Every finding on record at Celebrate Senior Living of Fort Wayne

Based on observation, interview, and record review the facility failed to ensure dignity for 4 of 5 residents reviewed. (Resident 3, Resident 11, Resident 16, and Resident 54)Findings include: 1) Resident 3's record review began on 4/12/2026 at 11:31 AM. Diagnosis included lung disease, heart disease, and diabetes.In an interview, on 4/13/26 at 10:03AM, Resident 3 complained of staff not knocking on doors prior to entering.2) Resident 11's record review began on 4/12/2026 at 10:02 AM. Diagnosis included lung disease and anxiety.In an interview, on 4/13/26 at 10:03AM, Resident 11 complained of staff not knocking on her door prior to entering.3) Resident 16's record review began on 04/14/2026 at 2:25 PM. Diagnosis included lung disease, hypertension, and depression.In an interview, on 4/13/26 at 10:03AM, Resident 16 complained of staff not knocking on her door prior to entering. 4) Resident 54's record review began on 04/12/2026 at 11:07 AM. Diagnosis included hypertension and schizophrenia. During an observation, on 04/12/2026 at 9:57 AM, Certified Nursing Assistant 5 (CNA) came into Resident 54's room without knocking, introducing herself, or asking permission to enter. CNA 5 asked Resident 54 if she was ready to shower. Resident 54 responded explaining her legs were hurting. CNA 5 stated, it smells like you need a shower. I will be back. Resident 54 put blanket over her head and did not respond. During a continuous observation on 04/14/2026 starting at 8:05 AM through 8:27AM the following was observed: At 8:09AM CNA 6 walked into a room in north hall and picked up a meal tray without knocking or announcing herself. At 8:18AM Licensed Practical Nurse (LPN) 4 walked into room [ROOM NUMBER], called out a resident name without knocking, announcing herself, or asking for admittance. CNA 6 walked in behind her and got a meal tray from within the room without speaking at all and exited the room. At 8:20AM Transportation staff walked into room [ROOM NUMBER] without knocking, announcing themselves, or asking for admittance. Upon exiting, she walked into room [ROOM NUMBER] without knocking, announcing herself, or asking for admittance. Upon exiting, she walked to room [ROOM NUMBER]. She walked in without knocking, announcing herself, or asking for admittance. A policy titled, Resident Rights Policy, dated 12/24 was provided by the Administrator on 4/15/26 at 11:33AM. The policy indicated.Residents have the right to dignity and respect. Be treated with consideration, respect, and full recognition of dignity and individuality. 410 IAC (Indiana Administrative Code) 16.2 3.1-3(a)

Based on record review and interview the facility failed to provide the bed hold notification to 2 of 5 residents reviewed. (Resident 3 and Resident 6)Findings include:Resident 3's record review began on 04/12/2026 at 11:31 AM. Resident 3's diagnosis included diabetes, lung disease, and stroke.Resident 3 was sent to the hospital on the following dates according to his census; 7/1/25, 7/14/25, 8/14/25, 8/26/25, and 12/29/25.One hospital nursing transfer form was available to review. The form was dated for the hospitalization 7/14/25 and included demographics, transfer details, key clinical information, key contacts, and bed hold notice.The nursing transfer form and bed hold notice was not available for review related to hospitalizations on 7/1/25, 8/14/25, 8/26/25, and 12/29/25.A review of Resident 3's progress notes did not indicate a bed hold notice was discussed or given on the dates of 7/1/25, 8/14/25, 8/26/25, and 12/29/25 hospitalizations or within the 24 hours following.2. Resident 6's record review began on 04/12/2026 at 11:41 AM. Resident 6's diagnosis included Cerebral Palsy, malnutrition, and constipation.Resident 6 went to the hospital on the following dates according to her census 5/18/25, 6/2/25, 7/16/25, and 2/11/26.Resident 6 did not have any nursing transfer forms for review for the dates of 5/18/25, 6/2/25, 7/16/25, and 2/11/26 in her medical record.Resident 6 did not have any progress notes to indicate a bed hold notice was discussed or given on the dates of 5/18/25, 6/2/25, 7/16/25, and 2/11/26 or within 24 hours. In an interview, on 4/13/26 at 1:21PM, the Administrator indicated she could scan in the notice of transfer or discharge that included the bed hold policy but the notices did not require a signature or proof of receipt from resident or resident representative to have them in medical record.In an interview, on 04/13/2026 at 2:02 PM, Nursing Supervisor 2 indicated staff made a copy of the bed hold when staff send the resident out. Then staff keep the notices in a binder. The facility was under the understanding this was proof of receipt of the bed hold policy. There were no other documentation and no signatures on bed hold notices provided. A policy titled, Transfer Discharge, undated was provided by the Administrator on 4/15/26 at 11:33AM. The policy indicated.Bed hold policy was also required at time of transfer or, in case of emergency within 24 hours. No state rule applies.

Based on observation, interview, and record review, the facility failed to ensure proper labeling and dating for tube feeding for 1 of 1 resident reviewed (Resident 6).Findings include:During an observation, on April 12, 2026, at 10:40 AM, Resident 6 was observed in her room. Her tube feeding bag was not labeled or dated to indicate when it was hung. The tube feed flush syringe was dated 04/10/2026.During an observation, on April 12, 2026, at 10:54 AM, Resident 6 was observed in her room. Her tube feeding bag was not labeled or dated to indicate when it was hung. The tube feed flush syringe was dated 04/10/2026.Resident 6's record was reviewed on April 13, 2026, at 12:14 PM. Diagnoses included cerebral palsy and severe protein calorie malnutrition.A physicians orders, dated 5/23/2024, included a regular, pureed textured, and thin consistency diet. An enteral feeding order, dated 10/6/2025, indicated to administer Vital 1.5 calorie (cal) at 30 milliliters (ml) per hour with a fluid flush of 100 ml while running continuously every 2 hours every shift for nutritional supplement.In an interview, on April 12, 2026, at 1:39 PM, the Assistant Director of Nursing (ADON) indicated she watched the nurse hang the tube feeding otherwise, she would not have known when it was hung. The ADON indicated the facility labeled and dated the tube feeding. The ADON indicated the nurse may have been busy and forgot to make a label for the feeding.Vital 1.5 cal instructions for use were provided by the Director of Nursing (DON) on April 15, 2026, at 11:41 AM. The instructions indicated, once opened, reclose, refrigerate, and use within 48 hours.A current policy, titled General Guidelines for Administering Medication Via Enteral Tube, dated 10/2024, was provided by the Administrator on April 13, 2026, at 10:04 AM. The policy indicated the manufacturer's written recommendations regarding suggested time period for hanging of the product are consulted when determining the schedule for enteral feeding administration.410 IAC (Indiana Administrative Code) 3.1-44(a)(2)

Based on observation, interview, and record review the facility failed to ensure proper technique during wound care treatment for 1 of 1 residents reviewed. (Resident 4)Findings include:During an observation, on 04/14/2026 at 10:09 AM: Employee 2 set up the supplies with no clean barrier between the supplies and the bedside table. She picked up a stack of 4x4 gauze pads from the treatment cart with bare hands and then placed the pads on the table. Employee 2 then donned a protective gown, sanitized her hands, and donned gloves. The 4X4 gauze was removed from the wound bed, gloves were removed, hands sanitized and gloves donned. Santyl cream (an agent to remove dead tissue) was applied to wound bed, then wet gauze soaked in Dakins (a wound care solution to decrease infective material in the wound) was packed into the wound. The wound was then covered with an Allevyn foam dressing.Resident 4's record was reviewed on 04/14/2026 at 12:00 PM. Diagnoses included Multiple Sclerosis, chronic pain, and decreased mobility.A review of Resident 4's current quarterly MDS indicated their BIMS was 15 (cognitively intact).A review of Resident 4's current care plan, titled Pressure Ulcer, indicated the resident had a problem of pressure ulcer infections, with a goal date of 03/27/2026. Interventions included administer supplements as ordered, monitor changes in skin status, and monitor nutritional status.A review of physician orders, dated 04/07/2026 at 12:00 PM, indicated Resident 4 received mighty shakes with meals (Protein fortified supplement), prostat (protein supplement) four times daily, and Dakins solution for wound care.A review of progress notes, dated 04/15/2026, indicated Resident 4 had an infection in their wound in January, February, and March 2026.In an interview, on 04/14/2026 at 1:15 PM, Employee 2 indicated they should have used a barrier between the table and supplies, and should not have picked up the 4x4 gauze with an ungloved bare hand.A current policy, dated 04/15/2026, indicated dressings should be changed using clean technique unless sterile technique is specified in the physician order.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's daily refusal of prescribed medication for 1 of 3 residents reviewed (Resident T).Findings include:On 11/17/25 at 2:00 p.m., Resident T's record was reviewed. Diagnoses included schizophrenia, heart failure, high blood pressure, and overactive bladder.A quarterly Minimum Data Set (MDS) assessment, dated 9/17/25, indicated Resident T had no cognitive impairment nor indicators of delirium. She had mood indicators of feeling down, depressed, and hopeless; trouble sleeping; feeling tired with little energy; and poor appetite or overeating almost every day. She had no indicators of psychosis, behaviors, nor rejection of care. She was frequently incontinent of bladder and was prescribed diuretics (water pills).Care plans indicated Resident T was prescribed anti-hypertensive and diuretic medications to treat high blood pressure. Interventions included giving the medications as ordered and monitoring side effects. The resident had behaviors including frequently refusing medications. Staff were to notify the physician of changes or increase in behaviors.A physician's progress note, dated 10/10/25, indicated Resident T had been seen by the Nurse Practitioner (NP) due to abnormal kidney function. The resident had lab work completed on 10/8/25. The lab results were creatinine elevated at 2.17. The resident did not have a history of chronic kidney disease, and her baseline creatinine was <1.0. During the visit, the abnormal lab results were discussed with the resident, and she was informed her current medication regimen would be adjusted and medications affecting her kidneys would be held. When asked, the resident denied any urinary tract infection (UTI) related symptoms. The plan was to obtain a urinalysis, discontinue her Ibuprofen, hold Losartan (blood pressure medication) and Spironolactone (water pill) for 5 days. Staff were to continue monitoring her.A nursing progress note, dated 10/10/25 at 12:23 p.m., indicated Resident T was seen by the NP and new orders received to collect a urinalysis for a diagnosis of Acute Kidney Injury (AKI), hold Losartan and Spironolactone for 5 days.An article, titled Creatinine and Acute Kidney Injury was retrieved from kidney.org on 11/17/25 at 3:25 P.M. The article indicated creatinine was a waste product from digestion of protein in food and normal breakdown of muscle tissue. It is removed from blood through the kidneys. Too much creatinine in the blood can be a sign of possible kidney problems. AKI was a sudden episode of kidney failure or damage that happens within a short period of time. AKI causes a build-up of waste products in the blood. This build up can affect other organs such as the brain, heart, and lungs. There are several causes of AKI including side effects of medications, or direct damage to the kidney or blockage of the urinary tract. Tests used to diagnose and investigate the cause of AKI include urinalysis which is a urine test used to find signs of kidney disease and kidney failure.Review of Medication Administration Records (MAR), dated September 2025, indicated Resident T had refused her oral medications, including Losartan and Spironolactone every day in September except 1 day. The MAR indicated she took her dose of Losartan on 9/26/25.A MAR, dated October 2025, indicated Losartan and Spironolactone were held 10/10/25 through 10/14/25 as ordered. Resident T took 1 dose of Losartan on 10/20/25 but refused the medication all other days of the month. She refused Spironolactone every day in the month of October.A MAR, dated November 2025, indicated the resident had not taken any oral medications, including Losartan and Spironolactone, from 11/1 through 11/17/25.There was no documentation completed, indicating the physician or NP had been notified of the residents refusal of oral medications, including refusals of Losartan and Spironolactone, in September, October, or November 2025. The NP treated Resident T's acute kidney injury in October 2025 by holding her doses of Losartan and Spironolactone from 10/10-10/14/25, however, the resident hadn't been taking the medications prior to or after the medications were held.On 11/18/25 at 12:44 P.M., the NP was interviewed. He indicated he was aware of Resident T's occasional refusal of medications but had not known the resident was not taking her medications routinely as ordered. He indicated he ordered her Losartan and Spironolactone held for 5 days, 10/10-10/14/25, to see if the medications had contributed to the rise in her blood creatinine. He had not been aware the resident had refused these medications months prior to or after the medications were ordered to be held.In a confidential interview, staff member 2 indicated ordering providers were to be notified of resident's refusal to take prescribed medication.During a confidential interview, staff member 3 indicated when a resident refused a medication, the MAR would be marked with a 2 meaning refusal and a note documented in the nurse progress notes. The NP or doctor would be notified and documented in the nurse progress notes. A current facility policy, titled Change in a Resident's Condition or Status, was provided by the Director of Nursing on 11/18/25 at 2:24 P.M. The policy indicated staff would promptly notify the attending physician of changes in the resident's medical/mental condition and/or status. The nurse was to notify the resident's physician when there had been a refusal of treatment or medications 2 or more consecutive times.This Citation relates to Intake 2646144.3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure labs were completed as ordered by the physician for 1 of 3 residents reviewed (Resident T).Findings include:On 11/17/25 at 2:00 p.m., Resident T's record was reviewed. Diagnoses included schizophrenia, heart failure, high blood pressure, and overactive bladder.Care plans indicated Resident T was prescribed anti-hypertensive and diuretic medications to treat high blood pressure. She was at risk for fluctuations in fluid balance and complications from bladder incontinence. Interventions included obtaining and monitoring lab/diagnostic work as ordered.A physician order, dated 10/10/25, was to collect a urinalysis (UA) for culture and sensitivity.A physician's progress note, dated 10/10/25, indicated Resident T had been seen by the Nurse Practitioner (NP) due to abnormal kidney function. The resident had lab work completed on 10/8/25. The lab results indicated blood creatinine level was elevated at 2.17. The resident did not have a history of chronic kidney disease, and her baseline creatinine was <1.0. When asked, the resident denied any urinary tract infection (UTI) related symptoms. The plan included obtaining a urinalysis to check for possible causes of her elevated blood creatinine level.An article, titled Creatinine and Acute Kidney Injury (AKI) was retrieved from kidney.org on 11/17/25 at 3:25 P.M. The article indicated too much creatinine in the blood could be a sign of possible kidney problems. AKI was a sudden episode of kidney failure or damage within a short period of time. AKI causes a build-up of waste products in the blood, affects other organs such as the brain, heart, and lungs. There are several causes of AKI including side effects of medications, direct damage to the kidney or blockage of the urinary tract. Tests used to diagnose and investigate the cause of AKI include urinalysis (a urine test used to find signs of kidney disease and kidney failure).A nurse progress note, dated 10/16/25 at 4:02 p.m., indicated the UA results were in and no pathogens (disease causing organisms) were detected. The Nurse Practitioner (NP) was notified with no new orders given.A lab report, dated 10/16/25, was provided by the Director of Nursing (DON) on 11/18/25 at 12:32 P.M. The report indicated there were no organisms detected in Resident T's urine test. The DON indicated only a culture and sensitivity was done on the urine and not a urinalysis as ordered by the NP but should have been. The DON indicated the specialty lab where the urine test had been sent, detected only pathogens in the urine but didn't process urinalysis tests.On 11/18/25 at 12:44 P.M., the NP was interviewed. He indicated he had ordered a urinalysis with culture and sensitivity if indicated as follow-up to the residents abnormal blood creatinine level. When asked, he indicated, the facility used a special laboratory, able to detect pathogens in the urine as well as best medications to use in treating the organisms. He indicated his understanding from the laboratory, was urinalysis would be completed in addition to detection of pathogens. A facility policy, provided by the nurse manager on 11/19/25 at 10:14 A.M., indicated the facility would obtain laboratory services through licensed laboratories, upon the order from a facility medical provider. Nursing staff would initiate providers orders, ensure timely collection, and collect specimens as ordered per the nurse's scope of practice.This Citation relates to Intake 2646144.

Based on observation, interview and record review, the facility failed to ensure treatment for a non-pressure related wound was completed as ordered for 1 of 3 residents reviewed (Resident K).Findings include:On 7/30/25 at 11:10 A.M., Resident K was observed seated in his electric wheelchair, his right leg dressed with an ace wrap from his toes to his knee. His toes were covered with a white thick bandage coming loose out from below the ace wrap. Resident K indicated he was very upset about his toes being amputated. He'd already lost his left leg (below left knee amputation) due to a wound and now, had lost all the toes on his right foot. He indicated he developed a sore to his outer right foot, by his 5th toe, the sore became infected and the toe had to be removed. The surgical site, where the 5th toe had been removed, got infected, split open and he had to go back to the hospital to have it repaired. He indicated the infection continued and he had to have his 2 remaining toes amputated. He was worried about having the entire foot amputated.On 7/30/25 at 1:29 P.M., Resident K's record was reviewed. Diagnoses included diabetes with neuropathy (nerve damage), osteomyelitis (bone infection) of right ankle and foot, peripheral vascular disease, and acquired absence of right foot toes.An annual Minimum Data Set (MDS) assessment, dated 5/27/25, indicated the resident had no cognitive impairment. He required set-up assistance with his activities of daily living (ADL). He was non-ambulatory due to below knee amputation to his left leg and required supervision for transfers to/from electric wheelchair and to/from toilet and bed. The assessment indicated he had no pressure ulcers or non-pressure related skin conditions such as diabetic, arterial, or venous ulcers, and no open skin lesion(s) to his feet. Care plans indicated the following:-Initiated 5/6/25: Resident K had a diabetic ulcer to his right outer foot due to diabetes. The goal was for the diabetic ulcer to heal without complications. Interventions included: Monitor and document the wound measurements; document progress in wound healing; monitor/document/report to physician signs/symptoms of infection; and provide treatments as ordered.A wound Nurse Practitioner (NP) progress note, dated 5/5/25, indicated Resident K was seen for a newly developed right foot wound. The wound was located on the lateral edge of his right foot; 80% of the wound was covered with eschar and measured, length (L) 0.5 centimeters (cm) by width (W) 1.0 cm. There was a small amount of serosanguinous (blood and clear liquid) drainage at the wound site and dried blood observed on his sock. The wound was assessed as a diabetic ulcer and treatment ordered. An x-ray of his foot was to be done to rule out a bone infection (osteomyelitis).A Wound Assessment, completed by the facility wound nurse, dated 5/5/25 at 10:22 p.m., indicated Resident K had a wound to his outer right foot which measured, (L) 0.5 cm by (W) 1.0 cm. The wound was 100% covered with black eschar (dry, dead tissue within a wound). There was no drainage, wound edges were regular and peri-wound was intact, dry, scaly and swollen. Resident K denied pain during treatment. Additional comments indicated the wound was a new area and assessed by the nurse and NP. Dressings were in place and new orders given for x-ray of the foot and antibiotics ordered. Wound assessments would be completed weekly until healed.A physician order, dated 5/5/25, was to wash wound to the right outer foot with wound cleanser, pat dry, apply Silver AG and cover with a foam dressing to be done daily.A medical NP progress note, dated 5/5/25, indicated the resident was seen for right foot cellulitis (infection of subcutaneous skin). Resident K had been seen by the wound NP. An antibiotic (Doxycycline) was ordered as well as x-ray to rule out osteomyelitis. His right foot was observed to have localized swelling, redness and warmth. The resident complained of some discomfort to the area.A Wound Assessment, completed by the facility wound nurse, dated 5/12/25 at 2:16 p.m., indicated Resident K's outer right foot wound measured (L) 2.0 cm by (W) 2.0 cm. The wound was 100% covered with black eschar. There was no drainage, wound edges were regular and peri-wound was intact, dry, scaly and swollen. The wound had worsened. There were no new orders and staff were to continue with the current treatment plan.A wound Nurse Practitioner (NP) progress note, dated 5/12/25, indicated Resident K's wound to his right foot, lateral edge, was covered with 90% eschar, measured L-2.0 cm by W-2.0 cm, was larger and the wound was worsening. The wound continued to have serosanguinous drainage and small amount of dried blood was observed on his sock. The plan was to continue the current treatment of washing the wound with wound cleanser, pat dry, apply Silver AG and cover with a foam dressing daily.A hospital Discharge summary, dated [DATE], indicated Resident K had been hospitalized 5/15-5/21/25 for syncope (fainting) and chest pain. The resident admitted to the hospital on [DATE] with a wound to his right foot.A re-admission nurse note, dated 5/21/25 at 3:44 p.m., indicated Resident K had returned from the hospital. He had a wound to his left (sic) foot toe. There was no further assessment completed for the wound.A Treatment Administration Record (TAR), dated May 2025, had no documentation of treatment completed to his right outer foot wound from 5/5/25 through 5/28/25. A treatment was started on 5/29/25. On 7/31/25 at 1:45 P.M., the facility wound nurse was interviewed. She indicated the order for Resident K's right foot wound, dated 5/5/25, had been on the physician order summary but she had not been aware the order hadn't made it onto the TAR. She indicated she had done the treatment as ordered on days she did rounds with the wound NP but wasn't able to say if other staff had done the treatment. The facility wound nurse indicated the wound treatment should have been done daily as ordered. On 8/1/25 at 11:54 A.M., the Director of Nursing provided a current copy of the facility policy, titled Wound Care. The policy was for both non-pressure related wounds and pressure ulcers. The policy indicated wound care procedures and treatments should be performed according to physician orders. Treatments were to be documented in the clinical record when treatments were performed.This Citation relates to Complaint 1774339.3.1-37

Based on interview and observations the facility failed to ensure sanitation measures were followed for 2 of 3 observations. 71 of 71 residents who resided in the facility received food prepared in the kitchen. Findings include: During an observation on 4/28/25 at 9:30 AM, a medal scoop was observed inside a tub of brown sugar. There was debris of grease like food around and under the sink. There were dried noodles, raisins and plastic debris observed under the racks in the pantry. There were small pieces of paper, dust in the corners, and unidentifiable small particles observed in the chemical room on the floor. During an observation on 4/29/25 at 10 AM, there were small cereal particles, dried meat of different shapes/sizes observed under the stand-up cooler, meal carts and stove area. In an interview on 4/28/25 at 9:30 AM, the Dietary Manager (DM) indicated the facility did not have a cleaning schedule. DM indicated the scoop from the brown sugar tub should not be left inside the tub. The DM indicated there should not be debris or dried particles on the floor or around/under the sink and appliances. In an interview on 4/30/25 at 2:03 PM, the Director of Nursing (DON) indicated the facility did not have a policy regarding sanitation in the kitchen. The DON indicated 71 of 71 residents received food prepared in the kitchen. 3.1-(i)3

Based on observation, interview, and record review the facility failed to ensure dignity was maintained for 1 of 18 residents reviewed. (Resident 52) Findings include: During an observation on the secured unit, on 4/28/25 at 10:11 AM, Licensed Practical Nurse (LPN) 4 was heard yelling from across the hall inside room [ROOM NUMBER] to another staff member at the nurses' station. LPN 4 yelled over to the other staff member at the station, Resident 52 has a boil the doctor wants to take a look at; he has to be laid down. There were 3 unidenified residents in close proximity to room [ROOM NUMBER] and could hear LPN 4. During an observation, on 04/28/25 at 10:22 AM, LPN 4 was easily overheard telling the Wound Nurse Practitioner Resident 52 was now laying down if she also wanted to look at the boil. In an interview, on 4/30/25 at 10:05 AM, the Unit Manager of the secured unit indicated LPN 4 was disciplined for his inappropriate behavior. The Unit Manager indicated the facility recently held an in-service regarding resident rights but LPN 4 did not attend the in-service. A record review on 4/30/25 at 1:15PM, indicated Resident 52's diagnosis included dementia, unspecified A current policy, titled Resident Rights dated 12/2024, indicated . 1. Dignity and Respect. Be treated with consideration, respect and full recognition of dignity and individuality. 5. Privacy and Confidentiality. Personal and medical information must be kept confidential. Residents are entitled to privacy in care, communication, and personal space . 3.1-3(a)

Based on interview and record review the facility failed to report a fall with a fracture to the Indiana Department of Health (IDOH) for 1 of 3 falls reviewed (Resident H). Findings Include: A facility reported incident was provided by the Administrator on 10/1/24 at 10:14 AM. The report, dated 9/25/24 at 10:01 AM, indicated Resident H was found on the floor in her room in a pool of blood coming from her nose. The report indicated Resident H was sent to the hospital and was found to have a probable subtle acute nondisplaced bilateral nasal bone fracture. Resident H's record was reviewed on 10/1/24 at 1:33 PM. Diagnosis included chronic pulmonary disease and type 2 diabetes mellitus. A nursing note, dated 9/22/2024 at 3:22 PM, indicated Resident H was found on the floor in her room in a pool of blood. The note indicated Resident H had a hematoma to her head and a swollen/bruised nose. The note also indicated Resident H was sent to the hospital. A nursing note, dated 9/22/24 at 10:19 PM, indicated a nurse spoke with the hospital regarding Resident H. The note indicated the nurse was informed Resident H was admitted for a fall, septal fracture and subdural hematoma. An interdisciplinary team (IDT) note, 9/24/24 at 11:05 AM, indicated a meeting was completed with the IDT team to determine the root cause and result of Resident H's fall. During an interview on 9/24/24 at 1:43 PM, the Administrator indicated Resident H fell on [DATE] with the result of a nasal fracture. The Administrator indicated she reported the incident to the IDOH on 9/25/24. The Administrator indicated she should have reported the fall with fracture within 24 hours of being notified of the fracture. A current policy, last reviewed 3/1/20, titled Abuse, Neglect and Exploitation Policy, was provided by the Administrator on 10/1/24 at 2:24 PM. The policy did not indicate when a fall with fracture should be reported. This citation relates to Complaint IN00444048. 3.1 - 28(e)

Based on interview and record review the facility to ensure assessment for elopement risk was completed for 1 of 5 residents reviewed. (Resident 53) Findings include: A record review began on 5/29/24 at 10:41 AM. Resident 53 diagnoses include, unspecified dementia, severe with psychotic disturbance and generalized anxiety disorder. A MDS (minimum data set) assessment, dated 4/8/24, indicated Resident 53 had a BIMS (brief interview mental status) 3 of 15, indicated Resident 53 had severe cognitive impairment. Resident 53's care plan, titled Elopement, dated 4/8/24 indicated Resident 53's focus was high risk for elopement related to dementia. Due to his cognition and poor safety awareness resident would reside on the secure memory care unit. Resident 53's goal was to remain safe within the facility unless accompanied by staff or other authorized persons through the review date. Resident 53's interventions included, but were not limited to: assess, record, and report to physician, risk factors for potential elopement such as wandering, repeated requests to leave facility, statements such as I'm leaving, I'm going home., and/ or attempts to leave facility. Complete an Elopement Risk Assessment per facility protocol, and every quarter, to make changes as needed. Encourage Resident 53 to participate in an activities program to divert attention and meet needs for social, cognitive stimulation. Supervise closely and make regular compliance rounds whenever Resident 53 is wandering around. The following assessments indicated elopement risk: -Dated 5/16/23, quarterly, Elopement Risk decision: the resident presently appears to be at risk to elope and should be placed on the elopement risk protocol, a care plan for elopement was indicated. Resident 53 resided on the secure memory unit. -Dated 12/28/23, Elopement Risk decision: the resident presently appears to be at risk to elope and should be placed on the elopement risk protocol, a care plan for elopement was indicated. Resident 53 resided on the secure memory unit. -Date 3/27/24, quarterly, Elopement Risk decision: the resident presently appears to be at risk to elope and should be placed on the elopement risk protocol, a care plan for elopement was indicated. Resident 53 resided on the secure memory unit. A quarterly elopement risk assessment was not completed between August - October 2023. A quarterly Social Services Progress note, dated 8/15/23, indicated Resident 53 had not wandered, and wandering behavior had not been exhibited. There was no other question in the assessment to pertain to elopement, and or wandering. A review of Resident 53's census list, indicated Resident 53 had an unpaid hospital leave from 10/1/23 and returned on 10/3/23. No other leaves had occurred. In an interview on 5/31/24 at 10:12 AM, the Memory Care Coordinator indicated elopement assessments were present only as elopement risk-not barred in another assessment. She indicated she would look into the resident's missing risk assessment. In an interview 05/31/24 at 10:38 AM, the Memory Care Coordinator and Social Worker indicated the resident did not have an elopement risk assessment done. They were unsure why the assessment had not been completed. A currently facility policy, Elopement management, dated 10/2018, was provided by the Memory Care Coordinator. The policy indicated . Upon admission and re-admissions, resident will be assess for elopement risk by completion of the elopement risk user defined assessment (UDA) in the electronic medical record in conjunction with the nursing admission data collection set .Following admission, residents are evaluated for elopement risk quarterly, annually and with significant change of condition or status using the Elopement Risk (UDA) and the Resident Assessment instrument process (RAI) .Care plan interventions are individualized to the resident and are based on the assessed risk of elopement 3.1-45(a)

Based on interview and record review the facility failed to ensure physician orders were followed for 1 of 4 residents reviewed. (Resident Y) Findings include: A list of facility appointments was received 1/24/24 at 9:32AM from SSD (Social Services Director). Resident Y was listed as having a dental appointment on 12/21/23 at 1pm. The special instructions were typed in all capitals; needs staff member to accompany. An interview on 1/24/24 at 12:15 PM, Driver 7 indicated she only drives on Wednesdays and Fridays. The remainder of her hours were used as a CNA (Certified Nursing Assistant). She indicated the scheduler let the driver know the scheduled appointments and any special instructions at the start of their shift. Driver 7 indicated residents from the dementia care unit and Resident Y always require an escort. She indicated when an escort was needed a second staff person was present and was expected to attend the entire appointment with the resident. Driver 7 indicated Resident Y required an escort because he had brain damage and a seizure disorder. An interview on 1/24/24 at 2:57 PM, People Operations Specialist (POS) from the Dentist office, indicated Resident Y had an appointment on 12/21/23 and was dropped off at 1pm for his appointment. There was no staff to accompany the resident. The driver left and said he would pick Resident Y up by 2PM. She indicated no one showed up. She indicated they made multiple attempts to contact the facility without an answer. The POS indicated they then called Resident Y's sister who came and picked him up. The POS stated the driver returned around 3:30 PM to pick up Resident Y. Resident Y's record review was begun on 1/25/24 at 11:06AM. Diagnoses included epilepsy, schizophrenia, and traumatic brain injury. His current MDS (Minimum Data Set) showed a BIMS (Brief Interview for Mental Status) score of 6. A score of 6 indicated moderate cognitive deficiency. Resident Y had a verbal physician order dated 12/4/23; Appt with [NAME] Dental @ 1pm NEEDS STAFF MEMBER to ACCCOMPANY one time only for 1 day. The order start and end date were 12/21/23. In an interview on 1/25/24 at 9:17AM, Driver 8 indicated he took Resident Y to the dentist appointment on 12/21/23. He indicated he would get an assignment sheet with the appointments and any special instructions. He indicated he was unsure if Resident Y was supposed to have an escort. He indicated he had multiple appointments 1/21/23 around the same time. He dropped off Resident Y and then took a peer to an ortho appointment with the intent to return at the conclusion of peer's appointment. He received a call from the facility, Resident Y was finished at the dentist and the family was upset he was left waiting. Driver 8 left peer at the ortho appointment to go pick up Resident Y who was no longer at the dentist upon his arrival. Current facility policies titled: Telephone Orders, Medication and Treatment Orders, and Medication Orders were received from the SSD on 1/25/24 at 11:35AM. None of the policies directly indicated following orders. No policy or further information was available at time of exit. This citation is realted to coimplaint IN00424579. 3.1-37

Based on observation, interview, and record review the facility failed to ensure fall prevention measures were in place for 3 of 4 residents reviewed. (Resident B, Resident C, and Resident D) Findings included: In an observation of Resident B and Resident C, on 1/24/24 at 9:52 AM, they were sitting on a couch. The couch had its back to the dining room tables. The couch area and dining room had the same flooring. Resident B and Resident C had on the same pair of fuzzy socks. The socks had no anti slip or grip to them. During an observation of Resident D on 1/24/24 at 9:52AM, Resident D was noted sitting in his wheelchair at a dining room table with staff. Resident D also had on fuzzy socks. The socks had no anti slip or grip to them. In an interview on 1/24/24 at 10:06 AM, CNA 6 (Certified Nursing Assistant) indicated all the residents should be wearing nonslip footwear unless laying in bed to prevent falls. During an observation on 1/24/24 from 9:52AM to 10:12AM there was no attempt by staff to ensure nonskid footwear was on the residents. 1) Resident B's record was reviewed 1/24/24 at 1:06PM her diagnoses included Alhzeimer's disease, diabetes, and edema. Resident B's current care plan indicated a focus on falls; Resident B was at high risk for falls related to age, impaired mobility, impaired cognition, incontinent episodes, use of high fall risk medications, dementia, pain, and gout. This was last updated 4/8/23. The most recent goal dated 10/7/23, indicated Resident B would not sustain serious injury through next review date. Interventions indicated to encourage use of appropriate nonskid footwear at all times and ensure she had on proper footwear- nonskid socks when in dining room. Resident B's current comprehensive MDS (Minimal Data Set) BIMS (Brief Interview of Mental Status) score was 5. The score of 5 indicated moderate cognitive decline. 2) Resident C's record was reviewed, 1/24/24 at 12:08PM, her diagnoses included lung disease, repeated falls, dementia, and schizoaffective disorder. Resident C's care plan indicated a focus of at risk for falls related to history of falling, decreased mobility, decreased safety awareness, medication usage, incontinence, disease process, and weakness. The goal indicated Resident C would not sustain serious injury through the review date. The interventions were to ensure the resident was wearing appropriate non skid footwear when ambulating or mobilizing in the wheelchair. Resident C's current comprehensive MDS (Minimal Data Set) BIMS (Brief Interview of Mental Status) score was 2. The score of 2 indicated severe cognitive decline. 3) Resident D's record was reviewed, 1/24/24 at 2:15PM, his diagnoses included dementia, restlessness, agitation, and history of falls. Resident Ds care plan indicated a focus of at risk for falls related to a history of falling, decreased mobility, decreased safety awareness, medication usage, agitation, aggression, incontinence, disease process, and weakness. The goal was Resident D would not sustain serious injury through the review date. The interventions for this goal were to ensure the resident was wearing appropriate non skid footwear when ambulating or mobilizing in the wheelchair. Resident D's current comprehensive MDS (Minimal Data Set) BIMS (Brief Interview of Mental Status) score was 5. The score of 5 indicated moderate cognitive decline A policy titled, Fall Occurrence Policy last revised 6/7/22 was provided by the Director of Nursing on 1/24/24 at 2:59PM. The policy stated 2. Those identified as high risk for falls will be provided fall interventions .6. The nurse may immediately start interventions to address falls on the unit .10. The interventions will be reevaluated and revised as necessary. This citation is realted to Complaint IN00425711. 3.1-45

Based on interview and record review, the facility failed to ensure an employee had met the certification requirements to provide resident care as a Certified Nurse Aide. 79 residents lived in the facility. An anonymous complaint to the Indiana Department of Health indicated there was a concern for an unqualified staff member (Employee 3) who had provided resident care as a Certified Nurse Aide (CNA). A record review was completed on 10/13/23 at 11:21 AM. The facility schedule dated September 2023 indicated Employee 3 had worked as a CNA on 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/8, 9/12, 9/13, 9/15, 9/18, 9/19, 9/20, 9/22, 9/26, 9/27 and 9/29.The facility schedule dated October 2023 indicated Employee 3 had worked as a CNA on 10/2, 10/3, 10/4, 10/6, 10/7, 10/8, 10/10 and 10/11. The facility employee certification and licensure binder indicated Employee 3 did not have a certification to practice as a Certified Nurse Aide. The Indiana Certified Nurse Aide Registry did not indicate Employee 3 had a certification to practice as a CNA. Employee 3's employee file indicated Employee 3 had not completed the facility orientation skills checklist. The facility orientation checklist did not indicate a hire date for Employee 3. A CNA test dated 10/4/22 indicated Employee 3 had not passed the skills evaluation portion of the Nurse Aide Competency Evaluation. The Facility Assessment Tool indicated the facility provided competency training upon hire and annually. The Facility Assessment Tool indicated facility staff certification and licensure requirements would be maintained as applicable. In an interview on 10/13/23 at 12:47 PM, the Administrator indicated the facility did not have a CNA testing policy. The facility was aware Employee 3 had not passed their first attempt for certification as a CNA. The Administrator indicated they were aware of the CNA requirement of passing the certification test with 120 days of the CNA course completion. The Administrator indicated they had believed Employee had scheduled another CNA test, but it was outside the 120 day requirement. The Administrator indicated they had attempted to reach Employee 3 to clarify if Employee 3 had tested again. The Administrator indicated they were awaiting a return call from the CNA testing facility in relation to Employee 3's further test attempts. This citation is related to complaint IN00417716. 3.1-14(i)

Based on observation and interview, the facility failed to ensure respect and dignity of personal belongings was maintained for 1 of 6 residents reviewed (Resident B). Findings include: During an observation 8/29/23 at 9:53 AM, there were 2 full black trash bags laying on Resident B's floor. In an interview on 8/29/23 at 9:53 AM, Resident B indicated the majority of her clothes were in 2 black trash bag laying on the floor due to not having access to the full wardrobe. Resident B indicated this made her feel like my personal belongings were trash. In an interview on 8/29/23 at 2:08 PM, the Social Worker indicated when Resident B moved into the current room the facility staff was supposed to put in a dresser for Resident B since the wardrobe was inaccessible. The Social Worker indicated she was unsure why the dresser had yet to placed in Resident B's room [ROOM NUMBER]-11/2 months later. The Social Worker indicated Resident B's personal belongings should not have been placed on the floor in trash bags. A record review was completed on 8/29/23 at 1:22 PM. Resident B's diagnoses included: paraplegia and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, dated 6/12/23, indicated Resident B had a Brief Interview Mental Status score of 15/15 (cognitively intact). An admission MDS assessment, dated 12/12/22 indicated Resident B preferences: taking care of personal belongings was very important. A current policy, dated October 2022, titled Resident Rights, was provided by the Administrator on 8/29/23 at 3:14 PM. The policy indicated residents have the right to dignity, self-determination and person-centered care. This Federal citation is related to Complaint IN00415489. 3.1-9(a)

Based on observation, interview, and record review the facility failed to ensure activities of daily living (ADL) were provided per resident's preference for 1 of 6 residents reviewed (Resident B). Finding include: 1. In an interview on 8/29/23 at 9:53 AM, Resident B was observed in her bed. Resident B indicated she preferred 3 showers weekly: Monday, Wednesday, and Friday. Resident B indicated she had not received her showers at least 3 times a week. A record review was completed on 8/29/23 at 1:22 PM. Resident B's diagnoses included: paraplegia and major depressive disorder. An order, dated 7/2/2023, indicated Resident B received showers Monday, Thursday and Sunday evening shift for personal hygiene. The Treatment Administration Record (TAR) and point of care report for Resident B, dated 8/1/23- 8/28/23, were provided by the Social Worker on 8/29/23 at 2:14 PM. The point of care report indicated Resident B received showers on Monday, Wednesday and Friday evenings. The reports indicated Resident B did not receive a shower at least 3 times during the following weeks: 8/6/23 - 8/12/23 A quarterly Minimum Data Set (MDS) assessment, dated 6/12/23, indicated Resident B had a Brief Interview Mental Status score of 15/15 (cognitively intact). The MDS indicated Resident B required total assistance with bathing and 2 people assisted. In an interview on 8/29/23 at 9:53 AM, Resident B also indicated she had not gotten up or offered by staff to get out of bed since she moved into her current room about 1-11/2 months ago. Resident B indicated she wanted to get up out of bed. A quarterly Minimum Data Set (MDS) assessment, dated 6/12/23, indicated Resident B required total assistance with transferring and 2 people assist. A point of care report, dated 8/1/23-8/28/23, was provided by the Social Worker on 8/29/23 at 2:14 PM. The report indicated Resident B was provided total dependent assistance by staff daily for transferring. 2. In an interview on 8/29/23 at 2:08 PM, the Social Worker indicated Resident B refused to get out of bed. The Social Worker indicated she had not seen Resident B get out of her bed since admission. In an interview on 8/29/23 at 10:50 AM, Certified Nurse Aide (CNA) 2 indicated showers/bathing were offered 2 times a week or by preference and dependent on staff schedule. Resident B was dependent on all ADLs, including bathing and transferring. CNA 2 also indicated Resident B did not get up out of bed. CNA 2 indicated she never offered Resident B to get up out of bed. CNA 2 also indicated Resident B did not refuse care. In an interview on 8/29/23 at 2:47 PM, the Director of Nursing (DON) and Social Worker indicated staff should not be documenting care the resident did not receive. The DON and Social Worker also indicated staff should document refused instead of Not Applicable when the resident refused. The Social Worker indicated she did not have any documentation of Resident B's refused care or refusal to get up. A policy, dated October 2022, titled Resident Rights, was provided by the Administrator on 8/29/23 at 3:14 PM. The policy indicated residents have the right to dignity, self-determination and person-centered care. This Federal citation is related to Complaint IN00415489. 3.1-38(a)(3)

Based on observation, interview, and record review the facility failed to ensure adequate supervision to support smoking for 4 of 4 residents reviewed. (Resident 43, Resident 4, Resident 51, and Resident 33) Findings include: During an observation, Resident 51, Resident 4, and Resident 33 were observed in courtyard smoking on 05/30/23 at 10:54 AM. Resident 51 required guidance (he held onto staff's shoulder and walked slightly behind her) out to the courtyard and his cigarette lit. Resident 51 then sat with Resident 4 and Resident 33 between him and the staff member. When Resident 51 was finished smoking he wiped ashes off of his clothes prior to being led back into the building. Resident 4 and Resident 33 remained in the courtyard. The staff member did not return after taking Resident 51 back into the building. Resident 33 was handing Resident 4 his stubbed cigarette after tapping it on his walker. Resident 33 dropped the blunted end of the cigarette on Resident 4's lap. There was no fire protection wear worn or visibly available during the observation of Resident 51, Resident 4, and Resident 33. During an observation, on 05/31/23 at 2:08 PM, 3 unidentified female residents were outside smoking in the courtyard. There were no staff present or within eyesight of the courtyard. There was no fire protection wear on the residents or visibly available to wear. In an interviewon 5/31/23 at 2:13PM, CNA 5 (Certified Nursing Assistant) identified Resident 43 as among the female smokers. The CNA indicated staff were to monitor while residents were smoking. CNA 5 indicated management remind them frequently to stay in courtyard when residents were smoking. The CNA further indicated Resident 43 did not follow rules and did what she wanted. On 5/30/23 at 11:16AM the ED provided a list of smokers as requested. Resident 43 was not listed as a smoker in the facility. The ED (Executive Director) indicated when Resident 43 came she was not smoking due to illness. The ED was unable to determine when Resident 43 began smoking again. 1. Resident 43's record was reviewed on 6/1/23 at 9:09AM. Resident 43's diagnoses included chronic pulmonary disease and altered mental status. A review of Resident 43's current MDS dated [DATE] indicated: Section C- BIMS (Basic Interview for Mental Status) score was 11 (mildly impaired). Section G-ADLs (Activities of Daily Living) one-person physical assist for all activities assessed. Section J-Health Conditions indicated no tobacco use. A review of Resident 43's smoking risk assessment dated [DATE] indicated she did not smoke. A smoking risk assessment done on 6/1/23 indicated: A. All residents who smoke must be supervised. B. Smoking Cessation was declined. C. Orientation no problem D. Behavior no problem E. Mobility no problem F. Injury Potential none G. History no problem H. Safety Gear none needed. I. Comments; May independently be able to handle smoking materials. A review of Resident 43's current care plan was updated on 6/1/23. The care plan indicated she used tobacco and was allowed to smoke independently in the courtyard. 2. Resident 4's record was reviewed on 5/30/23 at 10:54 AM. Resident 4's diagnoses included major depressive disorder, muscle weakness, vascular dementia, and history of a stroke. A review of Resident 4's current comprehensive MDS dated [DATE] indicated: Section C- BIMS (Basic Interview for Mental Status) score was 8 (moderately impaired). Section G-ADLs (Activities of Daily Living) one-person physical assist for all activities assessed. Section J-Health Conditions indicated tobacco use. A review of Resident 4's smoking risk assessment dated [DATE] indicated: A. All residents who smoke must be supervised. B. Smoking Cessation was declined C. Orientation no problem. D. Behavior no problem. E; Mobility no problem. F. Injury Potential no problem. G. History no problem H. Safety Gear none needed. I. Comments; 3/14/22 smoke with supervision ensuring hair was pulled away from face. There were no other smoking assessments documented. A review of Resident 4's current care plan dated 4/4/23 indicated the following; she used tobacco, was allowed to smoke independently without complications and the facility only allowed supervised smoking. An intervention was; assess smoking abilities; upon admission, quarterly, and as needed. 3. Resident 51's record was reviewed on 5/31/23 at 11:17AM. Resident 51's diagnoses included legal blindness, encephalopathy, pulmonary disease, and traumatic brain injury. A review of Resident 51's current MDS dated [DATE] indicated: Section C- BIMS (Basic Interview for Mental Status) score was 4 (severely impaired). Section G-ADLs (Activities of Daily Living) two-person physical assist for all activities assessed. Section J-Health Conditions indicated tobacco use. A review of Resident 51's most recent smoking risk assessment dated [DATE] indicated: A. All residents who smoke must be supervised. B. Smoking Cessation was declined C. Orientation minimal problem. D. Behavior no problem. E; Mobility minimal problem. F. Injury Potential minimal problem. G. History no problem H. Safety Gear none needed, and someone was to light his cigarette. I. Comments; 3/14/22 Resident 51 was legally blind and required supervision when smoking. A review of Resident 51's current care plan dated 4/4/23 had a focus on blindness. There was no care planned indication of tobacco use. 4. Resident 33's record was reviewed on 05/30/23 at 09:12 AM. Resident 33's diagnoses included lung disease, muscle weakness, and neurological disease. A review of Resident 33's comprehensive MDS dated [DATE] indicated: Section C- BIMS (Basic Interview for Mental Status) score was 12 (minimally impaired). Section G-ADLs (Activities of Daily Living) one-person physical assist for all activities assessed. Section J-Health Conditions indicated no tobacco use. A review of Resident 33's most recent smoking risk assessment dated [DATE] indicated: A. All residents who smoke must be supervised. B. Smoking Cessation was declined C. Orientation no problem. D. Behavior no problem. E; Mobility no problem. F. Injury Potential no problem. G. History no problem H. Safety Gear none needed. I. Comments: Resident 33 was allowed to smoke independently. A review of Resident 33's current care plan dated 11/14/22 indicated Resident 33 was an active smoker and able to smoke independently without complications. The interventions included assess smoking abilities quarterly, as needed and smoking materials to be kept at the nurse's station. An undated current facility smoking safety policy was provided by the ED, on 6/1/23 at 10:26 AM. The policy indicated . 2. the designated smoking area shall maintain appropriate safety devices including but not limited to; available smoking aprons, extinguishing blanket, and ashtrays made of noncombustible material and safe design. Metal containers with self-closing covers into which ashtrays can be emptied shall be readily available. An updated smoking regulation dated 3/10/22 provided by the ED, on 6/1/23 at 10:26AM indicated smoking schedule 10am-1015am; 1pm-115pm, and 4p-415pm. 1. Smoking breaks would be 15minutes or 2 cigarettes whichever comes first. 2. No borrowing or lending of cigarettes. 3. All smoking material would be kept at the nurse's station. 4. Residents were to provide their own smoking materials. 5. Residents could smoke with visitors in the courtyard but could not take other residents with them. 6. Smoking breaks would be cancelled upon inclement weather related conditions. 7. Smoke times could be affected by whether staff is available. 3.1-45(a)

Based on interview and record review, the facility failed to give proper notice of transfer or discharge before 4 of 4 residents were transferred or discharged . (Resident 2, Resident 51, and Resident 83). Findings include: 1. Resident 2's record was reviewed on 05/31/23 at 2:08 PM. Diagnoses included COPD (chronic obstructive pulmonary disease), presence of cardiac pacemaker, and history of TIA (transient ischemic attack, a stroke lasting a short period of time). A review of Resident 2's current Significant Change MDS (Minimum Data Set) indicated their BIMS (Basic Interview for Mental Status) score was 10 (moderate cognitive impairment). A review of progress notes dated 03/22/23 at 09:17 AM indicated Resident 2 was sent to the hospital from a routine pre-operative appointment due to low blood pressure and confusion. There was no transfer paperwork documented, notice of bed hold policy, or documentation of the facility providing pertinent medical information to the receiving hospital. 2. Resident 51's record was reviewed on 06/01/23 at 02:09 PM. Diagnoses included legal blindness, GAD (generalized anxiety disorder), and major depressive disorder. A review of Resident 51's quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 4 (severe cognitive impairment). A review of physician's orders indicated no orders for transfer to the hospital for evaluation and treatment after a witnessed fall on 02/27/23 at 9:50 AM. A review of progress notes indicated no documentation the Bed Hold Policy was provided to the resident or POA (Power of Attorney) prior to transfer to the accepting facility. In an interview on 06/01/23 at 4:30 PM the DON indicated the facility would send transfer documents with the resident to the hospital. They Indicated no copies were kept for resident records. In an interview on 06/02/23 at 2:25 PM, LPN 6 indicated the transfer on 2/27/2023 was a planned surgical procedure. LPN 6 indicated they did not do a transfer to hospital form but the resident's information was sent to the hospital prior to the procedure. No order to transfer for the planned procedure was present. In an interview on 06/02/23 at 2:30 PM the SSD (Social Services Director) indicated they were not aware a copy of the bed hold policy was to be given with each transfer. A review of Notice of Transfer or Discharge form dated 02/27/23 was provided by LPN 6 at 2:25 PM. There was no address for the receiving facility, the ombudsman information was not filled out, and there was no bed hold policy or pertinent medical information included for the receiving facility. 3. Resident 83's closed record was reviewed on 06/05/23 at 9:25 AM. Diagnoses included PTSD (post-traumatic stress disorder), heart failure, and muscle weakness. A review of progress notes dated 06/05/23 at 9:35 AM indicated Resident 83 was discharged on [DATE] at 07:23 AM. There was no documentation to indicate transfer forms or discharge instructions were completed. In a phone interview on 06/02/23 at 3:01 PM Resident 81 indicated the discharge was facility initiated, and they were given 3 days of notice. There was no discharge paperwork or care plan in place. Resident 83 indicated they signed no paperwork upon leaving the facility, received 3 days of meds, got on a CitiLink bus at 6:30 AM, and went to live with their husband in a motel room. A current Transfer and Discharge policy presented by the DON (Director of Nursing) on 06/02/23 at 2:25 PM indicated the facility will: * Obtain physician order for transfer. * Send the original state transfer/discharge/bedhold notice with the resident and/or representative responsible for care. * Make 2 copies of the health record necessary for care of the resident (physician's orders, history & physical, x-rays, lab work, etc.), and send with the resident/representative. * Fax the transfer order to the pharmacy. 483.15(c)(3-5)

Based on observation, interview and record review, the facility failed to implement COVID-19 prevention precautions. 20 of 80 current residents resided on the South hall. Findings include: A concern submitted to the Indiana Department of Health (IDOH) on 4/9/23, alleged a resident had not been moved when her roommate was diagnosed with COVID-19. The resident then became positive and symptomatic with the infection following her prolonged exposure. The concerned family member indicated they had visited with the resident and after being in the room for several hours, was then told the roommate was ill with COVID-19. The family member indicated there were no signs on the room door to indicate precautions were to be taken when going in the room nor did staff tell the family member their loved one was sharing a room with a COVID-19 positive roommate. The family member wanted his loved one immediately removed and placed in a non-COVID-19 room. An anonymous concern, submitted to IDOH on 4/11/23, alleged COVID-19 positive staff were being instructed to work despite being infected. The concern indicated this resulted in a major outbreak in the facility. On 4/17/23 at 9:30 A.M., on entrance to the facility, there was no signage on or near the main entrance to indicate the active COVID-19 cases in the building. There was no signage posted to alert visitors they should not enter the facility or to take actions when entering relaated to hand hygiene, limiting interactions with others in the facility, restricting visits to resident room, recommended PPE (Personal Protective Equipment) during thier visit, recommended monitoring for signs and symptoms of COVID-19 after thier visit and appropriate actions to take if signs or symptoms occurred. In an interview on 4/17/23 at 9:35 A.M., the receptionist, seated at a desk near the main entrance, indicated she would inform visitors when they entered the facility regarding a COVID-19 outbreak in the facility and required use of face masks during thier visits. When questioned, she indicated she worked 8-4:30 p.m., Monday-Fridays, but didn't know how visitors were informed of an outbreak and required use of masks when she wasn't working. In an interview on 4/17/23 at 9:40 A.M., the Administrator indicated the facility currently had 7 COVID-19 positive residents. Staff and visitors were to wear masks and posted PPE when entering rooms of residents on transmission based precautions (TBP). During initial tour on 4/17/23 at 9:50 A.M., there were resident rooms with red signs on the door indicating staff were to wear N-95 masks, gowns, gloves, and eye protection when entering the room. The signs indicated the door was to be kept closed but the room doors were open. In room [ROOM NUMBER], on the south hall, there was a TBP sign on the open room door. 3 residents resided in the room. 1 resident, near the open door, was observed lying in bed and coughing. During the tour, several staff members were observed wearing masks below their noses. -At 9:52 A.M., a staff member came out of room [ROOM NUMBER]. A sign on the door indicated the resident was on TBP. The room door was open and the staff member wore only a surgical mask, but no other PPE . 4/17/23 at 9:59 A.M., during an interview, Staff 3 indicated they'd recently had COVID-19 infection and had been off work for 8 days due to being very ill. The staff member indicated COVID-19 infections were going around the facility making many staff and residents sick. On 4/17/23 at 12:29 P.M., an unidentified CNA (Certified Nurse Aide) was observed to walk into room [ROOM NUMBER] wearing a surgical mask only, no other PPE per TBP had been donned. She wasn't observed to perform hand hygiene. She removed a shower chair from the room, brought the chair down the hallway and into another resident room without cleaning the chair. During a confidential interview, Staff 5 indicated staff were not using required PPE when going into COVID-19 positive rooms. Staff would just go in and out of the rooms wearing surgical masks without covering the nose. They believed this was part of the cause of the ongoing transmission of the virus. 4/17/23 at 3:10 P.M., the Administrator was interviewed. She indicated staff were to follow guidance for PPE when caring for COVID-19 positive residents and should wear an N 95 mask, gown, gloves, and face shields. Current COVID-19 policies and procedures, provided by the Administrator on 4/17/23, indicated the following: Policy: Resident with confirmed or suspected cases of COVID-19 will be cared for in accordance with guidelines as stipulated by the CDC. All efforts will be made to prevent transmission, treat symptoms, and provide necessary psychosocial support for infected residents .Patients with known or suspected COVID-19 will be provided with a private room when possible or per facility policy, isolate in place to avoid the spread of COVID-19 throughout facility. Resident with suspected or confirmed COVID-19 will no longer be required to have door shut .The following measures will be implemented for residents with known or suspected COVID-19: Transmission based precautions will be instituted. Caregivers will don appropriate personal protective equipment (PPE)-gown, mask, face/eye shield, gloves .COVID-19 Employee Screening, Exposure and Return to Work Guidelines .Return to work guidance for Employees with Confirmed or Suspected COVID-19 .HCP who are not symptomatic could return to work after the following criteria are met: Results are negative from at least 2 consecutive negative tests collected 48 hours apart. Tests should be collected on day 3 and 5 after positive test. Current Centers for Disease Control (CDC) recommendations to prevent COVID-19 spread in nursing homes state the following: -Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection: Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .For the safety of the visitor, in general, patients should be encouraged to limit in-person visitation while they are infectious .Counsel patients and their visitor(s) about the risks of an in-person visit .Facilities should provide instruction, before visitors enter the patient ' s room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy -Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic: Ensure everyone is aware of recommended IPC practices in the facility. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places .These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene) .When SARS-CoV-2 Community Transmission levels are not high, healthcare facilities could choose not to require universal source control. However, even if source control is not universally required, it remains recommended for individuals in healthcare settings who: Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection .work on a unit or area of the facility experiencing a SARS-CoV-2 -Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2: HCP who are not symptomatic could return to work after the following criteria are met: Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT This Federal tag relates to Complaints IN00406062 and IN00406174. 3.1-18(a) 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to provide dementia care and services to support psychosocial well-being for 2 of 3 residents reviewed for dementia care (Resident E and Resident K). Findings include: An Indiana report, dated 2/20/23 at 1:56 p.m., indicated Resident E had a physical alteration with another resident while walking past her at the nurses station. Resident E was sent to the hospital for a psychiatric assessment. The female resident (Resident K) involved was observed with discoloration below her left eye. Resident E returned to the facility the same day as the altercation and there had been no further altercations. Both residents resided on the locked memory care unit. On 3/14/23 at 10:43 A.M., Resident E's record was reviewed. Diagnoses included dementia with psychotic disturbance, major depressive disorder, generalized anxiety disorder, insomnia, and delusional disorder. A quarterly MDS (Minimum Data Set) assessment, dated 2/13/23, indicated a BIMS (Brief Interview Mental Status) score of 9-moderately impaired cognition. He had mood indicators of feeling down, depressed, hopeless; 12-14 days feeling tired with little energy; and 7-11 days having trouble concentrating. He had no behaviors or delusions. He was on an antipsychotic medication as well as a antidepressant and antianxiety medication. Care plans indicated the following: -Initiated 1/5/21, the resident had intermittent periods of confusion, demonstrated poor safety awareness, and had impulsive tendencies. Interventions included to remind him to slow down and think things through prior to proceeding with a task. -Initiated 2/16/22 and revised 2/22/23, the resident had combative behaviors towards other such as hitting, pushing, kicking, verbal aggression and refusing medications. He had the following behaviors: 2/16/22: resident to resident altercation; 7/14/22: resident pushed another resident down; 8/4/22: kicked at another resident; 12/4/22: smacked another resident on the back; and 2/19/23: combative with another resident. The goal was he would not harm himself or others. Interventions, with dates initiated, were: 2/16/22-analyze key times, places, circumstances, triggers, and what de-escalates behavior and document; 2/16/22-assess and anticipate resident's need for food, thirst, toileting, comfort, body position, and pain; 2/16/22-document and report to doctor or nurse practitioner (NP) of danger to self or others; 12/4/22-document observed behavior and attempted interventions in behavior log; 2/16/22-provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out a staff member when agitated; 2/16/22-psychiatric/psychogeriatric consult as needed; 7/14/22-reinforce unacceptance of combative behaviors towards others; and 2/16/22-when agitated, intervene before escalates, guide away from the source of distress, engage calmly in conversation and if aggressive, staff should walk away and approach later. -Initiated 6/20/22 and revised 2/15/23, the resident uses psychotropic medications related to anxiety, delusions, and dementia. He has had recent tremors secondary to possible side effects. His antipsychotic and antianxiety medications were discontinued. Interventions, all dated 6/20/22, were: administer medications as ordered and monitor for side effects; consult with pharmacy and doctor to consider dose reductions when appropriate; monitor/record occurrence for target behavior symptoms and document; and monitor/record/report side effects of medications. On 3/14/23 at 10:35 A.M., Resident E was observed seated in a rocking chair near the bird cage on the memory care unit. Activities were occurring at a table a short distance from his chair but his gaze was focused on a western on a TV located across the lounge. He was well groomed, rocked gently back and forth in the rocking chair, and had a flat but undistressed affect. Several female residents sat quietly dozing in their wheelchairs around another table that was near the TV the resident was looking at. At the table where a card activity was occurring, sat Resident K whom Resident E had an altercation with on 2/18/22. Resident K spoke loudly and shared her opinions with residents seated at the table. Resident E hadn't appeared to notice or acknowledge her. -During a continuous observation from 1:31 P.M. to 1:55 P.M., Resident E was observed seated in the same rocking chair as the morning. Residents, including Resident K, sat at the same table and were playing another game. 2 female resident's were wandering around the lounge area. Resident E was rocking quickly and with force in the rocking chair. He would look around often and was observed moving his lips as if talking to himself as there were no residents near him. His mouth was in a frown, eyebrows furrowed and he continued rocking hard and fast. His face indicated he was troubled. One of the wandering resident's walked past his chair and he stopped rocking until she passed and then resummed rocking. Progress notes indicated the following: -12/4/22 at 10: 16 p.m., indicated Resident E had walked past Resident K and smacked the back of her head and neck. He indicated he hadn't meant any harm, apologized and indicated he had thought she was another male resident. -12/14/22 at 1:26 p.m., a behavior note indicated the resident had been wandering around the unit, shutting off lights. Staff tried to redirect him but he would yell at staff when they turned the lights back on. He was agitated and aggressive. -12/15/23 at 9:57 a.m., a behavior note indicated the Social Services Director (SSD) followed up with the resident and his behaviors the day before. He was calm and in no distress. Activities were to work on getting some interactive activities going to help stimulate the residents. The note indicated the resident was cycling and his restlessness and agitation would increase during this time. -12/27/22 at 5:10 p.m., a behavior note indicated the the resident was calling staff names and using profanity. He wanted to contact the police to file a report against staff for being liars. He called the nurse a liar and a man and told her to leave his room. The psychiatric NP was notified and ordered an antipsychotic medication be given at that time. A psychiatric NP note, dated 1/3/23 at 7:07 a.m., indicated the resident had been seen due to agitation, refusal of care, and paranoia which was distressing to him. The resident was visited while he sat in the lounge area. He was observed speaking to himself. His mood was guarded, no anxiety but was irritable and agitated at times. The plan was for him to remain on his antianxiety medication 3 times per day and continue with an antipsychotic medication to be given 1 time per day before bed. He remained on medication to help him sleep at night. A nurse progress note, dated 2/10/23 at 9:17 a.m., indicated the resident was observed with his body violently jerking. The resident indicated he felt like his body was being shocked. The NP was in the facility and came to exam him. New orders were given for a 1 time dose of oral steroid and discontinue his antianxiety and antipsychotic medications. He was to be closely monitored. A behavior note, dated 2/18/23 at 8:46 a.m., indicated the resident was sent to the hospital due to increased behaviors and physically hitting another resident. Resident K's progress notes indicated on 2/18/23 at 9:49 a.m., Resident K was observed sitting by the nurses station in her wheelchair. Resident E walked up behind her and tried to move her wheelchair. Resident K said no. Resident E grabbed the resident's hair and hit her in the head 2 times. The residents were seperated, neurological checks were started on Resident K and she was given an ice pack for her head. She was administered Tylenol for complaints of a headache. On 3/14/23 at 2:00 P.M., the Memory Care Unit Director-LPN 3 (Licensed Practical Nurse) was interviewed. She indicated when Resident E was observed with tremors on 2/10/23 at 9:17 a.m., he was placed on 15 minute checks for 3 days to monitor for any further tremors which had not been observed. She indicated there had been no further altercations between Resident E and Resident K since 2/18/23. Resident E usually sat in his room and had no further behaviors. On 3/14/23 at 2:53 P.M., the SSD was interviewed. She indicated Resident E had a history of cycling (a pattern of distinct episodes) with behaviors but was not having any at this time. The care plan hadn't indicated when he cycled, what behaviors were associated with cycling, or interventions to prevent altercations between residents when cycling. When questioned, she indicated the resident had been put on an anti-psychotic medication in December 2022 due to his behaviors towards staff, not residents. There were no specific behaviors being monitored or behavioral interventions put into place following the altercation between Resident E and Resident F on 12/4/22 or 2/18/23. There was no analysis completed of key times, places, circumstances, triggers, and what de-escalates his behaviors. On 3/14/23 at 3:45 P.M., currrent copies of facility policies for Psychotropic Medication Management and Behavioral Health Management were provided which indicated resident's behavioral health needs were assessed, monitored and evaluated on an ongoing basis; pharmacologic interventions were used when clinically indicated or when non-pharmacologic interventions were ineffective; and those on psychotropic medications would have behaviors monitored, number of episodes, and interventions and outcomes documented. This Federal tag relates to Complaint IN00402192. 3.1-37

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed were free of significant medication errors (Resident D). This resulted in the resident experiencing a [CONDITION(S)], requiring hospitalization . Findings include: The clinical record for Resident D was reviewed on 4-5-21 at 1:45 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 8:00 P.M.), and [MEDICATION(S)] (an antiepileptic medication) 500 mg two tablets twice daily. According to [MEDICATION(S)].com, [MEDICATION(S)] is used to treat partial onset seizures and is used in addition to other antiepileptic medication to control generalized seizures. The article warns stopping [MEDICATION(S)] suddenly can cause seizures that cannot be stopped. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation on the record to indicate Resident D received the medication [MEDICATION(S)]([MEDICATION(S)]) 150 mg on dates: 3-13-21 at 8:00 P.M. through 3-19-21 at 8:00 A.M. (12 doses). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes indicated Resident D's guardian and the NP (Nurse Practitioner) were not notified Resident D did not receive the medication [MEDICATION(S)] ([MEDICATION(S)]) 150 mg 2 times a day. A progress note dated 3-19-21 at 12:13 P.M., indicated Resident D was transferred to hospital due to increased heart rate, increased mucous, and decreased responsiveness. An ER (emergency room ) record for Resident D dated 3-19-21 indicated Resident D experienced a myoclonic [CONDITION(S)] ([CONDITION(S)] with brief, jerky movements) [MEDICATION(S)] 5 minutes in the emergency room . A [MEDICATION(S)] level was within low therapeutic range (75 mcg/ml). The resident was admitted to the hospital with possible pneumonia A progress note dated 3-19-21 at 4:41 P.M., indicated the guardian of Resident D had chosen not to send Resident D back to the facility. During an interview on 4-6-21 at 9:40 A.M., Nurse 10 indicated the floor nurses were the ones who would complete the admissions for new residents. The nurses had an admission check off sheet they followed. They used the discharge paperwork to in put new orders, but if they did not have a hard script for a medication, they would call the NP, then the NP would send an electronic script to the pharmacy. During an interview interviewed on 4-6-21 at 10:00 A.M., Nurse 9 indicated she followed the medication reconcile when putting orders into the computer, but if she did not see a hard script for a medication, she would notify the NP to get one. The NP would see the new resident usually the next morning, as the NP came to the facility on Monday, Wednesday, and Fridays. Resident D's family member was interviewed on 4-6-21 at 11:09 A.M. The family member indicated she was never informed Resident D's medication, [MEDICATION(S)] ([MEDICATION(S)]) 150 mg tablet, was never filled. The family member indicated on several occasions, she did speak to nursing staff and no one mentioned Resident D was not getting the [MEDICATION(S)] medication. The family member indicated she was informed of this once Resident D was at the hospital. In an interviewed on 4-6-21 at 2:02 P.M., The DON indicated the facility's NP wrote a electronic script on 3-15-21 for the [MEDICATION(S)] ([MEDICATION(S)]) 150 mg to their pharmacy. She was not aware the NP was not notified regarding Resident D not receiving the [MEDICATION(S)] and she was not informed by nursing staff regarding Resident D not receiving the [MEDICATION(S)] medication during her stay at facility, until the evening of 3-19-2021. On the morning of 3-20-21, Resident D's guardian was informed the resident had not received the [MEDICATION(S)] during her stay. She indicated when a resident needed a certain medication, nursing staff could pull the medication from the EDK (Emergency Drug Kit). When the EDK did not have the medication, they could call the NP to have an emergency script sent to their pharmacy to fill the medication. The DON indicated [MEDICATION(S)] ([MEDICATION(S)]) 150 mg was not in the EDK. A policy for Medication Reconciliation was provided by Director of Nursing on 4-6-21 at 2:49 P.M The policy indicated .Purpose: reduce medication errors and potential harm to the resident. Procedure: 3. Contact the physician's office and possibly the transferring facility to resolve discrepancies. Documentation Guidelines: Contact with a physician, physician extender, hospital, pharmacy, family, or others to resolve medication discrepancies. Note whether or not the discrepancy was resolved This Federal tag relates to Complaint IN 392. 3.1-48(c)(2)

Based on observation, interview and record review, the facility failed to ensure pressure ulcers were monitored and interventions implemented timely for 2 of 2 residents reviewed. (Resident F, Resident G) This deficient practice resulted in Resident F's, admission to the hospital with an infected, unstageable wound. Findings include: 1. On 1/27/2021 at 10:30 a.m., the record of Resident F was reviewed. [DIAGNOSES REDACTED]., [MEDICAL CONDITION], obesity, [MEDICAL CONDITIONS], COVID-19, and major [MEDICAL CONDITION]. The most recent Minimum Data Set Assessment (MDS), quarterly assessment dated [DATE], indicated the resident had a BIMS (Brief Interview for Mental Status) was moderately impaired cognition, bed mobility, transfer and walk in room required limited assistance (resident highly involved in activity, staff provided guided maneuvering of limbs or other non weight bearing assistance, eating required supervision, there was no impairment to upper and/or lower extremities), was at risk of developing pressure ulcers, but currently did not have an unhealed pressure ulcer, and received a diuretic for 7 days of assessment period. A weekly skin assessment dated [DATE] at 1:50 a.m., indicated the resident had no open areas and/or no new areas of concern. A progress note dated 11/2/2020 at 4:51 p.m., indicated the resident tested positive for COVID-19. A progress note dated 11/5/2020 at 9:15 a.m., indicated the resident had no pressure injuries and no [MEDICAL CONDITION]. A progress note from the Nurse Practitioner (NP) dated 11/10/2020 at 1:59 p.m., indicated the resident had a right heel ulcer, it was necrotic and had a foul odor. No drainage or [DIAGNOSES REDACTED] was noted. There were no measurements or further description of the area. On 11/10/2020 (no time) an order from the NP was obtained for [MEDICATION NAME] (antibiotic) 1 Gm (gram) intramuscular one time a day for right heel necrotic ulcer to be given for 5 days. There was no documentation the family had been notified of the ulcer or the initiation of an antibiotic. Progress note dated 11/10/2020 at 9:39 p.m., indicated wound care had been provided to right heel. The area was approximately half dollar sized and painful to touch, had black cap on top, redness was spreading to front of right shin, the wound was malodorous (unpleasant smell), and treatment had been provided per order. There was no documentation in the record of the size (length, width, or depth), a description or assessment of the area. A progress note dated 11/12/20 at 8:39 a.m. from the NP, indicated the resident had a large right heel ulcer. The ulcer was necrotic and had a foul odor. No drainage or [DIAGNOSES REDACTED] was noted. The necrotic area was soft in the middle and firm to the surrounding edges. She noted an antibiotic and dressings were in place. She recommended to keep pressure off the heels using boots and pillows under ankles. The note indicated her plan to continue with Ivanz (antibiotic). The November 2020 MAR (medication administration record) was reviewed on 1/28/2021 at 11:10 a.m. On 11/11/2020 and 11/12/2020, documentation on the MAR indicated [REDACTED]. A physician order, dated 11/12/20 indicated to give Ivanz 1 GM (gram) intravenously one time a day for right heel necrotic ulcer for 5 days. There was no documentation to indicate the family had been notified of the need for IV medication. A weekly skin assessment dated [DATE] at 5:15 a.m., indicated right heel treatment was in place. There was no documentation regarding an assessment of the right heel area. A quarterly Braden scale, dated 11/13/2020 at 8:00 a.m. indicated the resident was at low risk to acquire pressure ulcers. A progress note dated 11/13/2020 at 4:04 p.m., indicated the resident had intravenous (IV) access started and maintenance fluids begun. The resident also had the first dose of Ivanz initiated. The November 2020 MAR indicated [REDACTED]. There was no documentation the physician was notified the medication had been held, or the family notified there was a problem with the medication. Progress notes dated 11/14/2020 at 10:27 a.m. indicated the resident had pulled her IV out. The documentation did not indicate how long the IV had not been functional. The documentation indicated the physician was aware. Progress notes dated 11/15/2020 at 4:04 p.m., indicated the IV had been pulled out by patient sometime the day before. It was reported to the MD (medical doctor) with no new orders given. The ADON (Assistant Director of Nursing) indicated to the nurse the IV was to be reinserted because the IV antibiotic was imperative. The nurse started an IV in the resident's left wrist and gave Ivanz dose that was due. She documented the resident had 2 doses of IV Ivanz, one on 11/13 and the second dose on 11/15. A progress note dated 11/16/20 at 11:17 p.m. indicated treatment was continued to the black cap and redness around it. the note indicated the resident had a boot to float the heel. There was no other description or measurements of the area. There was no documentation the family or physician had been notified of the status of the wound. A review of the November 2020 MAR indicated [REDACTED] A progress note dated 11/17/2020 at 2:02 p.m., indicated the resident's IV was found out and the NP was notified. A progress note dated 11/17/2020 at 11:04 p.m., indicated orders were pending from the NP to switch method of administering meds due to resident consistently pulling the IV out. The resident was provided with sips of water throughout shift. The November 2020 TAR (Treatment Administration Record) was reviewed on 1/28/20 at 1:10 p.m. A new treatment order, dated 11/18/2020 indicated to cleanse the right heel with soap and water, apply skin prep, cover with a non-adherent pad, place both feet in heel booties, and elevate both feet two times a day. On 11/22, 11/25, and 11/29, documentation was lacking of one of the two treatments a day having been completed. A progress note dated 11/18/2020 at 10:48 p.m., indicated the NS (normal saline) was held due to patient pulling out IV. The note indicated the facility was awaiting orders from the NP to switch over to IM (intramuscular) for antibiotic therapy. The note indicated the black cap to the right heel, was not malodorous. There was no documentation the family had been notified of the need to change the method of administration of the antibiotic. A progress note dated 11/21/2020 at 00:12 a.m. indicated there was a black cap on the resident's right heel, the heel was painful to touch, redness had been noted around the black cap and there was slight bleeding and discharge from wound. There was no further description or measurement of the wound. There was no documentation to indicate the physician or family had been notified. A progress note dated 11/21/2020 at 2:43 p.m., indicated IM antibiotics had been initiated. The November 2020 MAR indicated [REDACTED]. The medication was documented as having been administered on 11/21, 11/22 and 11/23. Documentation was lacking of administration on 11/24 but indicated the medication was administered on 11/25 and 11/26. There was no documentation the physician or family had been notified of the missed doses. A progress note dated 11/23/2020 at 10:44 p.m., indicated there was redness around the heel the heel had a black cap, and the foot was swelling, and was painful to touch. The plan was to continue to monitor the area. There was no documentation of the characteristics of the wound or size of the area. There was no documentation the physician or family was notified of the swelling or change in the foot. On 1/27/2021 at 11:15 a.m., the DON (Director of Nursing) was interviewed. She indicated she had been at the facility since mid November 2020. She indicated she developed her own Wound Report to track resident wounds. On the Wound Report for Resident F, the first entry was dated 11/25/20. The report indicated on 11/10/2020 the wound was in house acquired, on the right heel, was staged DTI (deep tissue injury) (when there isn't an open wound but the tissues beneath the surface have been damaged). On 11/25/20, the wound measured 6.0 x 5.5. There were no other characteristics of the wound documented in the report. On 12/2/20, the entry indicated the wound measured 5.5 x 3.1 x 2.0. The report indicated eschar covered the entire area. The report indicated the area was 4.5 x 7.5 cm (centimeters). On 12/9/20, the report indicated the area measured 5.5 x 3.0 x 2.0, the entire area was 5.0 x 7.5 cm, and the wound status was documented as no improvement. A weekly skin sheet, dated 11/27/2020, indicated there was an open area to the right heel, and the resident's skin was non tenting. There was no other documentation to indicate the characteristics of the wound or it's measurements. Progress notes dated 11/27/2020 at 10:45 p.m. indicated the right heel was painful to the touch, had some minor swelling and redness around the wound. There was no further documentation to describe the characteristics of the wound. A progress note dated 12/2/2020 at 1:20 p.m., indicated the right heel was assessed by the DON (Director of Nursing) and NP (Nurse Practitioner). The NP recommended the wound be checked regularly by nursing staff throughout all shifts. A Weekly Skin Sheet, dated 12/4/2020 at 5:46 a.m. indicated the treatment was in place staged right heel, and the resident's skin was non tenting. There was no further description of the area. A progress note dated 12/6/2020 at 5:11 p.m., indicated the resident felt warm to touch and had not had much of an appetite, her temperature was 99 degrees, and the DON was notified. There was no documentation to indicate the physician or family had been notified the resident now was febrile. A physician order, dated 12/6/2020 indicated to give [MEDICATION NAME] (antibiotic) 1 GM (gram) intramuscularly one time a day for fever. The December 2020 MAR indicated [REDACTED]. A progress note dated 12/7/2020 at 5:19 a.m. The note indicated the resident's temperature was 97.6, but the reisdnet had some shaking, she was still sweaty and clammy to the touch. The note indicated her vital signs were normal. The resident was alert and responsive. The note indicated routine Tylenol was given during the evening shift. A progress note dated 12/7/2020 at 2:58 p.m. indicated the resident's temperature was 99.2 at 6:00 a.m., 98.9 at 9:30 a.m., then spiked to 101.4 at 10:30 a.m., was 98.2 at 11:00 a.m., then stayed at 98.2 the rest of the shift. The note indicated the resident was occasionally shaking as if she had chills. The note indicated the residnet said she was cold at those times. The note indicated a recommendation of pushing fluids frequently throughout all shifts since resident would not leave an IV in. A progress note dated 12/8/2020 at 00:15 a.m. indicated the treatment to right heel was completed. Upon inspection the area appeared to be slightly malodorous. The note indicated the resident's temperature had elevated to 99.9 and the facility would continue to monitor. There was no documentation to indicate the physician or family had been notified the area had an odor, and the resident's temperature was 99.9. A progress note dated 12/8/2020 at 00:18 a.m. indicated there was a new order for [MEDICATION NAME] (antibiotic) 1 GM. The note did not indicate the family had been notified of the antibiotic. A progress note dated 12/8/2020 at 4:12 a.m. indicated the resident was having difficulty swallowing water. A progress note dated 12/8/2020 at 5:03 a.m. indicated the resident's temperature decreased throughout the shift. The note indicated the resident was clammy and warm to touch, and there was a decrease in output. The note indicated the resident was having difficulty swallowing water, and she refused dinner. The note indicated there was an increase in odor coming from the wound on the heel. There was no documentation to indicate the physician or family had been notified about the increase in the wound's odor. A progress note dated 12/8/2020 at 5:17 a.m., indicated the resident was not responsive enough to receive meds or swallow. A progress note on 12/8/20 after 5:17 a.m., indicated the DON assessed the resident's condition. The note indicated the resident had temps between 99 and 101.5 throughout day, her skin was cool and clammy. The NP had ordered NS (normal saline) via hypodermoclysis (infusion of sterile saline fluids into the subcutaneous space in the belly). A progress note on 12/8/20 after 3:17 p.m. indicated the resident had difficulty swallowing medication. Medication was held and NP notified. There was no documentation the family had been notified the condition of the resident. A progress note dated 12/8/20 at 9:56 p.m. indicated there was a slight amount of drainage, slight bleeding and the heel was malodorous. the note indicates the resident did not have a temperature. A progress note dated 12/8/2020 at 10:59 p.m. indicated NS was infusing at100 ml/hr. The resident did not have any urine output throughout shift, but she was afebrile. Documentation lacking in the record of the physician or family having been notified of the resident's change in condition as noted on 12/8/2020 at 3:17 p.m., 8:12 p.m. A progress note dated 12/9/2020 at 00:24 a.m., indicated the resident refused oral intake. The note indicated NS was infusing at 100 ml/hr through hypodermocolysis. A progress note 12/9/2020 at 10:16 a.m. indicated there was an order clarification from the NP. The order had been clarified to give [MEDICATION NAME] 1 GM (gram) IM daily x 7 days, give Normal saline at 100 ml/hr x 4 liters. The note indicated the resident was hard to awaken. The note indicated the area on the right heel was blackened with some bleeding noted, and there was a foul odor noted to site. A progress note on 12/9/2020 at 2:20 p.m. indicated a new order had been the received from NP to send the resident to the hospital for evaluation and treatment due to a change in condition. The resident was transferred resident to the hospital at 1:20 p.m On 1/27/2021 at 1:00 p.m., the records for the resident's emergency room visit, dated 12/9/2020 were reviewed. Documentation indicated the resident had significant heel breakdown, malodorous and concerning for a potential source [MEDICAL CONDITION]. A plan of care with a revision date of 2/7/2020 indicated the following: Is at risk for pressure ulcer development related to impaired mobility, impaired cognition, risk for incontinent episodes, need for adaptive device for ambulation, dementia, depression, [MEDICAL CONDITION], diabetes with [MEDICAL CONDITION], arthritis, [MEDICAL CONDITION], gout and obesity. Interventions included but were not limited to the following: Administer treatments as ordered and monitor for effectiveness; Encourage to turn and reposition every 2 hours and as needed with assistance; monitor nutritional status. Serve diet as ordered, monitor intake and record. A plan of care with revision date of 9/28/2020 indicated the following: Has Diabetes Mellitus; interventions included but not limited to, the following: check all of body for breaks in skin and treat promptly as ordered by Doctor; monitor/document/report to medical doctor as needed for signs and symptoms of infection to any open areas, redness, pain, heat, swelling or pus formation. On 1/28/2021 at 11:50 a.m., the DON was interviewed. She indicated she has been at the facility since mid November 2020. She indicated she was not aware if the resident had a blister to her right heel or not prior to the pressure area identified on 11/10/20. The DON indicated she made wound rounds with the NP weekly on Wednesdays and she and the NP monitored and measured the progress of the wounds. She indicated this was completed by observation and measuring the wounds. She indicated if they did not see progress in wounds within 2 weeks, they would change orders. The DON indicated when a new pressure area was identified, the NP was notified and an order for [REDACTED]. She indicated the wound should have initially been measured on 11/10/20 but was not measured until 11/25/2020. At this time, the DON's Wound Report was reviewed. She indicate she developed this form but it is not part of the clinical record. The first measurement on the report was dated 11/25/2020 and indicated the entire area measured 6.0 x 5.5. The DON indicated the area was black so was staged as unstageable. She indicated the next measurement was documented on 12/2/20 and measured 4.5 x 7.5 cm. She indicated this measure was for the entire area. She further indicated she was not sure why she documented a depth for the wound as there was no depth to it. The DON indicated the next measurement on the record (no date), reflected the measurements on 12/9/2020. She indicated she was unsure why she documented a depth as there was none. She indicated the entire area remained the same size at 5.0 x 7.5 cm and there was not depth. 2. The record review for Resident G began on 1-28-2021 at 11:06 a.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) admission assessment for Resident G was dated 10-2-2020 and indicated the BIMS (Brief Interview for Mental Status) was not assessed. The resident required an extensive assist of 2 persons for bed mobility, transfers, toileting, dressing, personal hygiene and locomotion off unit and was dependent on 2 persons for bathing. The resident was admitted with 1 stage 4 pressure ulcer and 2 aterial/venous ulcers. A quarterly MDS assessment for Resident G was dated 11-12-2020 indicated the BIMS was 15 of 15, which indicated the resident was cognitively intact. The resident required an extensive assistance of 2 persons for bed mobility, transfers, dressing and toileting and was dependent on 2 persons for bathing. The resident had 1 stage 4 pressure ulcer and 2 arterial/venous ulcers which were present upon admission. The resident had a pressure reducing device for bed/chair, nutrition/hydration intervention to manage skin problems, pressure ulcer injury care and had application of nonsurgical dressing and ointments/medications other than to feet marked. The most current Braden Scale score was 13 on 12-25-2020 and indicated a moderate risk for pressure ulcer development. A review of the current physician orders [REDACTED]. Orders dated 9-30-2020 indicated to cleanse the area with normal saline and pat dry, frame the periwound with the vac drape, apply the black foam, and cover with the drape suction at 100 mmHg (millimeters of mercury). The orders indicated to change the dressing on Mondays, Wednesdays and Fridays and as needed for dislodgement. Physician orders [REDACTED]. Skin assessments were to be completed every Monday night shift. A review of the current TAR (Treatment Administration Record) dated December 2020 regarding the wound vac dressing change for Resident G indicated there was no documentation for the completion of the dressing change on 12-25-2020. The TAR was also reviewed for a treatment for [REDACTED].) Documentation was lacking for completion of the treatments for January 4th and 15th, 2021 and December 12th, 21st and 27th, 2020. The DON provided a copy of the Wound Report for Resident G on 1-28-2021 at 10:12 a.m. The Wound Report indicated measurements of the coccyx wound on 1-6, 1-13 and 1-20-2021. No additional description of the wound was documented. The DON provided another Wound Report for Resident G on 1-28-2021 at 1:39 p.m. for the following dates, 9-30-2020, 10-7-2020, 10-14-2020 and 10-21-2020. The measurements of Resident G's wound were documented for each date, but a description of the wound was lacking. There was no other Wound Report provided for Resident's G wound measurements or description for November and December 2020. A review of Resident G's admission skin assessment dated [DATE] indicated the assessment lacked measurements and description of the identified unstageable sacrum pressure ulcer. Weekly skin assessments completed on 10-3, 10-19, 11-22, 12-14, and 12-21-2020, 1-10, and 1-25-2021 described the wound vac was in place, but no measurements or a description of the wound was documented. On 10-27-2020, Resident G was readmitted after a short hospital stay. The readmission assessment lacked the sacral wound measurements and description. The DON (Director of Nursing) provided the NP's (Nurse Practitioner) progress notes on 1-28-2021 at 3:47 p.m. The DON indicated the NP entered the wound information in her notes. A review of the NP notes indicated on 1-13-2021 and 1-6-2021, the coccyx wound was described as a large wound to coccyx. The note indicated the wound had significantly decreased in circumferential size and depth. The NP notes both on 1-13-2021 and 1-6-2021 lacked measurements or a description of the coccyx wound. The NP notes from 12-17-2020, 12-2-2020, 11-25-2020, 11-6-2020, 10-28-2020, 10-23-2020, and 10-9-2020 indicated the same wound description, .wound vac intact to coccyx The NP notes for 9-30-2020 indicated a large wound to coccyx with pink wound bed with active bleeding, no necrosis or signs of infection and no drainage. The NP notes for 9-28-2020 indicated a large wound to coccyx and buttock with wound vac intact. The NP notes lacked the measurements of the wound and a wound description for each observation. An interview with the DON on 1-28-2021 at 9:55 a.m., indicated the facility had only 1 resident who currently had a pressure ulcer, Resident G. The DON indicated she and the NP had changed the wound vac dressing on 1-27-2021 and the next dressing change was not due until 1-29-2021. The resident declined to allow a change of the dressing on 1-28-2021. An interview with the DON on 1-28-2020 at 1:00 p.m., indicated she and the NP would measure Resident G's wound and document the information on her wound care records. The DON indicated she did not enter any of the measurements or wound description into a wound assessment in Resident G's record. The Wound Report per the DON were for her use only to track the facility wounds. The DON's Wound Report lacked weekly wound descriptions. An interview with Nurse 4 on 1-28-2021 at 1:02 p.m., indicated she would enter in the progress notes for Resident G that the wound vac dressing if it is intact, but she did not do the measuring of the wound. Nurse 4 indicated the DON and the NP did the measuring yesterday and changed the wound vac dressing. She indicated if she did change the wound vac, she would put a note in the resident's record, and would describe the wound. An observation of Resident G on 1-28-2021 at 10:51 a.m., indicated the resident was in her room in bed with alternating air pressure mattress and the wound vac in place. An interview at this time with Resident G indicated the facility staff provided the care on her sacral/coccyx wound. A current, undated policy, Skin Care Pressure Injury/Wound Assessment and Management, was provided by the DON on 1-28-2021 at 2:10 p.m. The policy indicated, .To promote healing of pressure injuries and other wounds, the center will use standardized protocols, current standards of clinical practice and follow physician's specific orders for wound care .Optimal wound management will include 1. Assessment of the skin and wound .2. Use of standardized protocols .3. Regular assessment to monitor effectiveness of interventions .Assessment of Pressure Ulcers include: 1. Location 2. Stage 3. Size a. length (head to toe) b. width (side to side) c. depth 4. Undermining 5. Tunneling 6. Drainage/exudate a. amount b. color 7. Odor 8. Slough 9. Eschar 10. Granulation 11. Status of peri-wound area 12. Pain .Process .The nurse will 1. Do a completed skin assessment of each new resident upon admission to identify any wounds present including pressure ulcers, statis ulcers, surgical wounds .2. Document the size and description of the wound in the medical records. 3. Initiate a Skin Documentation, identifying the type of wound, the size, the location, and the status of the wound .7. Complete skin assessments on all residents weekly (after showers) or as assigned to check for new skin integrity impairment. If a new skin integrity impairment is identified, the results will be documented in the medical records .The Wound Nurse/designee will 1. Do a complete skin assessment of each new resident upon admission to identify any wounds present including pressure ulcers, stasis ulcers, surgical wounds, ect. If the assessment has been completed by the admitting nurse, assess the resident, and review the documentation for accuracy .3. Re-assess the wound weekly or more often as necessary to measure progress or decline in wound status. 4. Document the sound status on the Skin Documentation Form weekly. 5. Record the wound on the Weekly Pressure Ulcer Report or the Weekly Skin Report per policy. 6. Contact physician when a Pressure Ulcer Progresses from one stage to another .or when there is any significant change in the condition of a wound. 7. Contact responsible party when there is a significant change in the condition of a pressure ulcer or any wound. 8. Contact the physician when a pressure ulcer or other wound fails to respond to treatment after 2-3 weeks This Federal Tag relates to Complaint IN 149. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure the mechanical lift policy was followed by trained staff during a transfer of 1 of 1 resident reviewed for a fall. This resulted in a major injury and hospitalization . (Resident B) Findings include: During the initial tour on 7-14-2020 at 9:25 a.m., the ADON (Assistant Director of Nursing) indicated Resident B was in the hospital related to a fall. The record review for Resident B began on 7-14-2020 at 2:39 p.m. [DIAGNOSES REDACTED]. [MEDICAL CONDITION] of both knees, muscle weakness, difficulty in walking, [MEDICAL CONDITION], cognitive communication deficit, diabetes and [MEDICAL CONDITION] disorder. The most recent MDS (Minimum Data Set) quarterly assessment was completed on 5-19-2020 for Resident B. The resident had a BIMS (Brief Interview for Mental Status) score of 10 of 15, which indicated the resident was moderately cognitively impaired. The resident required an extensive assistance of two staff for bed mobility and transfers. The resident was dependent on two persons for toilet use. The resident's current weight was 318 pounds. A review of the physician current orders indicated Resident B should use a Hoyer lift for transfers. The order date was 10-26-2018 and the order was currently active. A review of the Fall Risk assessment dated [DATE] indicated Resident B's fall risk score was 17. The meaning of the score was not identified, but a written entry indicated the resident had the need to use a hoyer lift for traansfers. A review of the Fall Risk assessment dated [DATE] indicated Resident B's fall risk score was 14. The meaning of the score was not identified, but a written entry indicated the resident had a recent fall noted with pain to the lower left extremity and was sent to the emergency room for an evaluation. A current care plan titled risk for falls, indicated the need for assistance with transfers was initiated for Resident B on 10-14-2018. The fall risk care plan was revised on 7-8-2020 with an entry regarding a fall with a major injury on 7-7-2020. The interventions were updated on 7-8-2020, to ensure the resident was being transferred using appropriate equipment by trained personnel. A review of the nurse progress notes for Resident B on 7-7-2020 at 10:09 a.m., indicated a CNA (Certified Nurse Aide) notified the nurse that Resident B had slipped out of hoyer lift while being transferred to wheelchair from bed. The resident was noted to be laying on her back on the floor. The hoyer pad was noted to still be connected to lift. The resident was able to perform active range of motion to both upper extremities and the right lower extremity with discomfort. The resident complained of pain to the left lower extremity. The resident was alert and talking, the NP was made aware, and a new order was received to send the resident to ER for evaluation and treatment. The resident was transported to the hospital at 9:50 a.m. A nurse progress note for Resident B dated 7-7-2020 at 2:35 p.m., indicated the hospital called the facility and notified the nurse the resident had a displaced fracture of left femoral proximal shaft, and the resident would be having surgery the next morning. The DON (Director of Nursing) provided a fall investigation for Resident B on 7-14-2020 at 2:20 p.m. A review of the fall investigation indicated the fall happened on 7-7-2020 at 9:40 a.m. and was witnessed by staff members Housekeeper 1 and CNA 2. The investigation indicated the nurse entered the room, it was observed the hoyer sling was attached to the lift with 3 of 4 loops hooked onto the lift. One loop was off the hook. Statements were obtained from both staff members present during the fall. CNA 2 indicated the resident was positioned properly in the sling, the resident moved her leg while she was moving the hoyer away from the bed causing one of the loops on the hoyer sling to come off the hook. She indicated the resident then slid out of the sling suddenly and landed on her bottom. Housekeeper 1 stated he was asked to hold the wheelchair during the transfer, and it appeared the sling was fully attached to the lift when they began to transfer the resident. He indicated he noticed the resident started slipping suddenly and fell out of the sling. He indicated it was possible that one of the hooks may not have been on the lift properly. CNA 2 indicated that she asked Housekeeper 1 to assist her because she did not see any nursing staff available at the time that she was ready to transfer the resident. CNA 2 and Housekeeper 1 were re-educated regarding only trained staff would assist with any type of transfer including the use of mechanical lifts. The NP was notified at 1:45 p.m. the resident had a fracture to the left hip and would receive surgery. The DON provided a copy of CNA 2's education at orientation. The CNA checklist for CNA 2 indicated she was trained on 2-21-2019regarding transfer of a resident with a mechanical lift. No further education for CNA 2 on mechanical lifts was provided. A copy of CNA 2 and Houeskeepr 1's education was provided by the DON on 7-15-2020 at 12:44 p.m. the training indicated all staff members not trained on transfers would not assist with any resident transfers including any mechanical lift transfers. An interview with CNA 3 on 7-14-2020 at 3:30 p.m., indicated the mechanical lifts were stored in the shower room. The CNA indicated she had been trained on the hoyer lift and indicated two persons were needed to use a hoyer lift with a resident. CNA 3 indicated when the resident was over 300 pounds, the staff had been instructed to use three trained persons. CNA 3 demonstrated how to use the hoyer lift. She was observed to place the hoyer pad loops on the metal circle loops on the hoyer lift. CNA 3 indicated the loops had to be double checked all four loops were secured, so that teh loops would not slip off before the lift was raised to transfer a resident. She indicated once the loops were secured, the legs of the lifts were opened, the resident moved to the bed or wheelchair and then the legs of the lift were closed and the resident lowered. An interview with Housekeeper 1 on 7-15-2020 at 9:57 a.m., indicated he had not been trained on the use of a hoyer lift. He indicated he was just educated that he was not to assist a CNA on any duties, including hoyer lift transfers. He indicated if he was asked, he was to go get a nurse for assistance. An interview with the DON on 7-15-2020 at 10:15 a.m., indicated two CNAs were required for transfers with the hoyer lift, she was not certain when the resident's weight was over a certain amount, if that would require an additional CNA for assistance. A current, undated Safety Policy was provided by the DON on 7-14-2020 at 2:20 p.m. This policy was for orientation and annual review for .Gait Belts .Hoyer Lift .all nurses aides and nurses involved in the transfer of a resident requiring the use of a Hoyer Lift, failing to use such Hoyer Lift as specified, will be found guilty of willful intent to endanger a resident .Two to Three-Person Transfers .all nurses aides and nurses involved in the transfer or transport of a resident requiring assistance of more than one staff will be required to follow facility guidelines, and failure to do so will cause the nurse aide or nurse to be found of willful intent to endanger a resident At the bottom of the form, there were three signature lines for staff to sign regarding the policy and procedures for lifting, transferring and gait belt use for the facility. An current, undated policy, Residents Transfers was provided by the DON on 7-15-2020 at 3:55 p.m. The policy indicated, .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 .4. Resident transfers requiring mechanical lifts will be completed by two persons .6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques .9. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which .c. Provides training on safety, ergonomics and proper use of equipment The DON provided the User Instruction Manual for the hoyer lift on 7-16-2020 at 10:18 a.m. On page 4 under Warning a statement indicated .Do not lift a patient unless you are trained and competent to do so This Federal tag relates to Complaint IN 204. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to administer pain medications as ordered per the physician for 1 of 3 resident's reviewed for medication administration (Resident G). This resulted in Resident G experiencing unrelenting daily pain and aggressive behaviors which required hospitalization . Findings include: On 3/12/19 at 12:04 P.M., Resident G's record was reviewed. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 12/7/18, did not assess the resident's cognition or mood. During the assessment, he rejected care 1-3 days. He indicated he had moderate, constant, daily pain which limited his day to day activities. A Pain CAA (Care Area Assessment), dated 12/13/18, indicated the resident was alert and oriented with periods of confusion. He had chronic headaches and rated his pain a 10/10 on the pain scale. He had received scheduled [MEDICATION NAME] (pain medication used to treat acute moderate pain) and had a [MEDICATION NAME] (a topical anesthetic used to numb an area) prescribed. The CAA indicated Resident G's pain would be addressed in the care plan. There was no care plan developed to address the resident's pain. On 3/12/19 at 11:50 A.M., Resident G was observed sitting on the side of his bed in his room. He appeared thin, poorly groomed, unshaven, and his hair was uncombed. He kept running his hands through his hair. On 3/12/19 at 11:50 A.M., Resident G indicated he was in severe pain and explained that he had experienced unrelenting headaches for [AGE] years. He indicated the pain was in the back of his head and spread over the top to his forehead. He indicated he had received several treatments over the years to try and help with the pain but he always had it. He had a tattered, folded piece of paper that had the name and number of a pain clinic that he had asked staff to call to schedule him an appointment. He indicated he had been given injections into the occipital nerve in the past which had been effective in relieving some of his head pain. He indicated staff would not call the number for him. On 3/12/19 from 3:09 P.M. - 4:00 P.M., the resident was observed and interviewed. During the observation and interview, the resident was seated in a wheelchair at the nurses station. He was very agitated and raised his voice at times. He had tremors in both arms while at rest and with movement. He alternated between being articulate and insightful to periods of crying, holding his head, and running his hands repeatedly through his hair. He complained of severe pain in his head and the need to see a doctor. He requested an injection like he'd had before at the VA (Veterans Administration) Medical Center. He indicated the medication the staff gave him did not help his headaches so he didn't see the need to take it and continued to request he be sent to the hospital for pain relief. A VA Medical Center progress note, dated 12/23/18 at 10:51 p.m., indicated the resident was seen for Acute exacerbation of chronic muscle tension headaches. He was given a nerve block while in the emergency department which he tolerated well. The note indicated the resident was to be given 2 Fiorcet (pain medication used to treat tension headache, migraine and mild to moderate pain especially when antianxiety or relaxant effects are needed-retrieved from the mobile PDR (Physician Desktop Reference) on 3/12/19) tablets upon his arrival for his headache discomfort. The note also recommended to give a [MEDICATION NAME] as well. A Nurse progress note, dated 12/23/18 at 11:56 p.m., indicated the resident returned to the facility via taxi. The note indicated the resident had received a medical procedure for acute exacerbation of chronic muscle tension headache. The resident was recommended to receive Fiorcet tablets which was a narcotic. The resident didn't have this medication in the facility and the VA had not sent a prescription back with him. The nurse attempted to contact the VA but the calls made were repeatedly disconnected. The note indicated the information would be passed on in report to the oncoming nurse for follow up. A Nurse progress note, dated 12/24/18 at 10:12 a.m., indicated the resident continued to complain of anxiety. He indicated [MEDICATION NAME], given for his headaches, was not effective. He was given [MEDICATION NAME] (other the counter medication for migrain headache) 2 tablets by mouth at 8:30 a.m. for complaints of a severe headache. The note indicated the medication had no effect and the resident continued with a severe headache. The resident was to return to the VA center for a follow up appointment at 1:00 p.m. A VA hospital progress note, dated 12/24/18 at 2:18 p.m., indicated the resident had been seen for a headache and the injection administered the day before had not been effective in relieving his pain. Migraine protocol was ordered: IV fluids, [MEDICATION NAME] (pain medication), [MEDICATION NAME] (anti-[MEDICATION NAME]), and [MEDICATION NAME] (anti-nausea). The resident was to be discharged after he received the medications. The progress note indicated the resident's current medications for treatment of [REDACTED]. Nurse Progress notes indicated the following: 12/26/18 at 10:29 a.m., Resident G had been complaining of a severe headache since the start of the shift. Routine pain medications provided as ordered but the resident indicated the medications had little to no effect on his headache. Re-direction was ineffective, the resident continued to complain of pain and made negative statements about his life. 12/28/18 at 10:33 a.m., the resident had increased anxiety. He complained of a headache and indicated that no medications helped except narcotics. 1/8/19 at 6:18 a.m., at 1:45 a.m., the resident was found on the floor in his room having an altercation with another resident. The other resident had been standing over the resident as Resident G kicked at him. 1/10/19 at 10:15 a.m., the Social Service Director (SSD) indicated she had spoken with the resident's POA (Power of Attorney) who indicated the resident had called her 2 times and had stated he wanted to harm himself because his head hurt so bad. 1/10/19 at 10:59 a.m., the SSD indicated a referral had been made to a geriatric behavioral unit due to the resident making negative statements. The resident was then transferred to the hospital behavioral unit. Hospital progress notes from 1/10/19 - 1/16/19 indicated during his hospital stay, the resident complained of severe headaches which he'd dealt with for several years. The notes indicated had periods of irritability and anxiety when he complained of headaches, he requested narcotics and a spinal block for pain relief. 1/17/19 at 2:15 p.m., the resident continued to adjust to the facility after readmission from a psychiatric hospital stay. He complained of a headache and routine pain medications were administered as ordered. 1/18/19 at 2:39 a.m., The only negative statements made during the shift were related to the resident's headaches which never go away. 1/21/19 at 3:21 p.m., the resident indicated he was doing fine since readmission to the facility other than his head hurting. A VA Primary Care Attending progress note, dated 2/13/19 at 10:30 a.m., indicated the resident was seen for a routine visit. The note indicated the resident had chronic headaches which had been treated with acupuncture (nerve block) with some success. The resident was taking [MEDICATION NAME] for headache pain in addition to other medications. He complained of a screaming headache in the occipital (back of head) area. The resident was tearful. Orders were given to obtain a neurology consult, geriatric and mental health consults, discontinue [MEDICATION NAME], and repeat an injection of [MEDICATION NAME] which had been helpful at his prior visit. A review of Resident G's Medication Administration records dated (MONTH) (YEAR), January, February, and (MONTH) 2019 indicated [MEDICATION NAME] had not been given as ordered. On 3/12/19 at 4:05 P.M., the Unit Manager was interviewed. She indicated she was not aware that the resident had been seen by VA services in (MONTH) (YEAR). She had not been aware that the resident had orders for [MEDICATION NAME] to treat his headaches which had been prescribed by physicians at the VA center prior to his initial admission to the facility. She was aware the resident had headaches which he complained of daily. He was prescribed routine pain medication in addition to as needed medications but would often refuse them because he indicated they didn't help. The Unit Manager indicated there had been no follow up to the resident's VA emergency room visit on 12/23/18 or the visit on 12/24/18 where the VA physician's had indicated the resident was to take [MEDICATION NAME] after his ER visit and was ordered as needed for headaches 4 times per day. She indicated there were no orders on the chart written to discontinue [MEDICATION NAME] on 2/13/19. She indicated the resident was alert and able to be interviewed. On 3/13/19 at 12:35 P.M., the Medical NP (Nurse Practitioner) was interviewed. During the interview, she indicated she had not been aware that the resident had been seen by the VA in (MONTH) or that they had requested the resident be given [MEDICATION NAME] after this visit. She indicated it was her understanding that the resident was waiting to be assigned to a primary care physician at the VA. She had not prescribed [MEDICATION NAME]. On 3/13/19 at 12:49 P.M., LPN 2 indicated she had spoken with the VA center and learned that the resident had originally been prescribed [MEDICATION NAME] for his headaches in (MONTH) of (YEAR). She indicated during the resident's VA visits on 12/23/18, 12/24/18, and 2/13/19, the VA had [MEDICATION NAME] listed on the residents current medication records but [MEDICATION NAME] had never been ordered by the facility's physician's or NP's. She indicated she had just received, by fax, the resident's VA progress notes from 12/24/18 and 2/13/19. There had been no follow up completed after the 12/23/18 VA emergency room visit to clarify or obtain orders for [MEDICATION NAME] to treat the resident's severe headaches. This Federal tag relates to Complaint IN 099. 3.1-25(b)(9)

Based on observation, interview, and record review, the facility failed to provide tube feedings as ordered by the physician for 1 of 1 residents reviewed for tube feedings (Resident L). This resulted in significant weight loss for Resident [MI] Findings include: On 3/13/19 at 3:42 P.M., Resident L's record was reviewed. [DIAGNOSES REDACTED]. A admission MDS (Minimum Data Set) assessment, dated 2/18/19, indicated the resident's cognition was not tested due to his inability to speak. The resident was dependent with all ADL's (activities of daily living). He swallowed nothing by mouth and had a tube feeding which was to run continuously. His weight was 158 pounds. On 3/13/19 from 1:38 P.M. - 2:50 P.M., Resident L was observed sitting up in his w/c in his room next to his bed. His call light was observed on the other side of the bed and was clipped on the top of the room curtain divider. He was well groomed and had a [MEDICAL CONDITION] covered by an oxygen mask. The resident was alert and appeared to understand conversation as evidenced by nods, smiles, direct eye contact, and attempts to articulate words. The resident's tube feeding pump machine was observed off during the entire observation period and he did not receive any fluids or enteral tube feeding. A 1000 ml (milliliter) bag of water, with approximately 850 ml's of water present, was hanging on an IV pole and was attached to tubing that ran from a 1200 ml full bottle of enteral feeding labeled as Glucerna 1.2 calorie liquid supplement. Written on the label of the bottle was a date of 3/13/19, opened at 9:30 a.m. Tubing from the enteral bottle had liquid in it with multiple air bubbles and extended from the bottom of the enteral bottle into the feeding machine. Resident L's family member was present on 3/13/19 at 1:38 P.M. They expressed several care concerns including, but not limited to, the resident's gastric tube feeding. She indicated the resident had been noted, on several occasions, to not have his gastric tube feed running. The family member indicated the resident's tube feeding was to be continuous and around the clock because the resident was not able to eat anything. She indicated the resident had lost a significant amount of weight since admission to the facility. The family member expressed concern that the resident hadn't received any tube feeding since 9:30 a.m. On 3/13/19 at 2:54 P.M., the DON (Director of Nursing) was notified of the resident's gastric tube feeding not being turned on and that it had been observed off since 1:38 p.m. She entered the resident's room and indicated the tube feeding machine was turned off but should have been on as the resident was to receive continuous tube feedings. She summoned a nurse (LPN 5) to the room to restart the resident's feeding. On 3/13/19 at 3:02 P.M., the DON was interviewed. During the interview, she indicated she had spoken with the Rehabilitation Therapist to see if the resident had just received treatment and perhaps the tube feeding had yet to be restarted. The therapist indicated to her that the resident's tube feeding was not on or hooked up to the machine when he received his therapy treatments. On 3/13/19 at 3:50 P.M., Resident L was observed lying in bed with his gastric tube feeding machine on and running at 60 ml's per hour. The Glucerna 1.2 calorie supplement had approximately 1150 ml's in the bottle. On 3/13/19 at 3:52 P.M., LPN (Licensed Practical Nurse) 5 was interviewed. During the interview, she indicated she had reattached the resident's tube feeding after he was assisted to bed. She indicated the bottle of Glucerna had been full at 1200 ml before starting his feeding. The bottle stated it had been opened and hung on 3/13/19 at 9:30 a.m. however, the bottle was full and the machine had not been turned on when she had been asked to restart the residents feeding. Review of the resident's weights indicated the following: 2/11/19 - 158.3 3/4/19 - 159.4 3/7/19 at 12:51 p.m. - 132.0 3/7/19 at 2:05 p.m. - 132.0 3/14/19 - 134.2 A Physician order, dated 2/12/19 at unknown time, was for Glucerna 1.2 calorie liquid (Nutritional Supplement) - give 55 ml per hour by gastric tube every shift for enteral feeding. A Dietary progress note, dated 2/14/19 at 1:21 p.m., indicated the resident's current weight was 158.3. The resident was NPO (nothing by mouth) and received Glucerna 1.2 at 55 ml/hr continuously per tube feed. His estimated nutrient needs were: 1799-2015 calories per day which included 1.2-1.4 gm's (grams) of protein. He required 1799-2159 ml's of water. The resident had no pressure areas noted at the time but was at high risk of developing them. A recommendation was made to add 30 ml of ProStat sugar free 2 times per day for added protein and obtain weights on Mondays and Wednesdays. A Dietary progress note, dated 3/5/19 at 1:09 p.m., indicated the resident's current weight was 159.4. There were no changes or new recommendations made. A Physician order, dated 3/7/19 at unknown time, was to increase the Glucerna 1.2 calorie liquid (Nutritional Supplement) to 60 ml per hour by gastric tube every shift for enteral feeding related to the significant weight loss from 159.4 to 132. A review of the Medication and Treatment Administration records dated (MONTH) and (MONTH) 2019 did not indicate documentation of any tube feeding intakes. On 3/14/19 at 11:35 A.M., the DON indicated she was unable to find a facility policy regarding enteral nutrition and tube feedings. She indicated nurses were expected to follow the physician orders [REDACTED]. The resident's enteral feeding should have been administered continuously as ordered and intakes should hae been documented. This Federal tag relates to Complaint IN 099. 3.1-44(a)(2)

Based on interview and record review, the facility failed to provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident with a physician order [REDACTED]. (Resident 131) The Immediate Jeopardy was identified on [DATE] and began on [DATE] at (2043) 8:43 p.m., when LPN 2 found Resident 131 in her room with no vital signs, pupils fixed, no respirations or pulse, and was unresponsive to verbal and painful stimuli. CPR was not initiated. The Regional Director of Operations and Health Care Administrator were notified of the Immediate Jeopardy on [DATE] at 10:54 a.m. Findings include: On [DATE] at 4:50 p.m., the record of Resident 131 was reviewed. [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. Nurses notes, dated [DATE] 1430 (2:30 p.m.), (entered as a late entry on [DATE] at 10:24 a.m.), indicated the following: Resident admitted from (name of hospital) with alcohol induced dementia. Unable to get history from resident. Historical information obtained by report from nurse at (name of hospital). Resident was admitted per WC and assisted to bed. Call light in reach and explained to resident. Alert but confused. Able to state her name with hard to understand speech. Documentation was lacking in the nurse notes entry on [DATE] at 2:30 p.m., of the resident's code status. Nursing notes, dated [DATE] at 12:20 p.m., indicated .is alert to self, resident refusing to eat this shift. V/S (vital signs) stable, no distress noted . The next nurses note entered was on [DATE] at 20:43 (8:43 p.m.) and indicated Writer found resident in her room, in bed with no VS, pupils fixed, no respirations, no pulse, and no (sic) unresponsive to verbal and painful stimuli. DON (Director of Nursing), NP (Nurse Practitioner) are notified. The next nurses note entered was on [DATE] at 21:54 (9:54 p.m.) and indicated (County Coroner) has been notified .stated This is not a coroner's case. Order received from (name of nurse practitioner) to release the body to (name of funeral home). In the paper clinical record, physician orders [REDACTED]. The physician orders [REDACTED].Full Code . Documentation on the physician orders [REDACTED]. On [DATE] at 9:12 a.m., LPN 2 was interviewed. She indicated she came on duty on [DATE] at 3:00 p.m., saw the resident's name on a list but did not get report on the resident from the prior shift. She asked the prior shift QMA (Qualified Medication Assistant) about the resident, the QMA indicated I don't know. The prior shift didn't tell her the code status of the resident as they indicated they were not aware. LPN 2 indicated around 8:00 p.m., she went to the resident's room to begin her medication pass, she found the resident in bed with no VS, pupils fixed, no respirations, no pulse, and unresponsive to verbal and painful stimuli. She indicated the resident appeared as though she had been like that awhile. There was no CNA in the hall currently, so she went down the hall to find the other nurse in the building, RN 1. LPN2 and RN 1 arrived at the resident's room, RN 1 verified the resident's status as no pulse, no respirations and unresponsive. She reviewed the paper clinical record, the code sheet was not in the front of the chart, like it was supposed to be. She indicated the code sheet would have indicated the resident's code status. She didn't see the resident's code status in the physician orders. Neither she nor RN 1 performed CPR on the resident. LPN 2 looked through the resident's paper chart and found the code status on hospital papers, which were kept in the back of the chart. She indicated the resident was a full code, CPR status. The DON was notified (as she was out of the building at this time) Resident 131 had been found with no pulse, no respirations, unresponsive to verbal and painful stimuli and pupils fixed. The DON indicated to her, she had looked on the computer and was unable to locate a code status for the resident in the resident's chart. The DON began speaking to her, regarding the necessary paperwork to complete for a deceased resident. LPN 2 indicated neither the DON or RN 1 told her to perform CPR. On [DATE] at 10:44 a.m., the DON was interviewed. She indicated Resident 131 was a full code and when she had been made aware of Resident 131's condition (by RN 1 texting her, she (the DON) replied via text, to do CPR and call 911. She was notified approximately 15 minutes after the resident had been found. She arrived to the facility on [DATE] at approximately 11:30 p.m. The DON indicated staff did not perform CPR on the resident or call 911 for the resident. The resident was a full code status, as reported to her by RN 1. She indicated if the resident's chart didn't have a code status form in the front of the chart, the staff were instructed to perform CPR. After this incident, she had provided education to staff in regards to what to do if they find a resident unresponsive, with no pulse and/or respirations and there was no form specifying code status available. Staff were educated to perform CPR in such a circumstance. On [DATE] at 3:12 p.m., the DON was interviewed. She was reviewing the text messages on her phone and indicated the following: Resident 131 had been found unresponsive, no pulse and/or respirations at 8:43 p.m. on [DATE]. She indicated RN 1 texted her at 8:46 p.m. and told her the resident had passed and the NP (Nurse Practitioner) had been notified. The DON was not aware what the NP had been made aware of and/or what the NP's response was. The DON indicated at 8:49 p.m. RN 1 texted her regarding the resident's contacts. At 8:51 p.m., the DON texted RN 1 as to what had happened. At 8:55 p.m., she texted RN 1 regarding the resident's code status. At 8:56 p.m., RN 1 texted the resident was a full code. At 8:56 p.m , the DON indicated she texted RN 1 questioning if the EMS had been called and had staff started CPR. RN 1 texted back your wishes, that's why I'm texting you. At 8:59 p.m., she texted to RN 1 Policy states to start CPR and call 911. The DON indicated she instructed RN 1 twice to start CPR and call 911. She arrived at the facility at 11:30 p.m. on [DATE] and was made aware CPR had not been started and/or 911 had not been called. She thought the reason CPR was not started or 911 was not called was because LPN 2 felt like the resident was already gone. A policy and procedure for Cardio-pulmonary Resuscitation (CPR) dated [DATE], included, but was not limited to, the following: Guideline: It is the intent of the facility to ensure that all resident's suffering a cardiac or respiratory arrest will receive the treatment of [REDACTED].Basic CPR is defined as artificial respiration accompanied by external cardiac compressions .Responsibility: Licensed Nurses or staff trained in CPR: CPR will be performed by licensed nursing or staff trained in CPR .Residents who request FULL CODE STATUS will receive CPR is they arrest .Procedure: Check chart for code status. Assess resident to determine respirations have ceased/palpate or auscultate for absence of pulse/heartbeat. If a resident who wishes to be resuscitated appears to be having an arrest, the licensed nurse will assess the resident for absence of heartbeat using a stethoscope or palpate pulses and assess for absence of respirations. Call for assistance .If the resident has a cassation of heartbeat or cessation of respiration and if the resident wished to be resuscitated, delegate a person to page for assistance, call 911 .All available licensed nurses and staff trained in CPR will respond promptly to the code and assist as needed .clear the resident's airway, check for respiration .initiate basic life support .use ambu-bag and/or mouth to mouth .maintain party of the change in condition and transfer. Complete documentation in nurses notes . The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility completed record review of advance directives and physician orders [REDACTED]. This federal tag is related to complaint IN 575.

Based on interview and record review, the facility failed to provide adequate supervision and assistance for 1 of 3 residents reviewed for accidents (Resident B). Resident B sustained a fracture of unknown origin requiring hospitalization . Findings include: On 5/24/17 at 11:18 A.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B had severely impaired cognition. The MDS indicated the resident required extensive assistance of two staff for transfers and toileting and was non-ambulatory. Further, the MDS indicated the resident had limitations in range of motion to both lower extremities. On 5/24/17 at 1:17 P.M., Nurse progress notes were reviewed and indicated the following: 5/1/17 at 10:17 A.M., Resident noted with swelling and purple bruising to left arm. NP (Nurse Practitioner) in this shift. New order received to x-ray left arm. 5/1/17 at 11:29 A.M., Mobilex here at this time to obtain x-ray. Awaiting results. 5/1/17 at 2:30 P.M., results back from x-ray at this time. POA (Power of Attorney) and NP notified. New order to send resident to ER (emergency room ) for evaluation and treatment. POA aware. A Physician's Progress Note, dated 5/1/17, indicated the following: Resident seen at this time at the request of nursing staff r/t (related to) left arm edema and bruising, unknown etiology. Resident cries when NP attempts to assess left arm. Resident's left forearm with significant edema, extending to fingertips. Significant bruising to left forearm and upper arm. Some bruising to right forearm as well. A physician's orders [REDACTED]. Mobilex x-ray reports, dated 5/1/17, indicated Resident B had a fracture of the proximal ulna. On 5/1/17, (no time noted on Resident chart) Resident B was transferred to a local hospital where hospital records indicated the following: 5/1/17 at 4:18 P.M., Resident B had swelling and multiple coalescing (coming together) ecchymoses (bruises) along the left forearm. Swelling and redness in the upper left arm. Ecchymoses on the right forearm, ecchymoses on right chest-4 cm (centimeters). Additional diagnostic tests were completed. X-ray of the left forearm indicated a complete fracture through the olecranon (elbow) process and joint effusion in addition to a suspected non-displaced fracture through the radial head neck junction. A chest x-ray indicated suspected non-displaced left 5th and 6th rib fractures. On 5/24/17 at 3:00 P.M., the DON (Director of Nursing) was interviewed. The DON indicated an investigation into the cause of Resident B's injury was completed. Statements were obtained from staff members who worked from 5:00 p.m. Saturday, April 29th through Monday, May 1 at 10:15 a.m. Staff statements and interviews did not indicate Resident B had fallen nor were any staff aware of what could've caused the resident's injuries. On 5/24/17 at 3:15 P.M., the nurse and CNA (Certified Nurse Assistant) daily schedule for 4/29-5/1/17 was reviewed. The scheduled indicated on Sunday, 4/30/17, the North hallway where Resident B resided, was staffed with a QMA (Qualified Medication Aide) and one CNA from 3pm-7pm. On 5/24/17 at 3:25 P.M., QMA 2 was interviewed. During the interview, QMA 2 indicated she pulled CNA 4 from the memory care unit to work on the North hall on 4-30-2017 with she and CNA 3. CNA 3 worked until 7:00 p.m. and then left. QMA 2 and CNA 4 worked together the remaining shift. QMA 2 indicated she did not transfer any residents into bed. On 5/25/17 at 10:02 A.M., CNA 6 was interviewed. During the interview, CNA 6 indicated she had been assigned and worked the night shift on Sunday 4/30/17 on the South hall. CNA 6 indicated that CNA 7 asked her to help transfer Resident B from bed to wheelchair at approximately 6:45 a.m. on 5/1/17. When CNA 6 and CNA 7 sat Resident B up on the side of the bed, the CNA's noticed the resident's left arm was purple, bruised, and swollen. CNA 6 left the room to get LPN 9. After LPN 9 looked at the resident's arm, CNA 6 and CNA 7 transferred Resident B into her wheelchair. On 5/25/17 at 10:37 A.M., CNA 7 was interviewed. During the interview, CNA 7 indicated she was assigned and worked the North hall on the day shift, Monday 5/1/17. CNA 7 indicated she went into Resident B's room around 6:30 a.m. and assisted the resident with morning care. The CNA indicated Resident B was wearing a gown and lying on her back when she came into the room and the CNA provided care to the lower half of the residents body. CNA 7 then went and got CNA 6 to help her transfer the resident. CNA 7 indicated Resident B did not appear to be in pain and she did not notice the bruising to the resident's left arm until she and CNA 6 removed her gown. CNA 7 indicated Resident B's left arm was purple and there was a big knot on the back of her upper arm. On 5/25/17 at 10:45 A.M., CNA 5 was interviewed. During the interview, CNA 5 indicated she had worked the day shift on the North hall on Sunday, 4/30/17. CNA 5 indicated she worked with CNA 8. CNA 5 was assigned to Resident B and indicated the CNA Pocket Sheet indicated the resident required the assistance of 2 staff members to transfer into bed. CNA 5 asked CNA 8 to assist her to transfer Resident B into bed after lunch. CNA 5 indicated CNA 8 came into Resident B's room and told CNA 5 to stand back, I got this and proceeded to lift Resident B under her armpits from the wheelchair and placed her into bed without assistance from another staff member. CNA 5 indicated resident B should have been lifted with 2 persons. On 5/25/17 at 3:45 P.M., LPN 9 was interviewed by telephone. LPN 9 indicated she was the nurse responsible for Resident B on the night shift, Sunday 4/30/17. She indicated she flushed the resident's catheter between 12 a.m. and 1 a.m. but had not noticed any bruising to Resident B's arm nor had the resident complained of any pain. LPN 9 indicated she was called to the resident's room on Monday 5/1/17 to look at the resident's left arm. LPN 9 indicated Resident B's arm was red and swollen. LPN 9 went back to the nurses station and wrote Resident B's name down on the list to be seen by the NP who was due to visit that day. On 5/26/17 at 10:40 A.M., the NP was interviewed. During the interview, the NP indicated she had come to the facility on Monday 5/1/17 between 7:30 and 8:00 a.m. and was asked to see Resident B's left arm. The NP indicated the resident was sitting up in her wheelchair wearing a sweater. NP indicated staff tried to remove the sweater first from her right arm and then left arm but this was difficult because Resident B was crying and didn't want anyone to touch her. The NP indicated she noted a bruise to the top of the resident's right forearm but that it didn't appear acute. The NP noted the resident's left arm was purple and warm to touch. The NP indicated she did not see any other injuries rather was focused on Resident B's left arm injury. This Federal tag relates to Complaint IN 717 3.1-45(4)(2)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 residents who was dependent on a tube feeding (tube medically inserted into the stomach to provide nutrition to patients who can't obtain nutrition by mouth) had adequate calorie requirements met, which resulted in an unplanned, significant weight loss. (Resident 44) Findings include: On 3/15/17 at 3:15 p.m., the clinical record of Resident 44 was reviewed. [DIAGNOSES REDACTED]. Resident 44's MDS (Minimum Data Set) Assessment, dated 12/5/16 indicated the following: the resident had severely impaired cognition, extensive assistance was required for bed mobility, ther resident was totally dependent for eating, the percent of calorie intake by artificial route was 51% or more; and artificial intake by tube feeding was 501 cc (cubic centimeter which is interchangeable with ml (milliliters)/day or more. A review of the current policy and procedure for Enteral Tubes: Continuous (Pump) Feedings, revised on1/15/15, indicated the following: Policy: It is the policy of the facility to deliver ordered intermittent feeding and/or hydration via a pump method to provide necessary nutrition and hydration as required to maintain the residents caloric and hydration needs .Procedure: Verify physician's orders [REDACTED].When feeding is complete flush tube .complete all required documentation A plan of care, with Last Care Plan Review Completed date of 2/14/17 was reviewed. The focus of the care plan was, .receives tube feeding for the majority of her nutrition and hydration needs due to [MEDICAL CONDITION]. She is on oral pleasure feedings diet that is consistency altered. She has skin breakdown. The following date was documented for the Date initiated/Revision on: 2/17/17. The Goal, date initiated was documented as 1/13/17, with a revision date of 2/17/17. The goal was the following: .Resident .weight stable at 168 +/- 5 lb (pound) Interventions included the following: .Provide tube feeding and flush as ordered. Provide pleasure feedings as ordered .Monitor weights and intakes Date this intervention was initiated was 8/26/15 with revision on 9/1/15. On 3/14/17 at 9:00 a.m., Resident 44 was observed in her bed, with the tube feeding infusing of [MEDICATION NAME] 1.5 infusing at 55 ml ((milliliter, unit of liquid volume interchangeable with cc (cubic centimeters)/hr(hour)) per the pump. The 1 liter (1000 ml) bottle of [MEDICATION NAME] was observed to be dated 3/13/17 at 8:00 p.m. At this time, 9:00 a.m., there was observed to be 600 ml remaining in the bottle. On 3/14/17 at 10:07 a.m., the pump with feeding was observed to be working, lights on and the mechanism was observed to spin around in circular motion intermittently. The Vol (Volume) delivered area on the pump, indicated 240 ml. The level of [MEDICATION NAME] feeding in the bottle was observed to be slightly over 500 ml line on the bottle. On 3/14/17 at 12:15 p.m., the [MEDICATION NAME] feeding was observed to be a the level of 400 ml, with the total volume infused listed as 352 ml. The pump was observed on and running at a rate on the pump of 55 cc/hr. On 3/14/17 at 1:15 p.m., the [MEDICATION NAME] feeding pump indicated 409 ml infused. The pump was observed to on and running. The rate continued at 55 cc/hr and 350 ml was observed to remain in the bottle of [MEDICATION NAME]. On 3/14/17 at 1:16 p.m., CNA 9 was interviewed. She was observed to be working on the same hall as Resident 44 resided CNA 9 indicated Resident 44 did not receive meal trays for food to eat. On 3/14/17 at 1:25 p.m., the door to Resident 44's room was closed and the medication cart was outside the room. On 3/14/17 at 1:33 p.m., the door was now opened and the feeding tube pump, which had the [MEDICATION NAME] feeding on it was turned off. The [MEDICATION NAME] feeding bottle was no longer hanging on the pump. On 3/14/17 at 1:50 p.m., the bottle of [MEDICATION NAME] 1.5 was observed in the trash can in Resident 44's room. The [MEDICATION NAME] bottle was positioned in the same manner as it was observed hanging from the pump, with 400 cc observed remaining in the bottle. On 3/14/17 at 2:24 p.m., LPN 1 had documented 810 cc for Total intake of Enteral feeding every shift. On 3/15/17 at 8:50 a.m., Resident 44 was observed in her bed, with the tube feeding pump observed to be on and infusing, with the bottle of [MEDICATION NAME] 1.5 hanging. The rate on the pump was observed to be 55 ml/hr and the total intake was observed to be 178. At this time, there was observed to be 550 ml of [MEDICATION NAME] left in the the hanging bottle. On 3/15/17 at 11:00 a.m., the tube feeding pump was observed to be running. The pump was observed to have 301 (ml) for amount infused and 55 (ml/hr) for infusion rate. There was a total of 400 cc observed remaining [MEDICATION NAME] in the hanging bottle. On 3/15/17 at 12:30 p.m., the volume delivered on the machine was observed as 383, the rate was observed at 55 ml/hr and there was observed 350 ml level in the [MEDICATION NAME] in the level of the bottle. On 3/15/17 at 1:10 p.m., Resident 44 was observed in her bed. The [MEDICATION NAME] tube feeding was observed to no longer be infusing per the tube feeding pump. The bottle of [MEDICATION NAME] tube feeding was observed in the trash at the resident's bedside. At this time, when the bottle of tube feeding was held upright, in the same manner as the bottle was observed to hang on the tube feeding pump, 300 ml tube feeding was observed in the bottom of the bottle. On 3/15/17 at 1:55 p.m., LPN 1 was interviewed. She indicated the following: she calculated the total amount she documented in the MAR (Medication Administration Record) for Record total intake of Enteral feeding as 810 for 3/14/17 and 3/15/17. LPN 1 indicated I figured wrong. LPN 1 indicated the amount of Enteral feeding intake was recorded in cc's or ml's. She indicated she does not look at the level of the [MEDICATION NAME] tube feeding in the bottle. She indicated she calculated the total amount of [MEDICATION NAME] intake on her shift by multiplying the rate of 55 ml/hr by the 7 hours the [MEDICATION NAME] was infusing during her shift, 6:30 a.m. to 1:30 p.m. She indicated she doesn't do anything with the volume infused control button display total on the tube feeding pump. She indicated the [MEDICATION NAME] infusion was off from 1:30 p.m. to 7:30 p.m. She indicated the total of 810 cc's, which she documented on the MAR for 3/14/17 and 3/15/17 included the 55 cc/hr x 7 hours for a total of 385 cc's of [MEDICATION NAME]. She indicated she also adds in the 200 cc flushes of water, which she gives the resident through her tube feeding when she gives the resident her morning and afternoon medications. LPN 1 indicated she gave Resident 44 her afternoon meds when she (LPN 1) discontinued the [MEDICATION NAME] tube feeding at 1:30 p.m. LPN 1 indicated she does not include the small amounts of water she uses for the tube medication administration. LPN 1 indicated when she takes the [MEDICATION NAME] tube feeding bottle down, she always throws it away so a new bottle hung to infuse at 7:30 p.m. when the tube feeding resumes. On 3/15/17 at 2:10 p.m., the DON (Director of Nursing) was interviewed. At this time, the [MEDICATION NAME] 1.5 Bottle was observed to have the following documentation on the bottle: hung/started at 7:30 p.m. on 3/14/17, rate of infusion was 55 ml/hr. The DON indicated the current physician ordered rate for the [MEDICATION NAME] 1.5 was 55 cc/hr from 7:30 p.m. to 1:30 p.m. The DON indicated there was 325 cc [MEDICATION NAME] 1.5 feeding left in the bottle, which contained a total of 1000 ml feeding, when it was held up in the same position as it would have been by hanging on the tube feeding pole. The DON indicated at this time, if the [MEDICATION NAME] was infusing at a rate of 55 cc/hr for 18 hours, the resident should have received a total of 990 ml's of feeding. The DON indicated with a total feeding in the bottle of 1000 ml, the bottle should only have 10 ml's remaining in the bottle, as compared to the 325 ml's which were actually observed remaining in the bottle. The DON indicated the [MEDICATION NAME] bottle Probably didn't get hung right at 7:30 p.m. The DON indicated the facility does not document anywhere in the clinical record, with the exception of the [MEDICATION NAME] bottle, the exact time the bottle was hung. The DON indicated at this time, even with the hour window of hanging the tube feeding 1 hour before or after the designated time of 7:30 p.m., the resident should only have had 100 ml left in the tube feeding bottle. The DON agreed the resident did not receive the total amount of tube feeding [MEDICATION NAME] that Resident 44 was prescribed to have received, per the physician order. On 3/15/17 at 3:05 p.m., the DON was interviewed. She indicated the feeding tube pump was paused when staff turn the resident or get her up or lay her down. The DON indicated on the MAR (Medication Administration Record), the Record Total Enteral Feeding every shift . should be the documentation of the total amount of [MEDICATION NAME] 1.5 tube feeding only, not to include water used with flushes or meds (medications). It should only be [MEDICATION NAME] totals. The DON indicated the totals of the [MEDICATION NAME] 1.5 tube feeding should be as follows per shift: Evening shift: 7:30 p.m. to 11:00 for a total of 192.5 cc's, Night shift: 11:00 p.m. to 6:30 for a total of 412.5 cc's, Day shift: 7 x 55 = 385 cc's. With all three shift added together, resulted in a total of 990 ml to have been infused. The DON indicated the resident had an order for [REDACTED]. The DON indicated at this time, documentation was lacking in the clinical record for a February 2017 weight. On 3/15/17 at 3:50 p.m., the Social Service note, dated 2/20/17, was reviewed and indicated the following: .writer discussed Hospice services for extra support for (resident name) and Palliative care (approach which improves the quality of life of patients and families who are facing problems through life threatening illnesses thru prevention and relief of suffering) consult done at hospital. (name of resident mother) did not comment on hospice services or her opinion regarding services . On 3/15/17 at 3:38 p.m., the Dietary note dated 1/13/17, included, but was not limited to, the following: Resident is on [MEDICATION NAME] 1.5 at 55 ml/hr (milliliter per hour) for 18 hours off 6 hours a day. She receives a pureed honey thick liquids diet for pleasure only. Has an unstageable area to L (left) heel. Her needs are 1780 calories, 86 gms (grams) protein and .Her tube feeding provides 1485 calories and 63 grams protein .will ask for Prostat (liquid which provides high concentration of calories and protein in small serving size . 30 ml tid (three times a day) that will add an additional 300 calories and 51 gm (grams) protein. This will then meet her needs with 1785 calories and 114 gm protein .Weight 168.5 lbs. Documentation indicated the resident calories and protein intake needs were met at a minimum, with the [MEDICATION NAME] tube feeding and the addition of the Prostat supplement. A nurse practitioner (NP) progress note, dated 2/6/17, indicated the following: .Weight: 168.5 pounds . On 3/15/17 at 4:40 p.m., the Dietician note, dated 3/10/17, was reviewed. The following was documented: Quarterly Review: On a tube feeding with [MEDICATION NAME] 1.5 at 55 ml/hr (milliliter/hour ) from 7:30 p.m. to 1:30 p.m. Flush is 200 ml water 5 times daily. On Prostat 30 ml TID (three times a day) per tube .On a pureed diet with honey thick liquids for pleasure. Has a pressure area to foot that is being treated .TF (tube feed) and Prostat provide 1785 calories and 114 gm (grams) protein .No current weight. A Dehydration Risk Assessment, dated 2/3/17, was reviewed on 3/15/17 at 4:45 p.m. and indicated a total score of 9. A total score of 9 indicated the following: resident was totally dependent for fluid intake, eating, unaware of thirst sensation; no weight loss . On 3/15/17 at 4:28 p.m., the DON provided a copy of the resident's Weights and Vitals Summary. The form included the following: Height: 67 inches Weight: 3/13/17: 150.8 lbs. 1/11/17: 168.5 lbs. 12/15/16: 167.5 lbs 12/7/16: 172 lbs 11/25/16: 177 lbs 10/27/16: 176 lbs. 9/14/16: 171 lbs. Documentation was lacking on the log for a February 2017 weight. The March 2017 MAR (Medication Administration Record) indicated the following: Record total intake of Enteral feeding every shift related to [MEDICAL CONDITION] with a start date of 11/25/16. The day shift had a documented range of Enteral feeding intakes from 960 cc's (for 1 day) to 460 cc's (for 1 day). Ten of the days to date, had a documented intake of 810 cc's for the day shift. The evening shift had a documented range of Enteral feeding intakes from 55 cc's (for 1 day) to 960 cc's (for 1 day). The night shift had a documented range of Enteral feeding intakes from 230 cc's (1 day) to 899 cc's (for 1 day). A physician order, dated 11/25/16, was reviewed and indicated the following: [MEDICATION NAME] 1.5 at 55 ml/hr (milliliters per hour), on at 7:30 p.m. and off at 1:30 p.m .related to [MEDICAL CONDITION] . On 3/15/17 at 4:33 p.m., the DON indicated the resident had recently been in and out of the hospital and provided the following labs from 2/23/17: Basic Metabolic Panel (BMP) and Complete Blood Count with Differential (CBC with Diff). There was no protein level available for review. On 3/15/17 at 4:50 p.m., the DON provided a copy of the meal intake Amount Eaten for Resident 44 from 3/2/17 to 3/15/17. The document included the following information regarding documentation of Percentage of meal eaten: On 3/2/17 at 21:41 (9:41 p.m.) indicated 76-100% consumed; 3/3/17 at 14:09 (2:09 p.m.) indicated 51-75% consumed and at 21:42 (9:42 p.m.) indicated 76-100% consumed; on 3/10/17 at 1800 (6:00 p.m.) indicated 76-100% consumed; and 3/11/17 at 22:16 (10:16 p.m.) indicated 76-100% consumed; and 3/14/17 at 22:22 (10:22 p.m.) indicated 25-50% consumed. On 3/16/17 at 11:05 a.m., the Dietician was interviewed. She indicated the following: The resident was currently on a tube feeding of [MEDICATION NAME] 1.5, which infused at 55 cc/hr from 7:30 p.m. to 1:30 p.m., for a total of 990 cc's. She indicated 990 cc's of [MEDICATION NAME] 1.5 would contain 1485 calories and 63 gms (grams) of protein. She indicated 600 cc of [MEDICATION NAME] 1.5 would contain 900 calories and 38 gms of protein. She indicated 675 cc of [MEDICATION NAME] 1.5 would contain 1,012.5 calories and 43 gms of protein. On 3/16/17 at 11:30 a.m., the DON was interviewed. She indicated the Prostat was added to the resident's plan of care on 2/17/17. On 3/16/17 at 12:00 p.m., the DON and CNA 8 were observed to obtain a weight from Resident 44. The observed weight was obtained with a result of 148.6 lbs. Prior to obtaining the weight on the lift type scale, the CNA was observed to remove the resident's anti pressure heel booties, only apply the sling and not include the incontinent pad underneath the resident and also ensured both of the resident's nephrostomy bags were freely hanging and the scale was zeroed. On 3/16/17 at 12:08 p.m., the DON provided a copy of the current policy and procedure for SWAT (Skin and Weight Assessment Team) Program. The policy and procedure included the following: Purpose: To identify those residents at nutritional risk for related medical concerns. Policy: It is the policy of this facility to assess the nutritional status of each resident Indicators determining implementation of S.W.A.T. monitoring: 5% or more weight change (undesirable) in 30 days; 10% or more weight change (undesirable) in 180 days; .Tube feeding .Procedure: S.W.A.T. will meet weekly to discuss residents in need or addressing current health problems to determine current appropriate interventions, either dietary and/or clinical .S.W.A.T. will follow protocols .for addressing significant weight changes On-going weekly monitoring shall continue on each resident of S.W.A.T. until one of the following conditions has been met .Weight loss - Eight weeks at stable weight unless medical condition dictates otherwise, or a history of fluctuating weight is present. When weight .alternative interventions must be reviewed by the interdisciplinary teams Tube Feeding - On going .Weight Management .Review Weight: Resident's most current weight recorded weight by nursing .Calorie Count: 3 - day account of all foods consumed by the resident to determine nutritional status . On 3/16/17 at 12:46 p.m., the DON provided a copy of the facility policy and procedure, dated February (no day specified) 2017, for Enteral Tube Medication Administration. The policy included, but was not limited to, the following: .facility assures the safe and effective administration of Enteral formulas, routes and methods of administration .Procedure .The selection of the Enteral formula .route of administration and rate of flow is determined by the physician based on the nursing assessment of the resident's condition .Nursing assessment may require .dietician involvement for resident care planning .Calorie count per milliliter is verified before administration to assure the correct dosage is given to achieve calorie objectives . On 3/16/17 at 1:00 p.m., the DON was interviewed. She indicated the resident was being monitored on S.W.A.T. She indicated the weight on 3/13/17 (150.8 lbs) triggered for a 7.5% weight loss from the January assessment period weight of 168.5. The DON indicated she was unable to find a documented weight for this resident from February 2017. On 3/16/17 at 1:30 p.m., the DON was interviewed. She indicated she informed the facility Dietician on 3/13/17 of Resident 44's weight loss (150.8 lb on 3/13/17) and also that is was a significant weight loss as compared to the prior weight on 12/15/16 of 167.5 lbs. The DON indicated the facility Dietician indicated the resident would be reviewed in the SWAT meeting on 3/17/17. On 3/17/17 at 2:20 p.m the Administrator (Adm) provided a copy of Resident 44's Dietary Notes, dated 3/16/17 at 2:00 p.m. from the Dietician. The note included, but was not limited to, the following: .Reviewed resident with DON per phone conversation. Resident was reweighed and weight is 144.6 lb (this was inaccurate as the observed weight on 3/16/17 was 148.6 lb). This is a 23.9 lb loss since January or 14.2 percent. Recommend we increase [MEDICATION NAME] 1.5 to 60 ml/hr (milliliters per hour) for 22 hours . A 2:22 p.m., the Adm was interviewed. She indicated the Dietary note, dated 3/16/17, lacked documentation the physician was notified of the 14.2 percent weight loss in less than 3 months. On 3/17/17 at 4:13 p.m., the Corporate Nurse, was interviewed. She was asked to provide information regarding Resident 44, for review from the SWAT review notes. At this time, the Corporate Nurse provided the following SWAT notes for Resident 44: A note with a printed date of 2/16/17, indicated Resident 44 was a readmit, tube feeding, pureed consistency .honey thick liquids . An undated form, indicated Resident 44 was on Honey thick liquids and a tube feeding [MEDICATION NAME] 1.5 at 55 cc/hr 7:30 p.m. - 1:30 p.m. Another form, dated 2/23/17 Resident 44 was a readmit, tube feeding, pureed consistency .honey thick liquids . indicated the same information as was included on the above undated form, with [MEDICATION NAME] at 1.5 at 55 cc/hr from 7:30 p.m. to 1:30 p.m. Another undated note regarding Resident 44 indicated honey thick liquids tube feeding of [MEDICATION NAME] 1.5 at 80 cc/hr from 7 p.m. to 1 p.m. 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 residents who was dependent on a tube feeding (tube medically inserted into the stomach to provide nutrition to patients who can't obtain nutrition by mouth) had adequate calorie requirements met, which resulted in an unplanned, significant weight loss. (Resident 44) Findings include: On 3/15/17 at 3:15 p.m., the clinical record of Resident 44 was reviewed. [DIAGNOSES REDACTED]. Resident 44's MDS (Minimum Data Set) Assessment, dated 12/5/16 indicated the following: the resident had severely impaired cognition, extensive assistance was required for bed mobility, ther resident was totally dependent for eating, the percent of calorie intake by artificial route was 51% or more; and artificial intake by tube feeding was 501 cc (cubic centimeter which is interchangeable with ml (milliliters)/day or more. A review of the current policy and procedure for Enteral Tubes: Continuous (Pump) Feedings, revised on1/15/15, indicated the following: Policy: It is the policy of the facility to deliver ordered intermittent feeding and/or hydration via a pump method to provide necessary nutrition and hydration as required to maintain the residents caloric and hydration needs .Procedure: Verify physician's orders [REDACTED].When feeding is complete flush tube .complete all required documentation A plan of care, with Last Care Plan Review Completed date of 2/14/17 was reviewed. The focus of the care plan was, .receives tube feeding for the majority of her nutrition and hydration needs due to [MEDICAL CONDITION]. She is on oral pleasure feedings diet that is consistency altered. She has skin breakdown. The following date was documented for the Date initiated/Revision on: 2/17/17. The Goal, date initiated was documented as 1/13/17, with a revision date of 2/17/17. The goal was the following: .Resident .weight stable at 168 +/- 5 lb (pound) Interventions included the following: .Provide tube feeding and flush as ordered. Provide pleasure feedings as ordered .Monitor weights and intakes Date this intervention was initiated was 8/26/15 with revision on 9/1/15. On 3/14/17 at 9:00 a.m., Resident 44 was observed in her bed, with the tube feeding infusing of [MEDICATION NAME] 1.5 infusing at 55 ml ((milliliter, unit of liquid volume interchangeable with cc (cubic centimeters)/hr(hour)) per the pump. The 1 liter (1000 ml) bottle of [MEDICATION NAME] was observed to be dated 3/13/17 at 8:00 p.m. At this time, 9:00 a.m., there was observed to be 600 ml remaining in the bottle. On 3/14/17 at 10:07 a.m., the pump with feeding was observed to be working, lights on and the mechanism was observed to spin around in circular motion intermittently. The Vol (Volume) delivered area on the pump, indicated 240 ml. The level of [MEDICATION NAME] feeding in the bottle was observed to be slightly over 500 ml line on the bottle. On 3/14/17 at 12:15 p.m., the [MEDICATION NAME] feeding was observed to be a the level of 400 ml, with the total volume infused listed as 352 ml. The pump was observed on and running at a rate on the pump of 55 cc/hr. On 3/14/17 at 1:15 p.m., the [MEDICATION NAME] feeding pump indicated 409 ml infused. The pump was observed to on and running. The rate continued at 55 cc/hr and 350 ml was observed to remain in the bottle of [MEDICATION NAME]. On 3/14/17 at 1:16 p.m., CNA 9 was interviewed. She was observed to be working on the same hall as Resident 44 resided CNA 9 indicated Resident 44 did not receive meal trays for food to eat. On 3/14/17 at 1:25 p.m., the door to Resident 44's room was closed and the medication cart was outside the room. On 3/14/17 at 1:33 p.m., the door was now opened and the feeding tube pump, which had the [MEDICATION NAME] feeding on it was turned off. The [MEDICATION NAME] feeding bottle was no longer hanging on the pump. On 3/14/17 at 1:50 p.m., the bottle of [MEDICATION NAME] 1.5 was observed in the trash can in Resident 44's room. The [MEDICATION NAME] bottle was positioned in the same manner as it was observed hanging from the pump, with 400 cc observed remaining in the bottle. On 3/14/17 at 2:24 p.m., LPN 1 had documented 810 cc for Total intake of Enteral feeding every shift. On 3/15/17 at 8:50 a.m., Resident 44 was observed in her bed, with the tube feeding pump observed to be on and infusing, with the bottle of [MEDICATION NAME] 1.5 hanging. The rate on the pump was observed to be 55 ml/hr and the total intake was observed to be 178. At this time, there was observed to be 550 ml of [MEDICATION NAME] left in the the hanging bottle. On 3/15/17 at 11:00 a.m., the tube feeding pump was observed to be running. The pump was observed to have 301 (ml) for amount infused and 55 (ml/hr) for infusion rate. There was a total of 400 cc observed remaining [MEDICATION NAME] in the hanging bottle. On 3/15/17 at 12:30 p.m., the volume delivered on the machine was observed as 383, the rate was observed at 55 ml/hr and there was observed 350 ml level in the [MEDICATION NAME] in the level of the bottle. On 3/15/17 at 1:10 p.m., Resident 44 was observed in her bed. The [MEDICATION NAME] tube feeding was observed to no longer be infusing per the tube feeding pump. The bottle of [MEDICATION NAME] tube feeding was observed in the trash at the resident's bedside. At this time, when the bottle of tube feeding was held upright, in the same manner as the bottle was observed to hang on the tube feeding pump, 300 ml tube feeding was observed in the bottom of the bottle. On 3/15/17 at 1:55 p.m., LPN 1 was interviewed. She indicated the following: she calculated the total amount she documented in the MAR (Medication Administration Record) for Record total intake of Enteral feeding as 810 for 3/14/17 and 3/15/17. LPN 1 indicated I figured wrong. LPN 1 indicated the amount of Enteral feeding intake was recorded in cc's or ml's. She indicated she does not look at the level of the [MEDICATION NAME] tube feeding in the bottle. She indicated she calculated the total amount of [MEDICATION NAME] intake on her shift by multiplying the rate of 55 ml/hr by the 7 hours the [MEDICATION NAME] was infusing during her shift, 6:30 a.m. to 1:30 p.m. She indicated she doesn't do anything with the volume infused control button display total on the tube feeding pump. She indicated the [MEDICATION NAME] infusion was off from 1:30 p.m. to 7:30 p.m. She indicated the total of 810 cc's, which she documented on the MAR for 3/14/17 and 3/15/17 included the 55 cc/hr x 7 hours for a total of 385 cc's of [MEDICATION NAME]. She indicated she also adds in the 200 cc flushes of water, which she gives the resident through her tube feeding when she gives the resident her morning and afternoon medications. LPN 1 indicated she gave Resident 44 her afternoon meds when she (LPN 1) discontinued the [MEDICATION NAME] tube feeding at 1:30 p.m. LPN 1 indicated she does not include the small amounts of water she uses for the tube medication administration. LPN 1 indicated when she takes the [MEDICATION NAME] tube feeding bottle down, she always throws it away so a new bottle hung to infuse at 7:30 p.m. when the tube feeding resumes. On 3/15/17 at 2:10 p.m., the DON (Director of Nursing) was interviewed. At this time, the [MEDICATION NAME] 1.5 Bottle was observed to have the following documentation on the bottle: hung/started at 7:30 p.m. on 3/14/17, rate of infusion was 55 ml/hr. The DON indicated the current physician ordered rate for the [MEDICATION NAME] 1.5 was 55 cc/hr from 7:30 p.m. to 1:30 p.m. The DON indicated there was 325 cc [MEDICATION NAME] 1.5 feeding left in the bottle, which contained a total of 1000 ml feeding, when it was held up in the same position as it would have been by hanging on the tube feeding pole. The DON indicated at this time, if the [MEDICATION NAME] was infusing at a rate of 55 cc/hr for 18 hours, the resident should have received a total of 990 ml's of feeding. The DON indicated with a total feeding in the bottle of 1000 ml, the bottle should only have 10 ml's remaining in the bottle, as compared to the 325 ml's which were actually observed remaining in the bottle. The DON indicated the [MEDICATION NAME] bottle Probably didn't get hung right at 7:30 p.m. The DON indicated the facility does not document anywhere in the clinical record, with the exception of the [MEDICATION NAME] bottle, the exact time the bottle was hung. The DON indicated at this time, even with the hour window of hanging the tube feeding 1 hour before or after the designated time of 7:30 p.m., the resident should only have had 100 ml left in the tube feeding bottle. The DON agreed the resident did not receive the total amount of tube feeding [MEDICATION NAME] that Resident 44 was prescribed to have received, per the physician order. On 3/15/17 at 3:05 p.m., the DON was interviewed. She indicated the feeding tube pump was paused when staff turn the resident or get her up or lay her down. The DON indicated on the MAR (Medication Administration Record), the Record Total Enteral Feeding every shift . should be the documentation of the total amount of [MEDICATION NAME] 1.5 tube feeding only, not to include water used with flushes or meds (medications). It should only be [MEDICATION NAME] totals. The DON indicated the totals of the [MEDICATION NAME] 1.5 tube feeding should be as follows per shift: Evening shift: 7:30 p.m. to 11:00 for a total of 192.5 cc's, Night shift: 11:00 p.m. to 6:30 for a total of 412.5 cc's, Day shift: 7 x 55 = 385 cc's. With all three shift added together, resulted in a total of 990 ml to have been infused. The DON indicated the resident had an order for [REDACTED]. The DON indicated at this time, documentation was lacking in the clinical record for a February 2017 weight. On 3/15/17 at 3:50 p.m., the Social Service note, dated 2/20/17, was reviewed and indicated the following: .writer discussed Hospice services for extra support for (resident name) and Palliative care (approach which improves the quality of life of patients and families who are facing problems through life threatening illnesses thru prevention and relief of suffering) consult done at hospital. (name of resident mother) did not comment on hospice services or her opinion regarding services . On 3/15/17 at 3:38 p.m., the Dietary note dated 1/13/17, included, but was not limited to, the following: Resident is on [MEDICATION NAME] 1.5 at 55 ml/hr (milliliter per hour) for 18 hours off 6 hours a day. She receives a pureed honey thick liquids diet for pleasure only. Has an unstageable area to L (left) heel. Her needs are 1780 calories, 86 gms (grams) protein and .Her tube feeding provides 1485 calories and 63 grams protein .will ask for Prostat (liquid which provides high concentration of calories and protein in small serving size . 30 ml tid (three times a day) that will add an additional 300 calories and 51 gm (grams) protein. This will then meet her needs with 1785 calories and 114 gm protein .Weight 168.5 lbs. Documentation indicated the resident calories and protein intake needs were met at a minimum, with the [MEDICATION NAME] tube feeding and the addition of the Prostat supplement. A nurse practitioner (NP) progress note, dated 2/6/17, indicated the following: .Weight: 168.5 pounds . On 3/15/17 at 4:40 p.m., the Dietician note, dated 3/10/17, was reviewed. The following was documented: Quarterly Review: On a tube feeding with [MEDICATION NAME] 1.5 at 55 ml/hr (milliliter/hour ) from 7:30 p.m. to 1:30 p.m. Flush is 200 ml water 5 times daily. On Prostat 30 ml TID (three times a day) per tube .On a pureed diet with honey thick liquids for pleasure. Has a pressure area to foot that is being treated .TF (tube feed) and Prostat provide 1785 calories and 114 gm (grams) protein .No current weight. A Dehydration Risk Assessment, dated 2/3/17, was reviewed on 3/15/17 at 4:45 p.m. and indicated a total score of 9. A total score of 9 indicated the following: resident was totally dependent for fluid intake, eating, unaware of thirst sensation; no weight loss . On 3/15/17 at 4:28 p.m., the DON provided a copy of the resident's Weights and Vitals Summary. The form included the following: Height: 67 inches Weight: 3/13/17: 150.8 lbs. 1/11/17: 168.5 lbs. 12/15/16: 167.5 lbs 12/7/16: 172 lbs 11/25/16: 177 lbs 10/27/16: 176 lbs. 9/14/16: 171 lbs. Documentation was lacking on the log for a February 2017 weight. The March 2017 MAR (Medication Administration Record) indicated the following: Record total intake of Enteral feeding every shift related to [MEDICAL CONDITION] with a start date of 11/25/16. The day shift had a documented range of Enteral feeding intakes from 960 cc's (for 1 day) to 460 cc's (for 1 day). Ten of the days to date, had a documented intake of 810 cc's for the day shift. The evening shift had a documented range of Enteral feeding intakes from 55 cc's (for 1 day) to 960 cc's (for 1 day). The night shift had a documented range of Enteral feeding intakes from 230 cc's (1 day) to 899 cc's (for 1 day). A physician order, dated 11/25/16, was reviewed and indicated the following: [MEDICATION NAME] 1.5 at 55 ml/hr (milliliters per hour), on at 7:30 p.m. and off at 1:30 p.m .related to [MEDICAL CONDITION] . On 3/15/17 at 4:33 p.m., the DON indicated the resident had recently been in and out of the hospital and provided the following labs from 2/23/17: Basic Metabolic Panel (BMP) and Complete Blood Count with Differential (CBC with Diff). There was no protein level available for review. On 3/15/17 at 4:50 p.m., the DON provided a copy of the meal intake Amount Eaten for Resident 44 from 3/2/17 to 3/15/17. The document included the following information regarding documentation of Percentage of meal eaten: On 3/2/17 at 21:41 (9:41 p.m.) indicated 76-100% consumed; 3/3/17 at 14:09 (2:09 p.m.) indicated 51-75% consumed and at 21:42 (9:42 p.m.) indicated 76-100% consumed; on 3/10/17 at 1800 (6:00 p.m.) indicated 76-100% consumed; and 3/11/17 at 22:16 (10:16 p.m.) indicated 76-100% consumed; and 3/14/17 at 22:22 (10:22 p.m.) indicated 25-50% consumed. On 3/16/17 at 11:05 a.m., the Dietician was interviewed. She indicated the following: The resident was currently on a tube feeding of [MEDICATION NAME] 1.5, which infused at 55 cc/hr from 7:30 p.m. to 1:30 p.m., for a total of 990 cc's. She indicated 990 cc's of [MEDICATION NAME] 1.5 would contain 1485 calories and 63 gms (grams) of protein. She indicated 600 cc of [MEDICATION NAME] 1.5 would contain 900 calories and 38 gms of protein. She indicated 675 cc of [MEDICATION NAME] 1.5 would contain 1,012.5 calories and 43 gms of protein. On 3/16/17 at 11:30 a.m., the DON was interviewed. She indicated the Prostat was added to the resident's plan of care on 2/17/17. On 3/16/17 at 12:00 p.m., the DON and CNA 8 were observed to obtain a weight from Resident 44. The observed weight was obtained with a result of 148.6 lbs. Prior to obtaining the weight on the lift type scale, the CNA was observed to remove the resident's anti pressure heel booties, only apply the sling and not include the incontinent pad underneath the resident and also ensured both of the resident's nephrostomy bags were freely hanging and the scale was zeroed. On 3/16/17 at 12:08 p.m., the DON provided a copy of the current policy and procedure for SWAT (Skin and Weight Assessment Team) Program. The policy and procedure included the following: Purpose: To identify those residents at nutritional risk for related medical concerns. Policy: It is the policy of this facility to assess the nutritional status of each resident Indicators determining implementation of S.W.A.T. monitoring: 5% or more weight change (undesirable) in 30 days; 10% or more weight change (undesirable) in 180 days; .Tube feeding .Procedure: S.W.A.T. will meet weekly to discuss residents in need or addressing current health problems to determine current appropriate interventions, either dietary and/or clinical .S.W.A.T. will follow protocols .for addressing significant weight changes On-going weekly monitoring shall continue on each resident of S.W.A.T. until one of the following conditions has been met .Weight loss - Eight weeks at stable weight unless medical condition dictates otherwise, or a history of fluctuating weight is present. When weight .alternative interventions must be reviewed by the interdisciplinary teams Tube Feeding - On going .Weight Management .Review Weight: Resident's most current weight recorded weight by nursing .Calorie Count: 3 - day account of all foods consumed by the resident to determine nutritional status . On 3/16/17 at 12:46 p.m., the DON provided a copy of the facility policy and procedure, dated February (no day specified) 2017, for Enteral Tube Medication Administration. The policy included, but was not limited to, the following: .facility assures the safe and effective administration of Enteral formulas, routes and methods of administration .Procedure .The selection of the Enteral formula .route of administration and rate of flow is determined by the physician based on the nursing assessment of the resident's condition .Nursing assessment may require .dietician involvement for resident care planning .Calorie count per milliliter is verified before administration to assure the correct dosage is given to achieve calorie objectives . On 3/16/17 at 1:00 p.m., the DON was interviewed. She indicated the resident was being monitored on S.W.A.T. She indicated the weight on 3/13/17 (150.8 lbs) triggered for a 7.5% weight loss from the January assessment period weight of 168.5. The DON indicated she was unable to find a documented weight for this resident from February 2017. On 3/16/17 at 1:30 p.m., the DON was interviewed. She indicated she informed the facility Dietician on 3/13/17 of Resident 44's weight loss (150.8 lb on 3/13/17) and also that is was a significant weight loss as compared to the prior weight on 12/15/16 of 167.5 lbs. The DON indicated the facility Dietician indicated the resident would be reviewed in the SWAT meeting on 3/17/17. On 3/17/17 at 2:20 p.m the Administrator (Adm) provided a copy of Resident 44's Dietary Notes, dated 3/16/17 at 2:00 p.m. from the Dietician. The note included, but was not limited to, the following: .Reviewed resident with DON per phone conversation. Resident was reweighed and weight is 144.6 lb (this was inaccurate as the observed weight on 3/16/17 was 148.6 lb). This is a 23.9 lb loss since January or 14.2 percent. Recommend we increase [MEDICATION NAME] 1.5 to 60 ml/hr (milliliters per hour) for 22 hours . A 2:22 p.m., the Adm was interviewed. She indicated the Dietary note, dated 3/16/17, lacked documentation the physician was notified of the 14.2 percent weight loss in less than 3 months. On 3/17/17 at 4:13 p.m., the Corporate Nurse, was interviewed. She was asked to provide information regarding Resident 44, for review from the SWAT review notes. At this time, the Corporate Nurse provided the following SWAT notes for Resident 44: A note with a printed date of 2/16/17, indicated Resident 44 was a readmit, tube feeding, pureed consistency .honey thick liquids . An undated form, indicated Resident 44 was on Honey thick liquids and a tube feeding [MEDICATION NAME] 1.5 at 55 cc/hr 7:30 p.m. - 1:30 p.m. Another form, dated 2/23/17 Resident 44 was a readmit, tube feeding, pureed consistency .honey thick liquids . indicated the same information as was included on the above undated form, with [MEDICATION NAME] at 1.5 at 55 cc/hr from 7:30 p.m. to 1:30 p.m. Another undated note regarding Resident 44 indicated honey thick liquids tube feeding of [MEDICATION NAME] 1.5 at 80 cc/hr from 7 p.m. to 1 p.m. 3.1-47(a)(2)

Based on interview and record review the facility failed to follow its CPR policy to complete advance directives as ordered by the physician and as directed by the resident or responsible party for 1 of 3 residents reviewed for following advance directives. (Resident B) The facility also failed to assure advance directive orders and resident wishes matched for 1 of 12 in an extended sample. (Resident E) The Immediate Jeopardy was identified on [DATE] and began on [DATE] when 1 of 1 residents did not receive CPR as ordered by the physician, resulting in death. The Administrator, Director of Nursing (DON), and Nursing Consultant were notified of the Immediate Jeopardy on [DATE] at 2:30 PM. The Immediate Jeopardy was removed on [DATE], but remained at the lower scope and severity level of isolated actual harm that is not Immediate Jeopardy. Findings include: 1. Resident B's record was reviewed [DATE] at 10:24 AM. Resident B's [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. The physician's orders [REDACTED]. In an interview on [DATE] at 11:19 AM, the court appointed guardian stated she had taken over as guardian on [DATE], and had not had time to get to the facility to change the advance directive status. The guardian also stated she signed the residents advance directive status as Do Not Resuscitate (DNR) after the resident had already died because the original intent was to make the resident a DNR, but she did not have time to get to the facility before he had died . A review of Nurse's Progress Notes dated [DATE] at 8:15 AM written by Licensed Nurse 1 showed Resident B was RHC (Respirations Have Ceased) at 5:45 AM. In an interview on [DATE] at 10:55 AM Licensed Nurse 1 stated she was in Resident B's room giving a treatment to his roommate at 4:45 AM, Resident B was sleeping well when she left the room. At 5:40 AM, a CNA came down the hall and said Resident B was not breathing. Nurse 1 went into the room and found Resident B breathless, pulseless, cool to touch, and beginning to be stiff. I did not know if the resident was a code, so I went to the desk, and by the time I found his code status, it was too late to start CPR. I did not follow the policy. I should have started CPR. In an interview on [DATE] at 4:45 PM, CNA 2 stated she was not CPR certified, so when she found Resident B not breathing, she got the nurse who came right away. The nurse then went to get the chart and she went on to the next room. A current policy dated [DATE], titled Cardiopulmonary Resuscitation (CPR) provided by the Administrator on [DATE] at 10:55 AM showed It is the intent of the facility to ensure that all residents suffering a cardiac or respiratory arrest will receive the treatment of [REDACTED]. The facility immediately placed advance directive status on the first page of the chart and began reeducation of the staff. Interviews with staff on [DATE] and [DATE] stated they had been reeducated on the quick location of advance directives. 2. Resident E's record was reviewed [DATE] at 3:50 PM. Resident E's [DIAGNOSES REDACTED]. A review of Advance Directive dated [DATE] indicated the facility was not to attempt resuscitation. The form had not been signed by the physician. A review of Physician order [REDACTED]. In an interview on [DATE] at 4:10 PM, the Administrator stated the physician was on his way to the facility to sign the form. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility began reeducating staff on the facility policy of CPR, and identifying CPR certified staff on their schedule. Advance Directives were placed on the front of the chart and on medicine carts. Staff not reeducated by [DATE] are reeducated prior to working their next regularly scheduled shift. 50 of 56 nursing employees have received reeducation according to interview and inservice sign in sheets. The Medical Records clerk has been reeducated regarding maintaining the Advance directive forms and orders in the front of the chart. The noncompliance remained at the lower scope and severity level of Isolated Actual Harm that is not Immediate Jeopardy because reeducation of staff has not been completed and monitoring has not been initiated. 3XXX,[DATE](b)(5)