ext (extremities) 1-2 + [MEDICAL CONDITION]. A care plan dated 2/3/2012 indicated Resident P was at risk for the following: oxygen desaturation related to pneumonia and [MEDICAL CONDITION], potential for acute episode related to hypertension diagnoses, and a potential for either hyper or hypo glycemic episode related to diabetes mellitus. All problems had approaches to prevent complications which included administering medications as ordered. During an interview on 2/15/2012 at 915 A.M., LPN #1 and LPN #2 indicated Resident P was alert and oriented and able to answer questions accurately. A Minimum Data Set (assessment tool) dated 2/10/2012, indicated Resident P was alert and oriented. During an interview with Resident P on 2/15/2012 at 9:30 A.M., Resident P stated, "Pharmacy is terrible. I was admitted last week. Didn't get meds for 2 days." During an interview on 2/16/12 at 3:50 P.M., The DON (Director of Nursing) and Administrator where asked to provide information regarding Resident P's medication not being given the first two days of admission. During an interview on 2/17/2012 at 1:20 P.M., Resident P stated, "I finally went to sleep. Went to sleep praying. Prayed a lot I wouldn't have a grand mal [MEDICAL CONDITION]. You can't stop your [MEDICAL CONDITION] medication cold turkey. I told the nurse if I had a [MEDICAL CONDITION] I would fall out of this bed and if I fell out of this bed and fractured something someone would pay. I told the nurse if they couldn't get my medicine I would call my pharmacy and get them. She said they should be in but they didn't come. I have had [MEDICAL CONDITION] for [AGE] years. In 1981 or 82 I had a [MEDICAL CONDITION] and fractured my back at T12. I have had lots of fractures. My last grand mal [MEDICAL CONDITION] was September 2010. I came in with [MEDICAL CONDITIONS]. My lungs filled up at the hospital and I was on a lot of [MEDICATION NAME]. I didn't get my [MEDICATION NAME] for two days here. Insulin either. A friend of mine went down and told the nurse to call him when the meds arrived. Thank the Lord that nothing has happened yet. The last time I was here in February last year the same thing happened. During an interview on 2/17/2012 at 1:50 P.M., The DON and Administrator indicated no further documentation was available to explain why resident #P did not get the ordered medication. 2. The record for Resident Q was reviewed on 2/15/12 at 1:30 P.M.. Resident Q was admitted on [DATE] with [DIAGNOSES REDACTED]. Nursing notes dated 2/9, 2/10, and 2/12/2012 indicated Resident Q was alert and oriented. During an interview on 2/15/2012 at 0915 A.M., LPN #1 and LPN #2 indicated Resident #Q was alert and oriented and able to answer questions accurately. During an interview on 2/15/2012 at 1300, Resident Q stated, "I was a DON (Director of Nursing) for twenty-one years. I was admitted last Thursday. Did not get insulin 2 nights in a row. Both nights I told the Aide (they call them something different here). She said she would check with the nurse. Both nights I fell asleep and did not get insulin. Third day I asked my nurse if the order had been changed. She said no, I should have got my insulin and didn't." A physician's orders [REDACTED]. Review of Resident Q's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 2/16/12 at 3:50 P.M., The DON (Director of Nursing) and Administrator where asked to provide information regarding Resident Q's insulin not being given the first two days of admission as ordered. During an interview on 2/17/2012 at 1:50 P.M., The DON and Administrator indicated no further documentation was available to explain why Resident Q did not get the ordered insulin. 3. The record for Resident O was reviewed on 2/15/12 at 10:00 A.M. Resident O was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident O's MDS (minimum data set-assessment tool) dated 1/27/2012, indicated Resident O was alert and oriented. During an interview on 2/15/2012 at 0915 A.M., LPN #1 and LPN #2 indicated Resident O was alert and oriented and able to answer questions accurately. During an interview on 2/15/2012 at 1:30 P.M., Resident O stated, "I go to [MEDICAL TREATMENT] so I am not here for my 9:00 A.M. meds. When I get back some of the nurses will not bring me my 9:00 A.M. meds. I have to ask for them and explain why it is ok for me to take my 9:00 A.M. meds even if it is not 9:00 A.M. I especially have to have my [MEDICATION NAME] or my legs go crazy." Resident O indicated some nurses will bring them but some refuse. A physician's orders [REDACTED]. Resident O's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., on 2/2/12, 9:00 P.M. on 2/2/12, and 9:00 A.M. on 2/3/2012. During an interview on 2/16/12 at 3:50 P.M., The DON (Director of Nursing) and Administrator where asked to provide information regarding Resident O's [MEDICATION NAME] not being given as ordered. During an interview on 2/17/2012 at 1:50 P.M., The DON and Administrator indicated no further documentation was available to explain why resident O did not get the ordered [MEDICATION NAME]. 3.1-48(c)(2)