Every finding on record at Charlestown Place at New Albany

Based on interview and record review, the facility failed to ensure a resident's (Resident C) clinical record was updated, as requested by the resident's Power of Attorney, for 1 of 3 residents reviewed for resident rights. Findings include:The clinical record for Resident C was reviewed on 6/16/26 at 1:20 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (a progressive, incurable lung disease that caused obstructed airflow and breathing difficulties), diabetes (chronic condition where the body either cannot produce enough insulin or cannot effectively use the insulin it makes) and depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities).On 6/17/26 at 10:09 a.m., the Executive Director provided, and indicated, she had just found a document requested by Resident C's son. The note, dated 9/17/25, indicated that Resident C's son was allowed to receive healthcare information on Resident C. The note was signed by Resident C's Power of Attorney (POA)During an interview, on 6/17/26 at 10:45 a.m., Resident C's POA indicated she had provided the previous Executive Director with a handwritten note in September of 2025. The note granted permission for Resident C's son to receive health care information on Resident C.The clinical record lacked documentation for the resident's son to receive healthcare information.On 6/17/26 at 10:09 a.m., the Executive Director indicated she was unaware of the handwritten note as she was not here at the time the note was provided.This citation relates to Intake 3030651410 IAC (Indiana Authorization Code) 16.2-3.1-3(d)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) representative was notified of an acquired venous ulcer and a gradual dose reduction in medication for 1 of 3 residents reviewed for notification of changes. Findings include:The clinical record for Resident B was reviewed on 6/16/26 at 9:41 a.m. The resident's diagnoses included, but were not limited to, depression (a serious mood disorder that causes persistent feeling of sadness, emptiness, and a loss of interest in activities) and peripheral vascular diseases (a slow, progressive circulation disorder that narrows or blocks blood vessels outside the heart and brain).The nurse practitioner wound note, dated 4/14/26, indicated the resident had a vascular wound (sore on the skin caused by poor circulation) to the right calf and a treatment was implemented.The psychiatric nurse practitioner progress note, dated 4/29/26 at 12:08 p.m., indicated to discontinue Sertraline (medication used for depression) 25 mg (milligrams) in the morning for a gradual dose reduction (GDR) and continue the Sertraline 50 mg in the evening.The clinical record lacked documentation of family notification related to the vascular wound and the discontinuation of the Sertraline.During an interview, on 6/18/26 at 11:49 a.m., the Director of Nursing indicated the family should have been notified.On 6/18/26 at 3:32 p.m., the Executive Director provided a current copy of the document titled Change in a Resident's Condition or Status dated February 2021. It included, but was not limited to, Policy Statement.Our facility promptly notifies the resident.and the resident representative of changes in the resident's medical.condition.or status.This citation relates to Intake 3018317410 AIC (Indiana Authorization Code) 16.2-3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure monitoring was in place for residents (Resident B and Resident C) when a gradual dose reduction (GDR) was implemented for 2 of 3 residents; and failed to ensure a resident (Resident B) was immediately assessed for injury after a witnessed fall for 1 of 3 residents reviewed for quality of care. Findings include:1. The clinical record for Resident B was reviewed on 6/16/26 at 9:41 a.m. The resident's diagnosis included, but was not limited, depression (a common but serious mood disorder which causes persistent feelings of sadness, hopelessness and a loss of interest in activities).The April 2026 medication administration record indicated the resident received sertraline (medication for depression) 25 mg (milligrams) daily in the morning and 50 mg in the evening for depression. A psychiatric progress note, dated 4/29/26 at 12:08 p.m., indicated to discontinue the resident's sertraline 25 mg in the morning for a gradual dose reduction (GDR).The clinical record lacked documentation of a 72-hour follow-up for close monitoring when the sertraline 25 mg was discontinued.A progress note, dated 5/19/26 at 11:23 a.m., indicated Resident B had a witnessed fall and that the family had been notified.The clinical record lacked documentation of an assessment for injury at the time of the fall.During an interview, during the survey period, Staff Member 5 indicated when a resident falls, the nurse should immediately assess the resident for any injuries.During an interview, on 6/18/26 at 11:49 a.m., the Director of Nursing indicated the 72-hours follow up for GDR's should be documented in the progress notes.On 6/18/26 at 3:00 p.m., the Executive Director provided a current copy of the document titled Tapering Medications and Gradual Drug Dose Reduction dated July 2022. It included, but was not limited to, Policy interpretation and implementation .When a medication is tapered or stopped, the staff will closely monitor the resident 2. The clinical record for Resident C was reviewed on 6/16/26 at 1:20 p.m. The resident's diagnoses included, but were not limited to, depression (a common but serious mood disorder which causes persistent feelings of sadness, hopelessness and a loss of interest in activities).The physician's order, dated 9/18/26, indicated the resident was to receive Paxil (medication for depression) 5 mg daily.A psychiatric progress note, dated 12/3/25 at 9:02 a.m., indicated to discontinue the Paxil for a GDR.The clinical record lacked documentation of a 72-hour follow up for close monitoring when the medication was discontinued.This citation relates to Intakes 3018317, 3024762 and 3030651410 IAC (Indiana Authorization Code) 16.2-3.1-37

Based on interview and record review, the facility to ensure a resident (Resident B) was transferred, via mechanical lift, with two staff members present during the transfer for 1 of 3 residents reviewed for accidents. Findings include:The clinical record for Resident B was reviewed on 6/16/26 at 9:41 a.m. The resident's diagnoses included, but were not limited to, peripheral vascular disease (a slow, progressive circulation disorder characterized by narrowed or blocked blood vessels outside the heart and brain, most commonly affects the legs), polyneuropathy (damage or disease affecting multiple peripheral nerves simultaneously) and repeated falls. The quarterly MDS (Minimum Data Set) assessment, dated 3/23/26, indicated Resident B had intact cognition and limited range of motion to both of her upper arms.During an interview, on 6/16/26 at 12:50 p.m., Resident B indicated she did have a fall. CNA 7 was dressing her after her shower. She told CNA 7 that her shoulder hurt and that she could not hold on. CNA 7 told her to hold on because she was almost done. Resident B's hand came loose and she fell. A progress note, dated 5/19/26 at 11:23 a.m., indicated the resident had a witnessed fall.The IDT (interdisciplinary team) note, dated 5/20/26 at 3:27p.m., indicated the resident was lowered to the floor from the sit to stand lift when the resident's hand slipped from the handle. The resident was being transferred by one CNA (Certified Nursing Assistant) and the resident became uncomfortable in the sling and leg go of the handle.During an interview, on 6/16/26 at 2:34 p.m., the Director of Nursing indicated Resident B's fall happened in the resident's room after her shower. CNA 7 was transferring the resident when the fall started to happen. CNA 7 yelled for Licensed Practical Nurse (LPN) 8 for assistance. There should have been two staff members present when the mechanical lift was being used for the resident. On 6/18/26 at 3:00 p.m., the Executive Director provided a current copy of the document titled Safe Lifting and Movement of Residents dated July 2017. It included, but was not limited to, Policy Statement.In order to protect the safety and well-being of.residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.This deficient practice was corrected on 5/20/26, prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan which included the following: Immediate education was provided to the staff involved with the incident related to the use of sit to stand lifts according to manufacturer guidelines and the resident level of care needs; All staff were educated on how to properly use the sit to stand lift in accordance with the manufacturers guidelines and residents level of care required for transfers.This citation relates to Intake 3018317410 IAC (Indiana Authorization Code) 16.2-3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident C) medication administration record accurately reflected the administration of a medication for 1 of 3 residents reviewed for medical records. Findings include:The clinical record for Resident C was reviewed on 6/16/26 at 1:20 p.m. The resident's diagnosis included, but was not limited to, inappropriate sexual behaviors (encompasses physical or verbal actions of a sexual nature that violate social norms).The Nurse Practitioner note, dated 12/17/25, indicated to start Climara TD (transdermal) patch (medication used for inappropriate sexual behavior).The physician's order, dated 12/17/26, indicated the resident was to receive the Climara Transdermal Patch Weekly, 0.1 mg/24 hour. Apply one patch transdermally one time a day for sexually inappropriate behaviors in the morning.Review of the December 2025 and January 2026 medication administration records (MAR), indicated the resident received the medication on the following dates in the morning: 12/18/25 through 12/22/25; 12/26/25 through 12/28/25; 12/31/25; and 01/01/26 through 01/05/26.During an interview on 6/18/26 at 11:26 a.m., the Director of Nursing indicated the Nurse Practitioner had put the order in the system incorrectly. Some of the staff were signing the medication out as given and some did not. The facility never received the medication because the pharmacy was waiting on clarification of the order.On 6/18/26 at 3:00 p.m., the Executive Director provided a current copy of the document titled Administering Medications dated April 2019. It included, but was not limited to, The individual administering the medication initials the resident's MAR.after giving each medication.This citation relates to Intakes 3024762 and 3030651410 IAC (Indiana Authorization Code) 16.2-3.1-50(a)(2)

Based on interview and record review, the facility management failed to timely report an incident to the Indiana Department of Health when a resident (Resident E) acquired a second degree burn from a coffee spill for 1 of 5 residents reviewed for reportable incidents. Findings include:The clinical record for Resident E was reviewed on 5/11/26 at 8:14 a.m. The resident's diagnosis included, but was not limited to, second degree burn (damages to the top layer of skin and the second layer characterized by server pain, swelling, ad blisters) to left hip.The incident report, dated 5/11/26, indicated on 4/23/26, Resident E reported that she spilled coffee on herself during breakfast. The nurse practitioner evaluated Resident E and new orders were received. The nurse practitioner note, dated 4/23/26 at 10:48 a.m., indicated the resident reported she was having her morning coffee and spilled it on her left hip which caused a burn and blister. The assessment/plan was to apply Silvadene (prescription antibiotic cream used to treat infections in second and third-degree burns) 1% to the second degree burn every 4 hours as needed.Review of the facility reportable incidents, between 3/21/26 and 5/11/26 lacked documentation of the second-degree burn to Resident E's left hip.On 5/11/26 at 10:21 a.m., the Executive Director indicated the resident's burn had not been reported as she was unaware burns greater than first-degree needed to be reported.During an interview on 5/11/26 at 1:18 p.m., the Executive Director indicated the facility followed State guidance related to reporting incidents.The Indiana Department of Health Policies and Procedures titled Long-Term Care Abuse and Incident Reporting Policy included, but was not limited to, Purpose .To facilitate compliance with state and federal law and regulation, as applicable, related to reporting of .incidents in licensed long-term care facilities in Indiana .Types of Incidents Reportable Under Federal and State Rules.Major accidents.Burns greater than first degree.

Based on interview and record review, the facility failed to ensure blood pressure medications were not administered to residents (Resident C and Resident D) when out of the physician ordered parameter blood pressure readings for 2 of 4 residents reviewed for quality of care. Findings include:1. The clinical record for Resident C was reviewed on 5/11/26 at 7:52 a.m. The resident's diagnosis included, but was not limited to, hypotension (abnormally low blood pressure).The physician's order, dated 4/4/26, indicated the resident was to receive Midodrine (medication used to increase blood pressure) 10 mg (milligrams) three times a day at 8:00 a.m., 2:00 p.m. and 9:00 p.m. The medication was to be held if the resident's systolic blood pressure (SBP) was greater than 120.The April 2026 and May 2026 medication administration records (MAR) indicated the resident received the medication on the following dates and times:-On 4/07/26 at 9:00 p.m., the resident received the Midodrine with a SBP of 121-On 4/10/26 at 8:00 a.m., the resident received the Midodrine with a SBP of 129 and at 9:00 p.m. with a SBP of 148-On 4/11/26 at 8:00 a.m., the resident received the Midodrine with a SBP of 140-On 4/15/26 at 8:00 a.m., the resident received the Midodrine with a SBP of 138 and at 2:00 p.m. with a SBP of 124-On 4/16/26 at 2:00 p.m., the resident received the Midodrine with a SBP of 135-On 4/18/26 at 9:00 p.m., the resident received the Midodrine with a SBP of 133-On 4/20/26 at 2:00 p.m., the resident received the Midodrine with a SBP of 133 and at 9:00 p.m. with a SBP of 132-On 4/23/26 at 2:00 p.m., the resident received the Midodrine with a SBP of 122-On 4/24/26 at 2:00 p.m., the resident received the Midodrine with a SBP of 128 and at 9:00 p.m. with a SBP of 126-On 4/25/26 at 8:00 a.m., the resident received the Midodrine with a SBP of 132-On 5/03/26 at 2:00 p.m., the resident received the Midodrine with a SBP of 130-On 5/08/26 at 9:00 p.m., the resident received the Midodrine with a SBP of 132During an interview, on 5/11/26 at 12:49 p.m., Registered Nurse (RN) 5 indicated blood pressure medication should not be administered if a resident's blood pressure was out of parameters. 2. The clinical record for Resident D was reviewed on 5/11/26 at 10:14 a.m. The resident's diagnosis included, but was not limited to, heart failure.The physician's order, dated 1/31/25, indicated the resident was to receive Metoprolol Succinate (medication for high blood pressure) ER (extended release), 25 mg daily at 8:00 a.m. The medication was to be held if the systolic blood pressure was less than 120.The April 2026 and May 2026 medication administration records indicated the resident received the medication on the following dates:-On 4/24/26 at 8:00 a.m., the resident received the Metoprolol Succinate with a SBP of 109-On 5/02/26 at 8:00 a.m., the resident received the Metoprolol Succinate with a SBP of 110 On 5/12/26 at 10:44 a.m., the Executive Director provided a current copy of the document titled Medication Administration dated 6/21/17. It included, but was not limited to, Policy.Medications will be administered.in accordance.with accepted standards of practice. This Citation relates to Intake 2992467410 AIC (Indiana Authorization Code) 16.2-3.1-37

Based on interview and record review, the facility failed to ensure timely wound treatments were implemented for a resident (Resident E), upon admission, for 1 of 3 residents reviewed for pressure ulcer prevention. Findings include:The clinical record for Resident E was reviewed on 5/11/26 at 8:14 a.m. The resident's diagnoses included, but were not limited to, depression, sepsis (the body's extreme, life-threatening response to an infection) and anxiety.The progress note, dated 4/10/26 at 4:45 p.m., indicated Resident E was admitted back to the facility from the hospital.The admission evaluation, dated 4/10/26 at 8:05 p.m., indicated the following skin issues:-Blanchable redness on the buttocks-Skin tear to the upper clavicle area, left upper arm and right elbow.The skin note, dated 4/13/26 at 1:11 p.m., indicated the resident admitted with following:-Stage 3 pressure wound of the left posterior thigh-Stage 3 pressure wound of the right posterior thigh-Skin tear to the right lower shin-Skin tear to the right upper chest-Unstageable to the right heel-Unstageable to the left heel-Venous wound to the right footThe clinical record lacked documentation of the implementation of wound treatments for the wounds until 4/16/26.During an interview, on 5/11/26 at 10:23 a.m., the Director of Nursing indicated treatments should be implemented immediately, upon admission, for residents with wounds.On 5/11/26 at 10:44 a.m., the Executive Director provided a current copy of the document titled Skin Integrity and Wound Policy dated 11/7/23. It included, but was not limited to, Policy.Based on the comprehensive assessment of a resident, the facility must ensure that.A resident receives care, consistent with professional standards of practice.to promote healing, prevent infection.Examples of impaired skin integrity include, but are not limited to, pressure injuries, venous (stasis) ulcers.skin tears. This Citation relates to Intake 2992467410 IAC (Indiana Authorization Code) 16.2-3.1-40(a)(2)

Based on interview, and record review, the facility failed to prevent a Stage 4 pressure ulcer development (a severe, full-thickness wound extending to muscle, tendon, or bone, featuring deep tissue loss, often with slough, tunneling, and high infection risk) for a resident who was admitted without a skin impairment to the bilateral buttocks and sacrum, was identified by the facility to be at risk for the development of a pressure ulcer, who had co-morbidities, frequent moisture, and total dependence on staff for repositioning. The facility failed to ensure services were provided to the sacral wound and facility acquired full thickness skin tears on the bilateral buttocks obtained during a fall to prevent the wounds from deteriorating to a stage four pressure injury that required surgical debridement, and hospitalization for sepsis with in 3 weeks of admission. (Resident B) The Immediate Jeopardy began on 3/10/26 when an area to the buttocks/sacrum was identified by staff, and the facility had failed to prevent the development of a Stage 4 pressure ulcer within 3 weeks of admission. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 3/19/26 at 3:30 p.m. Findings include:The clinical record for Resident B was reviewed on 03/18/26 at 10:00 a.m. The resident's diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur (severe break in the thigh bone), difficulty in walking, morbid (severe) obesity, and bilateral primary osteoarthritis of hip (a degenerative condition where cartilage in both hips wears down). A nurse's note, dated 2/18/26, indicated the resident arrived by wheelchair. She was stable and had a surgical wound on her left leg. The Braden Scale for Predicting Pressure Sore Risk (evidence-based tool used to assess a resident's risk of developing pressure ulcers), dated 2/18/26, indicated Resident B was at an increased risk of developing skin impairment. The Scale indicated the resident had limited cognition; resident was chairfast; had limited mobility; friction and sheer were a potential problem. The admission Nursing Evaluation, dated 2/18/26, indicated that the resident's skin was normal in color, the skin was warm to touch temperature, and was moist. Areas noted on the admission skin assessment were the chest, right iliac crest (groin), left iliac crest (groin) all with excoriation (superficial skin abrasion of chafing, raw, irritated lesions characterized by damage from scratching, picking, or rubbing). A surgical dressing was on the resident's thigh area of the left extremity. No pressure injuries were documented. The care plan, dated 2/19/26 and revised on 2/26/26, indicated the resident had potential for skin impairment related to decreased mobility. The interventions, dated 2/19/26, included, but were not limited to, incontinence care every shift and as needed for incontinence episodes, treatments as ordered, observe skin during care and report any concerns to the nurse, turn and reposition to maintain skin integrity, pressure reducing mattress, skin check weekly and wheelchair cushion. No new interventions were documented after the 2/19/26 Care Plan listed interventions for the revision on 2/26/26. A physician's order, dated 02/19/26, indicated the resident was to have a pressure-reducing cushion on her wheelchair and pressure-reducing mattress on her bed. A wound note, dated 2/27/26, indicated the resident had a left proximal and left distal post-surgical wound. A facility document, titled Skin Check, dated 2/27/2026, indicated the skin was warm and dry with normal limits of skin color and no external devises on the skin. The resident's left and right inguinal region (groin area located in the lower portion of the abdomen wall where meets the thigh) had a rash, buttocks generalized with a stage one pressure ulcer/injury to the medial buttocks without undermining or tunneling. This pressure ulcer/injury was present on admission (documented as excoriation on the 2/18/26 admission assessment). A facility document, titled Skin Check, dated 3/6/26, indicated the skin was warm and dry with skin color within normal limits and no external devises on the skin. The left and right breast had redness, the left and right inguinal region had a rash, buttocks with a stage one pressure injury (localized injury to intact skin, characterized by non-blanchable redness that does not turn white when pressed) to the medial buttocks without undermining or tunneling. This pressure injury was present on admission. The resident was admitted on [DATE] and the admission skin assessment lacked a documented stage one pressure injury as documented on admission on the resident's Skin Checks, dated 2/27/2026 and 3/6/26, of the resident's medial buttocks. The 2/18/26 admission assessment indicated the resident had redden areas of excoriation. A Minimum Data set (MDS), dated [DATE], indicated the resident was cognitively intact. The resident was totally dependent on staff for toileting, hygiene, showering, and used a sit to stand for transfers. The resident needed substantial assistance with upper body dressing, rolling/turning in bed, sitting to lying, and lying to sitting. A wound note, dated 3/10/26, indicated the resident still had the left proximal and left distal post-surgical wounds. The resident had skin tears full thickness to the right and left buttocks and the sacrum. The Physician's order for a non-pressure wound of the resident's coccyx, left buttocks, and right buttocks, dated 3/10/26, indicated the resident was to have the wound cleansed with normal saline, pat dry, apply calcium alginate (a water insoluble, gelatinous, substance highly absorbent) and covered with a wound dressing as needed. A nurse's note, dated 3/10/26, indicated the resident was seen and examined by the wound nurse via video call with the assistant director of nursing. The assessment included the review of the resident's pressure sores on the buttocks area. The area was to have a wound dressing change twice daily: apply Dakin's solution (mild, diluted antiseptic solution used in wound care to clean, disinfect, and treat infected wounds), then put calcium alginate dressing on top and cover with abdominal gauze. A wound note, dated 3/11/26, indicated the resident had a selective debridement (precise removal of only necrotic, devitalized, or infected tissue) procedure on the right buttock and a surgical excisional debridement (use of a sharp instrument to cut away devitalized, necrotic, or contaminated tissue along with healthy tissue to promote healing) on the sacrum area. An alert note, dated 3/13/26, indicated the resident's buttock treatment was for staff to clean and flush the residents pressure injury (buttock/sacrum) with Dakin's and normal saline. The wound was tunneling and had a foul odor. Santyl (ointment to remove dead tissue from skin ulcers to promote healing) was applied with calcium alginate and border gauze. A nurse's note, dated 3/13/26, indicated the resident was sent to a local hospital for elevated temperature of 99.5 Fahrenheit and altered mental status (a sudden or gradual change in a person's baseline cognitive function, consciousness, or awareness). The Local Hospital emergency room noted, indicated on admission, that the resident was diagnosed with sepsis (a life-threatening medical emergency caused by the body's extreme, overactive response to an infection, which damages its own tissues and organs). The note indicated the resident's diagnosis of sepsis was likely due to the resident's infected sacral wound. As of 3/20/26, the resident remained in the acute hospital setting. During an interview, on 3/18/26 at 1:00 p.m., the wound care nurse practitioner (NP) indicated the resident had discoloration/abrasion on her buttocks on admission listed as excoriation. She saw the resident via telehealth medicine on 3/10/26 and did a conservative debridement on 3/11/26. The resident's wound was unstageable still after debridement. She could not answer if the wound was avoidable because the resident was overweight and did not move easily. She was supposed to see the resident on 3/6/26 but had to reschedule her time and had not seen the resident as planned. She indicated that the wound doctor had seen the resident on 2/27/26. During an interview, on 3/18/26 at 2:50 p.m., the Director of Nursing (DON) indicated that if an abnormal finding was found during a skin assessment check that the MD would be notified and if it was a stageable wound then the wound care company would be notified. A change of condition would then be completed in the electronic medical record. On 3/19/26 at 3:00 p.m., the DON indicated Resident B had slipped from the bed on 3/2/26 and later there was sheering noticed. The resident was admitted to the facility with redness on the coccyx. The sheering (a mechanical force that occurred when skin and underlying tissues are pulled in opposite directions) was the resident's noted skin tears. During an interview, on 3/18/26 at 1:15 p.m., CNA 4 indicated the most important way to prevent infection was to perform hand hygiene; and turning and repositioning a resident was one of the best ways to prevent pressure ulcers. During an interview, on 3/19/26 at 11:20 a.m., LPN 5 indicated that she was working on 3/13/26. At shift change, the daytime nurse (LPN 6) assessed the resident to find her lethargic, and only responding to pain. The doctor and family were notified, and the resident was sent to the emergency room. The LPN indicated that if she found a new skin area during a skin check she would notify the DON, notify the physician/nurse practitioner and family. A skin issue document would be completed, a change of condition form completed, and management would inform the wound care providers. The current policy, titled Skin Integrity and Wound Policy was provided by the Executive Director on 3/19/26. The policy indicated, Policy: Based on the comprehensive assessment.a resident receives care, consistent with professional standards of practice. The past non-compliance Immediate Jeopardy that began on 3/10/2026. The Immediate Jeopardy was removed and corrected by 3/17/26 after the facility implemented a systemic plan that included the following actions: staff education/in-services on daily wound monitoring; all residents were assessed for identifying skin impairments; all resident care plans, regarding skin issues, were reviewed; all residential pressure injury preventions were in place for at risk residents; and a wound team consisting of but not limited to the DON, ADON, Unit Manager, Wound Nurse will completed a risk management assessment of physician notification, obtaining new orders, transcribed new orders and contacting families of new order, updated care plans with new interventions and provide therapy referrals as needed. This citation relates to Intake 2805974. 410 IAC (Indiana Administrative Code) 3.1-40(a)(1)410 IAC 3.1-40(a)(2)

Based on interview and record review, the facility failed to follow medication administration parameters (Resident F and Resident K) for 2 of 3 residents reviewed for quality of care.Findings include: The clinical record for Resident F was reviewed on 12/8/25 at 2:53 p.m., The resident's diagnoses included, but were not limited to, hypertension and heart failure. The care plan, dated 4/16/25, indicated the resident had altered cardiovascular status due to hypertension and to administer medications as ordered. The physician's order, dated 8/22/25, indicated the resident was to receive Metoprolol Tartrate (medication for high blood pressure) 25 mg (milligrams) twice a day at 8:00 a.m. and 8:00 p.m. The medication was to be held if the resident's systolic blood pressure was less than 110. The September 2025 medication administration record indicated the resident received the medication on the following dates and times: -9/06/25 at 8:00 with a systolic blood pressure of 104-9/12/25 at 8:00 a.m. with a systolic blood pressure of 90 During an interview on 12/10/25 at 9:28 a.m., Staff Member 8 indicated if a resident's blood pressure was out of parameter, the medication should not be given. 2. The clinical record for Resident K was reviewed on 12/9/25 at 1:52 p.m. The resident's diagnoses included, but were not limited to, cerebrovascular disease and hypertension.The care plan, dated7/16/25, indicated the resident had altered cardiovascular status related to hypertension and to administer medications as ordered.The physician's order, dated 8/22/25, indicated the resident was to receive Metoprolol Succinate Extended Release (medication for high blood pressure) 100 mg daily in the morning for hypertension. The medication was to bed held if the resident's heart rate was less than 60.Review of the November 2025 and December 2025 medication administration indicated the resident received the medication on the following dates:-11/03/25 with a heart rate of 59-11/17/25 with a heart rate of 54-11/20/25 with a heart rate of 58-12/03/25 with a heart rate of 53 On 12/10/25 at 10:47 a.m., the Regional [NAME] President of Clinical Operations provided a current copy of the document titled Medication Administration dated 6/21/17. It included, but was not limited to, Policy.Medications will be administered.consistent with accepted standards of practice. This Citation relates to Intakes 2665096, 2670042 and 2675349 3.1-37

Based on interview and record review, the facility failed to ensure a resident's (Resident B) PICC (peripherally inserted central catheter) line dressing changes were completed for 1 of 1 resident reviewed for quality of care.Findings include: The clinical record for Resident B was reviewed on 12/8/25 at 10:32 a.m. The resident's diagnosis included, but was not limited to, cellulitis of the lower right leg. The physician's order, dated 9/29/25, indicated the resident was to receive Cefepime HCl (hydrochloride), 2 GM (grams) intravenously three times a day for a total of 115 doses at 12:00 a.m., 8:00 a.m. and 4:00 p.m. The resident's last dose was administered on 11/7/25 at 12:00 a.m. The clinical record lacked documentation of PICC line dressing changes throughout the course of the antibiotic administration. During an interview on 12/10/25 at 11:13 a.m., Staff Member 9 indicated PICC line dressing changes should be completed every 7 days. On 12/11/25 at 11:10 a.m., the [NAME] President of Clinical Operation provided a current copy of the document titled Peripheral and Midline IV Dressing Changes dated October 2024. It included, but was not limited to, Purpose.This purpose of this policy is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.General Guidelines.Change the dressing if it becomes damp, loosened or visibly soiled and.at least every 7 days. This Citation relates to Intakes 2665096, 2670042 and 2675349 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure respiratory assessments were in place for residents (Resident C, Resident D and Resident H) receiving nebulizer treatments for 3 of 4 residents reviewed for respiratory care.Findings include:1.The clinical record for Resident C was reviewed on 12/8/25 at 11:09 a.m. The resident's diagnoses included, but was not limited to, dyspnea, chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease.The physician's order, dated 10/22/25, indicated the resident was to receive Budesonide Inhalation Suspension (medication administered via nebulizer to make breathing easier), 0.5 mg (milligrams)/2 ml (milliliters) one vial orally via nebulizer twice daily for shortness of breath.The physician's order, dated 10/22/25, indicated the resident was to receive Ipratropium-Albuterol Inhalation Solution (medication administered via nebulizer used to treat bronchospasms), 3 ml every 6 hours for shortness of breath.The clinical record lacked documentation of completed respiratory assessments before, during and after the administration of the medication.During an interview, on 12/10/25 at 9:28 a.m., Staff Member 8 indicated respiratory assessments should be completed on residents throughout the treatment to ensure the breathing treatment was effective. The assessment included obtaining the residents' pulse, respirations and listening to lung sounds prior to the treatment and document those on the treatment record. After treatment, the nurse should again check the residents' pulse, respirations and lung sounds which would be documented on the treatment record.2. The clinical record for Resident D was reviewed on 12/8/25 at 2:23 p.m. The residents' diagnosis included, but was not limited to, wheezing.The physician's order, dated 10/22/25, indicated the resident was to receive Ipratropium-Albuterol, 3 ml via nebulizer two times a day for wheezing. The clinical record lacked documentation of completed respiratory assessments before, during and after the administration of the medication. 3. The clinical record for Resident H was reviewed on 12/9/25 at 11:21 a.m. The residents' diagnoses included, but were not limited to, anxiety and chronic obstructive pulmonary disease. The physician's order, dated 11/15/25, indicated the resident was to receive Ipratropium-Albuterol Inhalation Solution, 3 ml via nebulizer every 6 hours. The clinical record lacked documentation of completed respiratory assessments before, during and after the administration of the medication. On 12/11/25 at 9:35 a.m., the [NAME] President of Clinical Operations provided a current copy of the document titled Administering Medications through a Small Volume (Handheld) Nebulizer dated October 2010. It included, but was not limited to, Purpose.The purpose of this procedure is to safely and asepticall administer aerosolized particles of medication into the resident's airway.Steps in the Procedure.Obtain baseline pulse, respiratory rate and lung sounds.Approximately 5 minutes after treatment begins.obtain the resident's pulse.Obtain post-treatment pulse, respiratory rate and lung sounds. This Citation relates to Intakes 2665096, 2670042 and 2675349 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure monitoring was in place for a resident (Resident H) receiving hemodialysis for 1 of 1 resident reviewed for quality of care.Findings include:The clinical record for Resident H was reviewed on 12/9/25 at 11:21 a.m. The resident's diagnoses included, but were not limited to, end stage renal disease and dependence of renal dialysis. The resident discharged to the hospitalOn 12/9/25 at 10:38 a.m., the resident was observed with a dialysis fistula to his left antecubital space.The care plan, dated 8/31/22, indicated the resident had an alteration in kidney function due to end stage renal disease and dependence on renal dialysis. Nursing interventions included, but were not limited to, check the fistula site for signs and symptoms of infection, no blood pressure or lab draws in the right arm, dialysis center only to access site, observe for post-dialysis hangover including vital signs, mental status, excessive weight gain between treatments, nausea, vomiting, weakness, headache and severe leg cramps, observe for signs and symptoms of bleeding, and observe thrill and bruit daily and document findings.The physician's order, dated 3/24/25, indicated the resident was to receive dialysis every Monday, Wednesday and Friday.The physician's order, dated 3/24/25, indicated to check vital signs post-dialysis every shift for 24 hours.The physician's order, dated 3/26/25, indicated to check vital signs prior to dialysis.The physician's order, dated 3/24/25, indicated to obtain the resident's weight three times a week on Monday, Wednesday and Friday post-dialysis.The physician's order, dated 3/24/25, indicated to auscultate Bruit and palpate thrill every shift.The physician's order, dated 3/24/25, indicated if bleeding occurs from dialysis port, apply pressure and call 911.The physician's order, dated 3/24/25, indicated to observe the fistula site for signs and symptoms of infection every shift.The progress note, dated 11/12/25 at 6:52 a.m., indicated the resident was sent to the hospital for evaluation.The progress note, dated 11/15/25 at 2:10 a.m., indicated the resident readmitted to the facility on [DATE] at 9:15 p.m.The clinical record lacked documentation of any physician dialysis orders between 11/15/25 and 12/10/25. During an interview on 12/11/25 at 9:45 a.m., the [NAME] President of Clinical Operations indicated the previous dialysis orders should have been in place upon hospital return.This Citation relates to Intakes 2665096, 2670042 and 26753493.1-37(a)

Based on observation, record review and interview, the facility failed to ensure care plan interventions and treatments were in place or completed as ordered by the physician for 5 of 7 residents reviewed for pressure wounds (Residents 2, 52, 64, 14, 73). This deficient practice resulted in a resident acquired bilateral unstageable heel wounds (Resident 2). Findings include:1.During an observation on 8/26/25 at 10:30 a.m., Resident 2 was sitting up in his wheelchair with his feet resting on the foot pedals. The resident was assisted back to bed for wound dressing changes to the right and left heels. The wound Nurse Practitioner (NP) removed the old dressings. The resident had pressure wounds to the right and left heels. The left pressure wound measured 4.1 centimeters (cm) in length and 4.2 cm in width. The peri wound tissue was pink in color. The right heel wound measured 2.7 cm in length and 2.3 cm in width. A small amount of serosanguinous drainage was on the old dressings. The record for Resident 2 was reviewed on 8/23/25 at 8:49 a.m. The resident's diagnoses included, but were not limited to, pain in the left foot, pain in the right foot pressure-induced deep tissue damage to the right heel, pressure-induced deep tissue damage to the left heel, and a Stage 3 pressure wound of the sacral region. The admission Minimum Data Set (MDS) assessment, dated 7/3/25, indicated the resident was moderately cognitively impaired. The clinical record lacked documentation to indicate the resident had a care plan and preventive interventions for the bilateral heels in place prior to the development of bilateral heel wounds on 7/8/25. The Braden Skin assessment, dated 7/3/25, for risk of pressure wounds indicated the resident was at high risk for pressure wounds. On 7/4/25, the admission assessment indicated the resident had redness to the peri area, an ulcer to coccyx area Stage 2 and no other skin areas were observed. On 7/12/25, the resident's skin was warm, dry and intact. He had a pressure wound to the coccyx, redness to peri area, and no other new skin concerns were observed. 1.a. The physician's order, dated 8/2/25, indicated staff were to cleanse the resident's left heel pat dry, apply a nonstick dressing and wrap with a gauze every day for a pressure wound. The order was discontinued on 8/5/25. The physician's order, dated 8/4/25, indicated staff were to apply skin prep to the resident's bilateral heels daily and float heels with pressure reducing boots while in bed daily. The order discontinuation date was 8/12/25. The physician's order, dated 8/13/25, indicated Santyl external ointment 250 units/gm (grams) was to be applied to the resident's left heel topically every day shift for a deep tissue injury to the left heel and as needed. The order discontinuation date was 8/25/25. The physician's order, dated 8/25/25, indicated staff were to cleanse the resident's left heel pressure wound with wound cleanser, pat dry, apply calcium alginate, and apply Santyl to the wound bed and wrap with gauze daily and as needed. The resident's skin assessments notes indicated the following: On 7/26/25, the resident indicated that he had redness to the left heel. On 8/2/25, a new pressure area was observed to the resident's left heel. No other skin concerns were observed. On 8/9/25, the resident's skin to the left heel was pale in color and warm to touch. Wound care was following the resident and the treatment continued. On 8/16/25, treatment continued to the bilateral heels. The review of the Wound Observation Tool indicated the following: On 8/8/25, the resident acquired an unstageable pressure wound (due to necrosis) of the left heel on 8/2/25. The wound was 100 percent necrotic tissue. The left heel wound measured 4.5 (centimeters) cm length by 4.3 cm width and 0.1cm in depth. Serous drainage and no odor. The treatment plan included, apply calcium alginate and Santyl to the wound bed, cover with a ABD pad and wrap with gauze daily and as needed. On 8/11/25, the pressure wound to the resident's left heel was unstageable. The wound had visible slough and necrotic tissue with serosanguinous drainage. The wound measured 4.7 cm in length, 4.3 cm in width, and 0.1 cm in depth. The treatment included applying calcium alginate and Santyl to the wound bed, covering with a ABD pad and wrap with gauze daily and as needed. On 8/15/25, the resident had an unstageable pressure wound to the left heel. Necrotic tissue was present with serosanguinous drainage. The wound measured 2.4 cm in length, the width measured 2.5 cm, and the depth measured 0.1 cm. The treatment included applying calcium alginate to the wound bed, once daily and as needed. On 8/22/25, the resident had an unstageable pressure wound to the left heel. The wound tissue had slough and necrotic tissue present with a moderate amount of serosanguinous drainage. The measurements included 4.4 cm in length, 4.4 cm in width, and 0.1 cm in depth. The treatment included applying calcium alginate and Santyl to the wound bed, covered with an ABD pad and wrap with gauze daily and as needed. 1.b. The physician's order, dated 8/12/25, indicated staff were to apply skin prep to the resident's right heel with pressure-reducing boots while in bed daily. The order discontinuation date was 8/19/25. The physician's order, dated 8/25/25, indicated staff were to cleanse the resident's wound to the right heel with wound cleanser, apply a dime size Santyl ointment, cover with calcium alginate and wrap with gauze daily and as needed. The physician's order, dated 8/26/25, indicated staff were to cleanse the resident's right heel with wound cleanser, pat dry, apply calcium alginate and Santyl to the wound bed. Wrap with gauze once daily and as needed. The skin assessments notes indicated the following: On 8/16/25, treatment continued to the resident's bilateral heels. The review of the Wound Observation Tool indicated the following: On 8/8/25, the resident acquired an unstageable deep tissue injury to the right heel. The wound measurements for the resident's right heel was 2.3 cm in length, 2.7 cm in width, and 0 depth. On 8/11/25, the pressure wound to the resident's right heel was an unstageable deep tissue injury. The measurements included length 2.4 cm, width 2.7 cm and 0 depth. The treatment was for staff to apply skin prep once daily and as needed. On 8/22/25, the resident had an unstageable pressure wound to the right heel. Necrotic tissue was present with serosanguinous drainage. The measurements included length 2.4 cm, the width was 2.7 cm and the depth was 0.1 with serosanguinous drainage. The treatment included applying calcium alginate and Santyl to the wound bed, covering with a ABD dressing and wrapping with gauze daily and as needed. 1.c. The care plan, dated 7/7/25 and revised on 7/15/25, indicated the resident had potential for skin impairment. The interventions included, but were not limited to, apply treatment as ordered, observe the resident's skin during care and report any concerns to the nurse, a pressure-reducing mattress, skin check weekly, and a wheelchair cushion. The Braden Skin assessment, dated 7/3/25, for risk of pressure wounds indicated the resident was at high risk for pressure wounds. The physician's order, dated 7/14/25, indicated zinc oxide external cream 10 percent topical was to be applied to the resident's coccyx topically two times a day for redness. The medication was discontinued on 8/25/25. The skin assessments notes indicated the following: On 7/4/25, the admission assessment indicated the resident had redness to the peri area, an ulcer to coccyx area Stage 2 and no other skin areas were observed. On 7/12/25, the resident's skin was warm, dry and intact. He had a pressure wound to the coccyx, redness to peri area, and no other new skin concerns were observed. The review of the Wound Focus Exam indicated the following: On 7/18/25, the resident had an unstageable deep tissue injury to the sacrum related to pressure. The pressure wound measured 5 by 5 and was not documented with cm. No exudated was observed. The intact skin had purple and maroon discoloration. The treatment plan indicated apply zinc ointment twice a day and as needed. On 7/25/25, the resident had a Stage 3 pressure wound to the sacrum with full thickness. The wound measured 5 cm in length by 4 cm in width and 0.1 cm in depth. No exudated was observed. The wound had 25 percent granulation, intact normal skin color, and the wound progress had evidence of improvement. The treatment plan was to apply zinc ointment twic3 a day and as needed. On 8/1/25, the resident's Stage 3 pressure wound to the sacrum had resolved. During an interview, on 8/22/25 at 10:35 a.m., the Wound Physician indicated the resident was not admitted with the unstageable bilateral heal pressure wounds. The wounds occurred related to the resident resting his heels on the foot petals. She indicated she thought the wounds were healable, but they would need to be debrided at some point. During an interview, on 8/26/25 at 11:00 a.m., the Assistant Director of Nursing (ADON) indicated to the resident's family member the heel wounds were pressure from the resident sitting up in the wheelchair with his feet resting on the foot pedals. During an interview, on 8/27/25 at 10:30 a.m., Licensed Practical Nurse 3 (LPN) indicated pressure wound interventions included, but were not limited to, off-loading, heel boots, reposition every 2 hours and before when needed, low air mattress, a cushion in the resident's wheelchair, and weekly skin assessments. The pressure reducing interventions should have begone on admission. 2. The record for Resident 52 was reviewed on 8/22/25 at 10:00 p.m. The resident's diagnoses included, but were not limited to, moderate protein malnutrition, muscle weakness, edema, open wounds to the bilateral lower extremities. The physician's order, dated 8/2/25, indicated Zinc Oxide External Cream 12 percent, was to be applied to the resident's coccyx topically every day and night shift for redness. Staff were to clean the wound well with soap and water before applying The care plan, dated 5/7/25 and revised on 8/15/25, indicated the resident had an actual skin impairment. A Stage 3 coccyx wound. The interventions included, but were not limited to, incontinence care every shift and as needed for incontinence episodes, the wound physician to assess and treat as indicated, treatment as ordered, observe skin during personal care and report any concerns to the nurse, turn and reposition to maintain the skin integrity, medications as ordered and a cushion to the wheelchair. The clinical record lacked documentation indicating accurate weekly skin assessments. The review of the weekly skin assessments indicated the following: On 7/10/25, the resident had no areas of concern observed, skin warm, dry, and intact. On 7/17/25, the resident's bilateral lower extremities had edema noted and tight yet not pitting. The resident started taking Lasix on 7/16/25 On 7/18/25, the resident developed a Stage 3 pressure wound. The wound measured 0.7cm in length by 0.8 cm in width and 0.3 cm in depth. On 7/24/25, the resident had a coccyx wound, scattered wounds on the bilateral lower extremities, and staff were to continue with treatments. On 7/31/25, the resident had no new areas noted. On 8/7/25, the resident's coccyx and bilateral lower extremities wound continued. On 8/15/25, the resident's Coccyx wound was acquired on 7/11/2025. The wound was a Stage 3, worsening, with granulation 100% serous drainage. The wound measured: length 0.7 cm x (by) width 0.8 cm x depth 0.1 cm. The staff were to apply Leptospermum honey and cover with a gauze island dressing with border once daily and as needed. Not at goal due to generalized decline of patient. On 8/21/25, the resident had no new skin issues to note. On 8/28/25, the resident had no new skin issues noted. The Focused Wound Exam indicated the following: On 7/18/25, the resident had a Stage 3 pressure wound to the coccyx with full thickness. The etiology was pressure. The healing potential was fair. The wound size included length 0.7 cm by 0.8 cm width by 0.3 cm in depth. The wound had moderate serosanguinous drainage. The treatment plan included applying Alginate calcium once daily and as needed: if saturated, soiled, or dislodged. For 30 days On 7/25/25, the resident had a Stage 3 pressure wound. The etiology was pressure. The wound measurements included 0.5 cm by 0.5 cm by 0.3 cm. The wound had light serosanguinous drainage. The wound had improved evidenced by decreased surface area. The treatment plan included applying Zinc ointment twice daily and as needed if saturated, soiled, or dislodged. On 8/1/25, the resident had a Stage 3 pressure wound with full thickness. The measurements included length 0.5 cm by width 0.5 cm and 0.1 cm in depth. The wound had 100 percent granulation tissue. The treatment plan included applying Zinc ointment twice daily and as needed for saturated, soiled or dislodged. On 8/8/25, the resident had a Stage 3 pressure wound. The wound measurements included length 0.5 cm by width 0.4 cm and 0.1 cm in depth. The wound had been improved by evidence of decreased surface area. The treatment plan included applying Zinc oxide twice daily and as needed for saturation, soiled, or dislodged. On 8/11/25, the resident had a Stage 3 pressure wound to the coccyx with improvement by decreased surface area and full thickness. An ultrasound mist therapy was performed on the wound. The treatment plan included adding Zinc ointment twice a day and as needed. The goal of treatment was healing evidenced by 64 percent decrease in the surface area within the wound bed in comparison to the previous wound care visit. On 8/22/25, the resident had a Stage 3 pressure wound to the coccyx. The wound measurements included the length 0.4 cm by 0.5 cm in width and 0.1 cm in depth. The wound had 20 percent slough and 80 percent granulation tissue. The wound had improved evidenced by decreased surface area. The treatment plan included applying Zinc oxide twice daily and as needed. A debridement procedure was attempted but aborted related to pain. The wound underwent treatment with non-contact, non-thermal, low frequency ultrasound. The wound was treated for the indicated time based on wound size and features. An absorbent pad was placed to protect the patient's clothing and bedding. A fresh bandage was applied. 3.During an observation, on 8/26/25 at 9:15 a.m., Resident 64 was sitting up in his wheelchair with his left foot resting on the foot pedals. The resident had a sock on his left foot, however there was no pressure relieving heel boot to offload his foot. There was no sheep skin cushion on the wheelchair. During an observation, on 8/27/25 at 8:30 a.m., the resident was lying on his left side with no protective heel boots in place. During an observation, on 8/28/25 at 10:15 a.m., the resident was lying on his left side with no protective heel boots in place During an observation, of wound care on 8/29/25 at 9:00 a.m., wound care was performed in accordance with the physician's orders. Hand hygiene completed by staff. The left heel wound measured 4 cm long by 5.26 cm wide by 0.2cm depth. A second newer left calf wound was observed on 8/28/25 and resulted from the resident supporting the left leg with a towel. The wound to the left calf measured at 2.08 cm long by 4.22 cm wide by 0.2cm depth on 8/29/25. The wound care was observed with the Wound Physician and treatment included Medi-honey to the newest wound on the left calf topically one time a day. The record for Resident 64 was reviewed on 8/26/25 at 10:16 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, pain in left lower leg, need for assistance with personal care, right below the knee amputation, and Stage 3 pressure ulcer of the left heel. The care plan, dated 11/26/24 and revised on 8/18/25, indicated the resident had actual or the potential for skin impairment. The interventions included, but were not limited to, heel boots while in bed, sheep skin to the right side of the wheelchair, pressure reducing mattress, skin check weekly, lymphedema care management via compression wraps, turning and repositioning, and a wheelchair cushion. The physician's order, dated 7/29/25, indicated staff were to cleanse the resident's left heel pressure wound with normal saline, apply Santyl and calcium alginate, abdominal (ABD) pad, and wrap one time a day every dayshift and as needed. The order discontinuation date was 8/12/25. The Braden Skin assessment, dated 7/30/25, indicated the resident was at high risk for pressure wounds. The State Optional Minimum Data Set (MDS) assessment, dated 8/13/25, indicated the resident was cognitively intact. The physician's order, dated 8/13/25, indicated staff were to cleanse the resident's left heel pressure wound with normal saline, apply Santyl and calcium alginate, abdominal (ABD) pad, and wrap one time a day every dayshift and as needed. The order discontinuation date was 8/15/25. The physician's order, dated 8/16/25, indicated staff were to cleanse the resident's left heel pressure wound with normal saline, apply Leptospermum honey and calcium alginate, cover the wound with an abdominal (ABD) pad, and wrap with kerlix one time a day and as needed. The resident's skin assessment notes indicated the following: On 5/21/25, the assessment indicated the resident's skin was warm, dry, and intact. On 5/28/25, the assessment indicated the resident's skin was warm, dry, and intact. On 6/6/25, the assessment indicated the skin was intact with no skin issues. On 6/15/25, the assessment indicated the resident had redness to his bilateral buttocks, and a prevention cream in place. On 6/21/25, the assessment indicated the resident had no new skin issues noted, and the skin was warm, dry, and intact, The review of the Wound Observation Tool for the left heel wound indicated the following: On 6/19/25, the resident acquired an unstageable pressure wound of the left heel. The wound was 100 percent necrotic tissue. The left heel wound measured 3 cm length by 3 cm width and 0.1cm in depth. Serous drainage and no odor. The treatment plan included, apply calcium alginate and Santyl to the wound bed, cover with an ABD pad and wrap with gauze daily and as needed. On 7/3/25, the resident has an unstageable pressure wound of the left heel. The wound was 100 percent necrotic tissue. The left heel wound measured 3 cm length by 4 cm width and 0.1 cm in depth. Serous drainage and no odor. The treatment plan included, apply calcium alginate and Santyl to the wound bed, cover with an ABD pad and wrap with gauze daily and as needed. As a result of a surgical debridement, the nonviable tissue in the wound bed decreased from 100 percent to 20 percent. On 8/1/25, the resident had an unstageable pressure wound of the left heel. The wound was 50 percent necrotic tissue. The left heel wound measured 4 cm length by 4.5 cm width and 0.1 cm in depth. Serous drainage and no odor. No signs of infection. The treatment included applying calcium alginate and Santyl to the wound bed, covering with an ABD pad and wrap with gauze daily and as needed. Surgical debridement was completed on that date. On 8/8/25, the resident had an unstageable pressure wound of the left heel with full thickness The wound was 50 percent necrotic tissue. The left heel wound measured 4 cm length by 4.5 cm width and 0.1 cm in depth. Serous drainage and no odor. No signs of infection. The treatment included applying calcium alginate daily and for 30 days applying Santyl to the wound bed, covering the wound with an ABD pad and wrap with gauze daily and as needed. Surgical debridement was completed on this date. On 8/15/25, the resident had a Stage 3 pressure wound of the left heel with full thickness The wound was 50 percent necrotic tissue. The left heel wound measured 4 cm length by 4.5 cm width and 0.1 cm in depth. Serous drainage and no odor. No signs of infection. The treatment included applying calcium alginate daily and for 30 days applying Santyl to the wound bed, covering the wound with an ABD pad and wrap with gauze daily and as needed. Surgical debridement was completed on this date. On 8/22/25, the resident had a Stage 3 pressure wound of the left heel with full thickness The wound was 50 percent necrotic tissue. The left heel wound measured 4.3 cm length by 4.5 cm width and 0.1 cm in depth. Serous drainage and no odor. No signs of infection. The treatment included, applying calcium alginate once daily and as needed. For 16 days; apply Leptospermum honey once daily, covering the wound with an ABD pad and Gauze roll 4.5 daily and as needed. On 8/25/25, the resident had a Stage 3 pressure wound of the left heel with full thickness The wound was 50 percent necrotic tissue. The left heel wound measured 4.3 cm length by 4.5 cm width and 0.2 cm in depth. Moderate Serosanguinous drainage and no odor. No signs of infection. The duration of the wound was greater than 76 days. The treatment included applying calcium alginate once daily and as needed. For 13 days; apply Leptospermum honey once daily, covering the wound with an ABD pad and Gauze roll 4.5 daily and as needed. During an interview, on 8/29/25 at 11:00 a.m., the Wound Physician indicated that there was redness on the resident's left calf and continued down to left foot. A wound culture would be ordered. A doppler was ordered and was negative for abnormalities and the residents had good pedal pulses. The resident has been compliant with interventions but needed assistance with bed mobility, transfers, and placing the boot on his left heel. The clinical record lacked documentation to indicate the resident had accurate skin assessments completed by the nursing staff and failed to ensure adequate preventive interventions to avoid the development of new wounds in the resident's care plan. 4. During an observation of Resident 14 on 8/26/25 at 1:07 p.m., the Wound Company NP and the facility Wound NP, performed hand hygiene and applied PPE (personal protective equipment). The Wound Company NP indicated the main goal of the treatment was for infection control, debridement, and odor control. The resident was on hospice care. The old dressing was dated 8/26/25 where it had been changed due to soilage. Serosanguinous drainage was visible on the dressing. The wound had clean edges with a beefy red wound bed. There was undermining and the wound measured 6.3 cm long by 2.1 cm wide by 3 cm deep. The undermining was at 12 o'clock with a depth of 4 cm. There was no odor present. The wound was cleansed with gauze soaked in Dakins. The Wound NP indicated no flagyl was needed and the Wound Company NP indicated it would be discontinued. The wound was packed in calcium alginate and no concerns with the wound appearance were observed. The Wound Company NP indicated the wound had an odor last Friday, but none was present today. The resident usually ate well, but the wound was not expected to heal. The wound would have times of reducing in size and then increasing. The wound had been the same size since the resident was admitted . The wound company started care on 7/25/25. The record for Resident 14 was reviewed on 8/26/25 at 11:10 a.m. The resident's diagnoses included, but were not limited to, muscle weakness, multiple sclerosis, hypertension, repeated falls, osteoarthritis, vitamin B12 deficiency anemia, difficulty walking, pain in the left hip, and the need for assistance with personal care. The care plan, dated 3/4/25 and revised 7/18/25, indicated actual and/or potential skin impairment related to limited mobility, fragile skin, multiple sclerosis, medication use, anemia, pain, osteoarthritis, hypothyroidism, anxiety, and depression. Unstageable pressure ulcer to the buttocks. The interventions, dated 3/4/25, included, but were not limited to, incontinence care every shift and as needed for incontinent episodes. Dated 7/18/25, notify hospice of declines in skin integrity or pressure ulcer development. Dated 3/18/25, the wound physician was to assess the wound, provide treatment as ordered, observe skin during care and report any concerns to nurse, turn and reposition to promote healing of current areas, pressure reducing mattress, skin check weekly, medications as ordered, and wheelchair cushion. The nurse's note, dated 2/22/25 at 2:45 p.m., indicated the resident arrived at the facility with family members at 2:30 p.m. by wheelchair. The resident was alert and oriented. The physician's order, dated 2/23/25, indicated to apply a pressure reducing mattress to the resident's bed. The physician's order, dated 2/23/25, indicated to apply a pressure reducing cushion to the wheelchair. The physician's order, dated 2/24/25, indicated the resident was to have their wound assessed by the wound company. The wound company's initial assessment, dated 2/27/25, indicated the resident had a Stage 2 pressure ulcer to the sacral area, that measured 1 cm long by 0.4 cm wide by 0.1 cm deep. There were open areas with exposed dermis. The primary dressing was for zinc ointment to be applied twice daily for 30 days. The recommendations were to off-load the wound and to reposition per facility protocol. The wound company's assessment, dated 3/3/25, indicated the resident's Stage 2 wound had resolved. The dietary progress note, dated 4/30/25 at 10:23 a.m., indicated the resident triggered for a significant weight loss of 7.4% of 10.4 pounds in a month. The resident's current body weight was 129.2 pounds and in March the resident weighed 139.6 pounds. The weight loss was unplanned and was due to poor oral intake. The resident tolerated a regular diet with a meal intake of 25 to 75%. The resident admitted she had never been a big eater but did enjoy the food that was served. The resident was willing to try Ensure for added nutrition support. Will continue to monitor the resident's oral intake, weight, and skin. The physician's order, dated 4/30/25, indicated the resident was to receive Ensure Plus drinks after meals for nutritional support related to poor intake. The physician's note, dated 5/17/25 at 8:03 a.m., indicated that the resident had a 1 cm long split in the intergluteal cleft, which was barely open, with no blood. There was no sign of pain or discomfort. The resident's condition was stable. This was an acute new problem. The order was to apply gentle care to avoid a deeper tear. Notify a clinician of any change in condition. The wound company's assessment, dated 5/27/25, indicated the resident had a new wound to the sacrum, which measured 1.5 cm long by 1 cm wide by 0.1 cm deep with 10% slough and 90% granulation tissue. The estimated time to heal was 1 to 4 weeks. The treatment plan was to apply alginate calcium daily and as needed for 28 days. The dressing was a gauze island with border daily and as needed. The resident refused debridement due to pain. The resident was educated. The wound company's assessment, dated 6/19/25, indicated the resident's wound to the sacral area measured 2 cm long by 2 cm wide by 0.1 cm deep with 10% slough and 90% granulation tissue. The treatment was to continue the calcium alginate to the wound bed and cover with a bordered island dressing daily and as needed. The wound company's assessment, dated 6/29/25, indicated the resident's wound to the sacrum remained stable, measuring 3 cm long by 3 cm wide by 0.1 cm deep with a moderate serous drainage. The wound was progressing at goal. The treatment was to continue the calcium alginate to the wound bed and cover with a bordered island dressing daily and as needed. The nurse's note, dated 7/3/25 at 2:07 p.m., indicated to provide Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure was not available. The nurse's note, dated 7/3/25 at 5:05 p.m., indicated to provide the resident with Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure was not available. The nurse's note, dated 7/6/25 at 4:42 p.m., indicated the resident's sacral wound was not responding to the treatment and had a strong odor. The wound needed to be followed by the wound doctor. The nurse's note, dated 7/10/25 at 5:12 p.m., indicated to provide the resident with Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure was not available. The wound company's assessment, dated 7/11/25, indicated the unstageable wound to the resident's coccyx had exacerbated due to generalized decline of patient, measuring 3 cm long by 2 cm wide by 0.3 cm deep with 70% thick adherent devitalized necrotic tissue and 30% slough present. There was a moderate amount of serous drainage. The order was to continue the calcium alginate, apply leptospermum honey to the wound bed and cover with a bordered island dressing daily and as needed. The nurse's note, dated 7/15/25 at 7:04 a.m., indicated to treat the resident's wound with Medi honey wound/burn dressing external gel. Apply to the sacrum topically one time a day and apply calcium alginate. Awaiting the delivery of the supplies. The nurse's note, dated 7/16/2025 7:16 a.m., indicated to treat the resident's wound with Medi honey wound/burn dressing external gel. Apply to the sacrum topically one time a day and apply calcium alginate. Awaiting the delivery of the supplies. The physician's order, dated 7/16/25, indicated to notify the hospice company for all resident condition changes and medication needed every shift. The nurse's note, dated 7/17/25 at 8:49 a.m., indicated to treat the resident's wound with Medi honey wound/burn dressing external gel. Apply to the sacrum topically one time a day and apply calcium alginate. Awaiting the delivery of the Medi honey. The wound company's assessment, dated 7/25/25, indicated the unstageable necrosis wound to the resident's sacrum measure 3.7 cm long by 2.5 cm wide by 1.5 cm deep with heavy serous drainage and 100% thick adherent devitalized necrotic tissue. The resident was on palliative care and debridement was not indicated at this time. The same treatment plan was in place. The nurse's note, dated 7/25/25 at 5:46 p.m., indicated to provide the resident with Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure drink could not be located with all storage rooms checked. The nurse's note, dated 7/30/25 at 9:34 a.m., indicated to apply Dakins (1/2 strength) External Solution 0.25 % to the coccyx topically one time a day for wound treatment. Soak the gauze with Dakins and pack the wound and cover with mepilex. The Dakins was not found on the treatment cart and was reordered. The Braden Skin assessment, dated 7/30/25, indicated the resident had a very high risk for pressure ulcers. The nurse's note, dated 7/31/25 at 9:46 a.m., indicated to apply Dakins (1/2 strength) External Solution 0.25 % to the coccyx topically one time a day for wound treatment. Soak the gauze with Dakins and pack the wound and cover with mepilex. The Dakins was not found on the treatment cart and was reordered on 7/30/25. The nurse&rs

Based on record review and interview, the facility failed to ensure a resident received periodic gradual dose reductions for the anti-psychotic and anti-depressant medications to determine necessity at current dosages for 1 of 5 residents reviewed for unnecessary medications. (Resident 56) Findings include: The record for Resident 56 was reviewed on 8/27/25 at 1:33 p.m., The resident's diagnoses included, but were not limited to, cognitive communication deficit, generalized anxiety disorder, major depression recurrent, insomnia and vascular dementia with other behavioral disturbance. The physician's order, dated 4/4/24 with a secondary order dated 7/22/25, indicated staff were to administer the resident 7.5 milligrams (MG) of Clorazepate Dipotassium Oral Tablet. The resident was to receive one tablet three times a day (TID) to treat anxiety disorder. An anti-depressant was ordered on 4/28/25 for the resident to receive Trazadone HCI (hydrochloriide) 50 mg. The staff were to give one and half tablets to the resident at bedtime, to treat insomnia. Dated 2/17/25, the resident was to receive escitalopram oxalate (Lexapro) 10 mg. The staff were to administer two tablets in the morning for depression.An Annual Minimum Data Set (MDS) assessment, dated 8/2/25, indicated the resident was cognitively intact, often felt depressed and had no issues with behaviors or sleep.The review of the psychiatric and physician progress notes, between 3/1/25 and 8/29/25, indicated the resident's mood and anxiety to be stable and no issues with sleep. A pharmacy review, dated 3/24/25, indicated the resident was receiving clorazepate dipotassium oral tablet 7.5 mg three times and day for anxiety. All psychotropic medications needed to be evaluated for a gradual dose reduction (GDR) twice in the first year of therapy, and annually thereafter. Consider attempting a GDR to ensure the resident was receiving the minimum effective dose. If a GDR was not appropriate, please include a statement documenting a reason a GDR was contraindicated at that time.Documentation was lacking, between 3/24/25 and 8/29/25, of a GDR or a reason why a GDR was contraindicated for the resident.During an interview with the Social Services Director, on 8/29/25 at 12:40 p.m., she indicated she was unable to find any files where the resident had received a gradual dose reduction on the resident's anti-depressant for insomnia and the anti-anxiety medications.A review of the facility's current policy on Psychotropic Medication Use, included, but was not limited to, Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: .anti-depressants; anti-anxiety medications; and hypnotics .16. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications.Review of the facility's current policy on Tapering Medications and Gradual Dose Reduction, included, but was not limited to, Policy Statement: .2. All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions. 3. Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Policy Interpretation and Implementation: .3. The staff and practitioner will consider tapering of medications ass one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident .5. The physician will periodically review whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose. Cross Reference F756 3.1-48(b)(2) No Notes

Based on observation, record review, and interview, the facility failed to ensure the prevention of UTIs (Urinary Tract Infections) and proper infection control techniques for 1 of 2 residents reviewed for bowel and bladder. (Resident 2)Findings include: During an observation, on 8/22/25 at 12:41 p.m., Resident 2's indwelling catheter tubing was laying on the floor. The resident's urine was leaking onto the floor. The urine was cloudy and pink tinged in color. The resident clinical record indicated the resident currently had a Urinary Tract Infection (UTI).During an observation, on 8/26/25 at 1:30 p.m., Resident 2's indwelling catheter tubing was observed laying on the floor. Light pink urine was observed in the tubing. The record for Resident 2 was reviewed on 8/22/25 at 2:50 p.m. The resident's diagnoses included, but were not limited to, hematuria, dehydration, acute prostatitis, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, urinary tract infection, and urinary retention.The care plan, dated 7/15/25, indicated the resident had an indwelling urinary catheter. The interventions included, but were not limited to, positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, observing for pain or discomfort due to the catheter, observing as needed for signs and symptoms of a UTI, observing the tubing for kinks, and obtain intake and output as per ordered.The physician's order, dated 7/20/25, indicated staff were to provide indwelling catheter care every shift and as needed every shift. The admission (MDS) Minimum Data Set assessment, dated 7/3/25, indicated the resident was moderately cognitively intact.The nurse's note, dated 8/16/25, indicated the resident was observed to have hematuria in his indwelling catheter and dysuria with urination. A new order was received to do a uranalysis reflex with culture, a Complete Blood Count (CBC), and flush the catheter until it clears for 24 hours.The urinalysis results, dated 8/19/25, indicated the resident's urine was positive for pseudomonas fluroescens/putida. The organism was known to possess inducible Beta-Lactamase. The Nurse Practitioners (NP) note, dated 8/16/25, indicated the resident had a history of hematuria and dysuria. The resident had his indwelling catheter changed at his urology appointment per nurse patient had his indwelling catheter changed at a doctor's appointment. He complained of burning and lower abdominal pain and bladder pain. The indwelling catheter was irrigated with some clearing. A uranalysis was ordered. The physician's order, dated 8/22/25, indicated staff were to administer the resident's Cefepime 1 gram (gm) intramuscular (IM) one time a day for three days related to a UTI.The Nurse Practitioner (NP) note, dated 8/22/25, indicated the resident had been to a Urology Physician for Uroflow testing. His indwelling catheter remained at the bedside related to time a failed post void residual in the Urology office. He was continued on Flomax and the Urologist added finasteride for BPH. The resident currently had a UTI and received IM Rocephin.During an interview, on 8/28/25 at 2:00 p.m., RN 8 indicated the UTI interventions included, proper peri care, proper catheter care, encourage plenty of fluids, keep the urine bag and tubing off the floor, keep the indwelling catheter bag lower than the bladder, monitor the resident for signs and symptoms of a urinary tract infection. During an interview, on 8/28/25 at 2:15 p.m., Certified Nursing Aide 9 (CNA) indicated he would wear gloves when providing personal care, provide good peri and catheter care, hydration, and keep the indwelling catheter bag lower than the bladder. The bag should be in a dignity bag. The bag and the indwelling catheter tubing should never be touching the floor.The review of the Infection Prevention and Control Policy, dated 2017, indicated .An infection and prevention program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure nutritional supplements were provided to 2 of 9 residents reviewed for skin treatments and nutrition. (Residents 14 and 92)Findings include:1. The record for Resident 14 was reviewed on 8/26/25 at 11:10 a.m. The resident's diagnoses included, but were not limited to, muscle weakness, multiple sclerosis, and vitamin B12 deficiency anemia.The care plan, dated 2/23/25 and revised 7/11/25, indicated the resident had a nutritional problem or potential nutritional problem related to multiple sclerosis, hypertension, gastroesophageal reflux disease, anxiety, and depression, and a pressure injury. On 4/30/25, the resident had a significant unplanned weight loss of 7.4% per month. On 5/13/25, the resident had a significant planned weight gain of 7.9% per month. On 7/6/25, the resident's diet was downgraded under hospice care. The interventions, dated 7/8/25, included, but were not limited to, the resident refused to eat and appeared concerned during meals. Staff were to obtain and monitor the resident's weight monthly and as needed (PRN); dated 4/30/25, staff were to provide and serve Ensure supplements as ordered.The nurse's note, dated 2/22/25 at 2:45 p.m., indicated the resident arrived at the facility with family members by wheelchair. The resident was alert and oriented. The wound company's initial assessment, dated 2/27/25, indicated the resident had a Stage 2 pressure ulcer to the sacral area, that measured 1 cm long by 0.4 cm wide by 0.1 cm deep. There were open areas with exposed dermis. The primary dressing was for zinc ointment to be applied twice daily for 30 days. The recommendations were to off-load the wound and to reposition per facility protocol.The wound company's assessment, dated 3/3/25, indicated the Stage 2 wound had resolved.The dietary progress note, dated 4/30/25 at 10:23 a.m., indicated the resident triggered for a significant weight loss of 7.4% of 10.4 pounds in a month. The resident's current body weight was 129.2 pounds and in March the resident weighed 139.6 pounds. The weight loss was unplanned and was due to poor oral intake. The resident tolerated a regular diet with a meal intake of 25 to 75%. The resident admitted she had never been a big eater but did enjoy the food that was served. The resident was willing to try Ensure for added nutrition support. Will continue to monitor the resident's oral intake, weight, and skin. The physician's order, dated 4/30/25, indicated the resident was to receive Ensure Plus drinks after meals for nutritional support related to poor intake.The nurse's note, dated 7/3/25 at 2:07 p.m., Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure was not available.The nurse's note, dated 7/3/25 at 5:05 p.m., indicated to provide the resident with Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure was not available.The nurse's note, dated 7/10/25 at 5:12 p.m., indicated to provide the resident with Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure was not available.The nurse's note, dated 7/12/25 at 3:41 p.m., indicated the resident was to have comfort medications only until the resident was able to tolerate oral intake. Nectar Thickened liquids. The physician's order, dated 7/13/25, indicated to provide a diet with small portions with a dysphagia pureed texture, and thickened liquid of nectar consistency.The physician's order, dated 7/16/25, indicated to notify the hospice company for all condition changes and medication needed every shift.The nurse's note, dated 7/25/25 at 5:46 p.m., indicated to provide the resident with Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure drink could not be located with all storage rooms checked.The nurse's note, dated 8/1/25 at 12:25 p.m., indicated to provide the resident with Ensure Plus after meals for nutritional support related to poor oral intake. The Ensure was not available.During a confidential interview, between 8/21/25 and 8/27/25, Staff B indicated if supplies were out of stock, the Unit Manager would be notified, because the Unit Manager could get the needed supplies quickly. The supply of Ensure nutritional supplements had run out, but she would check elsewhere to get it. Staff B would check the supply room on the 400 Hall for the Ensure.During an interview, on 8/27/25 at 2:16 p.m., Licensed Practical Nurse (LPN) 5 indicated the Ensure had run out at times. She asked the Unit Manager about it. The residents received it when they didn't take in enough nutrients for their wound or if they had weight loss. During an interview, on 8/27/25 at 2:25 p.m., the Unit Manager 6 indicated she was unsure where the Ensure came from. The Ensure was a nutritional drink for weight loss or was a preferred drink for the residents. It would also help with wound healing. During an interview, on 8/28/25 at 10:08 a.m., LPN 3 indicated she had not observed any issues with Ensure being out of stock. The full-time RN for the 600 Hall kept the Ensure well stocked. The 100 Hall supply room was where the stock was supplied. There was one box of Ensure on the shelf. Hospice also supplied Ensure. Otherwise, it came from the supply company and was delivered weekly. The Unit Manager observed the charting and indicated if one RN was documenting the Ensure supply being out of stock, then it meant she did not want to go get it from supply. During an interview, on 8/29/25 at 8:10 a.m., the wound physician indicated Ensure nutrition was important for wound healing. 2. The record for Resident 92 was reviewed on 8/27/25 at 2:35 p.m. The resident's diagnoses included, but were not limited to, protein calorie malnutrition, vitamin B12 deficiency anemia, and abnormality of albumin and liver function studies. The care plan, dated 2/4/25 and revised 7/9/25, indicated the resident was at risk for malnutrition as evidenced by score of 6 out of 14 on Mini Nutritional Assessment (MNA) Nutritional Screening Tool. The interventions, dated 2/4/25, included, but were not limited to, consult dietician as indicated, notify dietitian or physician for supplementation for nutritional needs as needed, and obtain weight for gain or loss as ordered, provide ordered diet. The care plan, dated 7/19/23 and revised 6/6/25, indicated the resident had a nutritional problem or potential nutritional problem related to dysphagia, dementia, malnutrition; dated 7/25/24, the resident was malnourished related to MNA score 4 out of 14; dated 3/3/25, the resident had a significant weight loss of 9.6% per month; dated 7/31/2025, administer intravenous fluids (IVF for Hydration). The interventions, dated 7/19/23 and revised 8/30/24, included, but were not limited to; dated 1/18/24 observe for signs and symptoms of dehydration and encourage fluids; dated 7/29/24 and revised 8/30/24, observe and report to the physician as needed for signs and symptoms of malnutrition; dated 3/3/24 and revised 8/4/25, provide nutrition supplement as ordered. The dietary review note, dated 5/23/25 at 10:02 a.m., indicated the resident presented with a skin tear to the left wrist. The resident was tolerating a regular dysphagia diet with meal intake of 50 to100%. She had orders for Ensure and Pro-stat. The resident's weight was obtained on 6/2/25 and was 150 pounds,The nurse's note, dated 6/26/25 at 10:28 a.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was out.The nurse's note, dated 6/26/2025 12:59 p.m., indicated to provide Ensure Plus after meals for promote weight gain. The Ensure Plus was not available.The nurse's note, dated 6/26/2025 05:27 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available. The nurse's note, dated 6/27/2025 1:49 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 6/27/2025 05:50 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 6/29/2025 12:05 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 6/29/2025 05:09 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 6/30/2025 11:35 a.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 6/30/2025 12:16 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 6/30/2025 05:03 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note dated 7/1/2025 12:40 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 7/1/2025 12:41 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The nurse's note, dated 7/1/2025 05:20 p.m., indicated to provide Ensure Plus after meals to promote weight gain. The Ensure Plus was not available.The resident's weight of 149 pounds was obtained on 7/1/25 The physician's order, dated 7/14/25, indicated to provide the resident with a regular diet, dysphagia advanced texture, and thin liquid consistency.The resident's weight was obtained on 8/1/25 and was 143 pounds. The Nutrition and Hydration to Maintain Skin Integrity policy, revised in October 2010, included, but was not limited to, . General Guidelines 1. When there is a decline in a resident's appetite, nutritional intake, weight, or overall condition, caregivers should first attempt to discover the factors compromising nutritional status and offer support with eating. 2. If intake continues to be inadequate, impractical, or impossible, nutritional support must be implemented according to the plan of care. 4. Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions have been proven conclusively to prevent or heal pressure ulcers. 5. Healing of acute (e.g., postoperative) and chronic (e.g., pressure ulcers) wounds requires enough protein and calories so that the body will not use lean body mass for energy and wound repair.Cross Reference F6863.1-46(a)(1)

Based on record review and interview, the facility failed to follow up on 2 of 8 Consultant Pharmacy recommendations with the physician for 1 of 5 residents reviewed for unnecessary medications (Resident 56)Finding includedThe record for Resident 56 was reviewed on 8/27/25 at 1:33 p.m. The resident's diagnoses included, but were not limited to, cognitive communication deficit, generalized anxiety disorder, major depression recurrent, insomnia and vascular dementia with other behavioral disturbance. A Pharmacy recommendation, dated 3/24/25, indicated the resident had the following pertinent medication order: Cloazepate Doptassium Oral Tablet 7.5 mg. Staff were to administer one tablet by mouth three times a day for anxiety. Please consider a gradual reduction while monitoring for re-emergence of behavioral and/or withdrawal symptoms.R Review of the physician's orders, between March and October 2025, indicated the documentation was lacking of a response to the Pharmacy recommendation.A Pharmacy recommendation, dated 5/13/25, indicated the following: The Resident had the following pertinent medication order: carBAMazepine ER (extended release) Oral Tablet Extended Release 12 Hour 200 MG. Staff were to administer one tablet by mouth two times a day for epilepsy. It was recommended to monitor a Carbamazepine level and TSH (thyroid functions) yearly with carbamazepine therapy. Please consider ordering labs on next convenient lab day, if appropriate. Review of the physician's orders, between May and October 2025, indicated the documentation was lacking of a response to the Pharmacy recommendation. During an interview with the Director of Nursing (DON) on 8/28/25 at 1:30 p.m., she indicated the pharmacy liaison emailed the recommendations to her and she then printed them out and gave them to the appropriate Physician/Nurse Practitioner (NP) to address. Once they were completed, they were returned to her and she would forward them back to the liaison. The Physicians/NP usually returned them within a week to her. The Physicians/NP wrote their own orders. She could not account as to why these two recommendations were not addressed.Review of the facility's current policy on Medication Monitoring, included, but was not limited to, Policy:.The pharmacist must report any irregularities to the Attending Physician, the facility's Medical Director and the Director of Nursing, and these reports must be acted upon in a manner that meets the needs of the resident and regulatory regulations. Procedure:.4. A written report of all irregularities and recommendations resulting from the medication regimen review are provided a facility designee for the Attending Physician, Director of Nursing and Medical Director.4b. Report will be submitted within the same day as the actual review.7. For non-urgent recommendations, the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident - but no later than their next routine visit to assess the resident - and the Attending Physician should document in the medical record: a. What the irregularity has been reviewed; b. What action has been taken to address the issues.9. If the Attending Physician fails to address a recommendation or document a rationale for rejecting a recommendation: a. The Director of Nursing will be notified, and a summary shall be provided to the QAPI (Quality Assurance Performance Improvement) committee on a periodic basis. b. The DON, Medical Director or designee should review the incomplete recommendation with the Attending Physician.Cross Reference F605 3.1-25(j)

Based on observation interview and record review, the facility failed to ensure a resident (Resident D) received showers per her preference and failed to ensure a resident (Resident H) received his mail unopened and in a timely manner for 2 of 3 residents reviewed for resident rights.Findings Include:1 The clinical record for Resident D was reviewed on 8/11/25 at 1:08 p.m. The resident's diagnoses included, but were not limited to, depression and anxiety. The annual Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the resident's cognition was intact.On 8/8/25 at 2:40 p.m., the resident was observed sitting up in her wheelchair watching television. The resident's hair was observed to be flat and oily in appearance and her bilateral lower extremities were wrapped with ace wraps. The resident indicated she preferred a shower, but they were bathing her in bed due to her legs being wrapped. She had not had a shower for about a month. She feels so much better when she gets a shower. The resident's shower days were on Wednesdays and Saturdays.The annual MDS assessment, dated 6/3/25, indicated the resident's bathing preference was very important to her.The care plan, dated 8/24/24, indicated the resident required assistance with Activities of Daily Living and staff were to assist with showers twice weekly or per the resident's preference.Review of the resident's bathing record, between 7/13/25 and 8/11/25, indicated the following:-On Wednesday, 7/16/25, the resident received a bed bath-On Saturday, 7/19/25, the resident received a shower-On Wednesday, 7/23/25, the resident received a bed bath-On Saturday, 7/26/25, no bathing documentation-On Wednesday, 7/30/25, the resident received a bed bath-On Saturday, 8/02/25, the resident received a bed bath-On Wednesday, 8/06/25, the resident received a bed bathDuring an interview, on 8/12/25 at 10:30 a.m., Licensed Practical Nurse (LPN) 4 indicated the new Certified Nursing Assistants now were not taught about covering legs that were wrapped. She was unaware that the resident was not getting her showers until just recently. The resident liked to get her showers.The document titled Resident Rights was provided on 8/12/25 by the Clinical Support at 10:28 a.m. It included, but was not limited to, The resident has the right to a dignified existence .The right to receive the services .included in the plan of care 2 The clinical record for Resident H was reviewed on 8/11/25 at 1:40 p.m. The resident's diagnoses included, but were not limited to, asthma, diabetes, chronic obstructive pulmonary disease, chronic pain and depression. The quarterly MDS assessment, dated 6/22/25, indicated the resident's cognition was intact. During an interview, on 8/10/25 at 9:49 a.m., the resident indicated on 7/23/25, a staff member (name unknown) from the front office came into his room and told him his Medicaid application had been denied and provided him with a 30-day discharge notice. He had just called the Medicaid office the week before and was told his application was still pending. He asked the lady how she knew his Medicaid had been denied and it was reported to him that they had received a letter in the mail. He told them he wanted to see the letter. On Monday, 7/28/25, the lady came in and showed him the letter, which had his name on it. He asked her why they opened the letter when it was addressed to him and she told him that anything with FSSA (Family and Social Services Administration) on it, the facility was allowed to open. He asked her to show him where, in the Federal Regulations, that it said they could open someone's mail without their permission. Again, he was told that they were allowed to open any mail with FSSA on it. He was also told on 7/28/25 that he had signed for the representative to receive his information. The only thing he had signed was a form giving permission for the representative from (name of the outside company) that helps individuals navigate the Medicaid application process to assist him with the paperwork for Medicaid. At 9:55 a.m., the resident provided the letter for the surveyor to review. The mailing date was 7/18/25 and the letter was observed to be addressed to the resident only.The progress note, dated 7/23/25 at 3:15 p.m., indicated the Director of Social Services, Business Office Manager and Assistant Business Office Manager visited the resident in his room to present a discharge letter and transfer/discharge notice of and discharge date d of 8/23/25Review of the admission Packet Agreement, signed by Resident H on 11/13/24, included, but was not limited to, the following Section 1: Parties to the Agreement .This admission and Consent to Treat Agreement .is made between the Resident identified above (Resident) and/or by the Resident Representative identified above on behalf of the Resident .and the Facility listed above .Resident Mail .The Resident will receive all mail unopened unless requested otherwise as indicated below .Forward all mail unopened to the Resident Representative The admission Packet Agreement lacked documentation of a resident representative listed for Resident H.On 8/11/25 at 9:55 a.m., the State Form 55386, Authorized Representative for Health Coverage was reviewed. It included, but was not limited to, If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is authorized to do. You can select [NAME] than one representative and choose the same or different functions. The representative may be an individual or an organization. Complete ONE form per authorized representative. Both you and your representative must sign and date this form The form was singed on 4/4/25 by Resident H and the representative from Medicaid Done Right. The clinical record lacked documentation of any other authorized representative forms.On 8/11/25 at 10:53 a.m., the Executive Director indicated that the authorized representative form provided to surveyor was signed by the person from the (name of company) that helps individuals navigate the Medicaid process. The facility had always opened the mail for FSSA for residents so they could scan the information and ensure timeliness of provided information to the outside company. It allowed the (name of company) the ability to follow up with any issues quickly. They are now going to take Resident H the mail and open with him.On 8/12/25 at 1:45 p.m., the Social Services Director indicated the discharge notice was provided to the resident on 7/23/25 really for no reason. The previous notice was overturned by the court, so we were trying to figure out how to move forward.This Citation relates to Complaint 25754913.1-3(a)3.1-3(s)(1)

Based on interview and record review, the facility failed to ensure a blood pressure medication was held for a resident (Resident K) with out of parameter blood pressures for 1 of 3 residents reviewed for quality of care.Findings Include: The clinical record for Resident K was reviewed on 8/11/25 at 2:16 p.m. The resident's diagnosis included, but was not limited to, hypertension.The care plan, dated 6/9/25, indicated the resident had altered cardiovascular status due to hypertension and medications were to be administered as ordered by the physician.The physician's order, dated 4/5/25, indicated the resident was to receive Lisinopril (medication for high blood pressure) 10 mg (milligrams) daily in the morning. The medication was to be held if the resident's systolic blood pressure (SBP) was less than 110.Review of the July 2025 and August 2025 medication administration record indicated the resident received the medication on the following dates:-On 7/08/25, the Lisinopril was administered to the resident with a SBP of 100-On 7/11/25, the Lisinopril was administered to the resident with a SBP of 100-On 7/23/25, the Lisinopril was administered to the resident with a SBP of 106-On 7/28/25, the Lisinopril was administered to the resident with a SBP of 100-On 7/29/25, the Lisinopril was administered to the resident with a SBP of 104-On 8/04/25, the Lisinopril was administered to the resident with a SBP of 106-On 8/05/25, the Lisinopril was administered to the resident with a SBP of 103-On 8/06/25, the Lisinopril was administered to the resident with a SBP of 109During an interview, on 8/12/25 at 10:30 a.m., Registered Nurse (RN) 5 indicated if a resident's blood pressure was out of parameters, the medication should not be given. On 8/12/25 at 12:44 p.m., the Executive Director provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Medications will be administered .in accordance to applicable State, Local and Federal laws, consistent with accepted standards of practice .Obtain and record any vital signs as necessary prior to medication administration This Citation relates to Complaint 25809923.1-37

Based on record review and interview, the facility failed to ensure prompt notification to the physician of rectal bleeding for a resident on an anticoagulant, which resulted in the resident's hospitalization for anemia and acute blood loss. The resident had to have a blood transfusion for 1 of 3 resident's reviewed for physician notification. (Resident 82) Findings include: The clinical record for Resident 82 was reviewed on 7/26/23 at 10:16 a.m. The diagnoses included but were not limited to, iron deficiency anemia secondary to blood loss, hemorrhage of anus and rectum, diverticulosis of intestine without perforation or abscess without bleeding, acute posthemorrhagic anemia, presence of cardiac implants and grafts, chronic atrial fibrillation, heart disease, and left ventricular failure. The Admission MDS (Minimum Data Set) assessment, dated 6/2/23, indicated the resident was cognitively intact. The care plan, dated 6/5/23, indicated the resident was on anticoagulant therapy related to atrial fibrillation and risk for deep vein thrombosis. The goal was for the resident to be free from extensive bruising or bleeding. The interventions included, but were not limited to; administer medications as ordered by the physician; and monitor for side effects every shift; monitor, document, and report as needed any adverse reactions such as dark or bright red blood in stools. The physician's order, dated 5/27/23, indicated the resident received Eliquis (blood thinner/reduces blood clotting) 5 mg (milligrams) twice daily for congestive heart failure related to left ventricular failure The physician's orders, dated 5/28/23, indicated the resident received aspirin low dose 81 mg daily for coronary artery disease. The physician's order, dated 5/29/23, indicated to observe the resident for bleeding, including black tarry stools, and to chart the appropriate code and notify the physician if any symptoms were observed. The nurse's note, dated 7/15/23 at 3:05 p.m., indicated the resident complained of constipation and rib pain. A laxative was given, the resident had a large bowel movement, and was bleeding from the rectum with the bowel movement. The resident was cleansed, and the bleeding was monitored. The nurse did not see any active bleeding. The NP (Nurse Practitioner) gave new orders for a chest x-ray. The NP note, dated 7/15/23 at 11:50 p.m., indicated the resident was seen by the NP for complaints of rib pain. An order was given for a chest x-ray. The note did not address any symptoms of bleeding. The Resident's MAR (medication administration record) for July 2023 indicated the following: - On 7/15/23 the resident's aspirin and Eliquis were administered as ordered and no bleeding was documented on the resident's anticoagulant symptom monitoring. - On 7/16/23 the resident's aspirin and Eliquis were administered as ordered and no bleeding was documented on the resident's anticoagulant symptom monitoring. - On 7/17/23 in the morning the resident had symptoms of bleeding, as indicated by a Y for yes, however it did not indicate what symptoms the resident displayed and did not indicate any physician notification. The resident's aspirin and Eliquis were administered as ordered. The MAR (electronic medication administration record) note, dated 7/18/23 at 7:23 a.m., indicated the resident's Eliquis 5 mg tablet was held due to rectal bleeding. The Change in Condition note, dated 7/18/23 at 11:15 a.m., indicated the resident had gastrointestinal (GI) bleeding. The nurse was notified by the CNA (Certified Nurse Aide) that the patient had a large amount of dark red blood and blood clots found in her brief. The nurse went to evaluate the resident and she reported she had not voided in two days. The patient was catheterized and 750 mL (milliliters) of amber, cloudy, thick urine was removed. The NP was notified and recommended to send the resident to the hospital. The Hospital note, dated 7/21/23, indicated the resident reported she had begun having red blood clots in her bowel movements. She had been on Eliquis for about 1 year and the bleeding was spontaneous. She reported epigastic pain and urinary hesitancy. She was admitted in consultation with gastroenterology. Her aspirin and Eliquis were held. She was transfused with 2 units of packed red blood cells. She underwent colonoscopy which showed no active bleeding but did show evidence of likely diverticular bleeding recently that was likely exacerbated by the presence of Eliquis therapy. She was instructed to restart her Eliquis on 7/22/23 and her aspirin on 7/25/23. During an interview on 7/25/23 at 8:55 a.m., Resident 82 indicated she had gone to the hospital after two days of bleeding from her rectum. During an interview on 7/26/23 at 12:25 p.m., RN 8 indicated he was the RN on duty when the resident went out to the hospital. She was having large amounts of blood in her stool. He was told in report she had some blood but wasn't showing any symptoms of blood loss, so he waited for the NP to come in because it was morning. Then the CNA had told him there was some blood in her brief. That's when he checked it out. They did not tell him how long it had been going on. He was told in report from the night shift nurse the resident had a few large clots in her brief. He had no clue if they'd reported it to the doctor. He was not aware of any bleeding a few days prior. He held the Eliquis because the night shift nurse said she had blood clots. She had just been changed by night shift before coming in, so he didn't see anything. He took them at their word and the CNA came and got him shortly after pill pass. He didn't actually see the blood, as the CNA had already taken out the trash and she had already tossed it. He did assess her rectum and he didn't see any hemorrhoids. She had a little bit of blood in her brief. It was just spotty at that point. He would notify the physician of bleeding for residents on anticoagulants normally right away. During an interview on 7/28/23 at 11:14 a.m., CNA 11 indicated she had worked with the resident on 7/15/23 for an entire shift. She had observed a very large amount of blood in the resident's brief. It was a lot of blood mixed in with her bowel movement and it filled her brief. It looked like there were clots in it. She immediately let her nurse know but she did not know if the nurse informed the doctor. During an interview on 7/28/23 at 11:35 a.m., NP 9 indicated she saw the resident on 7/15/23 for rib pain. She did not know of any bleeding. That was not the issue she was notified of. She would definitely expect to be notified of bleeding because of her being on a blood thinner. If she had active bleeding, she would have looked at her medications and definitely done some laboratory tests, such as a stool sample or a complete blood count. On 7/15/23 no one informed her of any bleeding, and they definitely did not tell her the resident had blood in her brief. During an interview on 7/28/23 at 2:36 p.m., NP 10 indicated she was the one who sent the resident out and she did observe the bleeding. The brief was saturated with [NAME] blood and there were blood clots which were approximately silver dollar sized. It was concerning. She did not believe she was notified between 7/15/23 and 7/18/23. She'd had concerns of not being notified related to resident concerns since the turnover of the DON (Director of Nursing). The change in a Resident's Condition or Status policy, provided on 7/31/23 at 8:10 a.m. by the DON, last revised 2/2021, included, but was not limited to, . The nurse will notify the resident's attending physician or physician on call when there has been a(an) . c. adverse reaction to medication . d. significant change in the resident's physical/emotional/mental condition . i. specific instruction to notify the physician of changes in the resident's condition . a 'significant change' of condition is a major decline or improvement in the resident's status that . will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure the appropriate interventions were in place to prevent the development of two unstageable pressure ulcers for 1 of 7 residents reviewed for pressure ulcers. This deficient practice resulted in a Stage 3 heel and Stage 3 sacrum pressure ulcer. (Resident 34) Findings include: The record for Resident 34 was reviewed on 7/28/23 at 9:15 a.m. The diagnoses included, but were not limited to, lack of coordination, unsteadiness on feet, muscle weakness, type 2 Diabetes Mellitus, hyperglycemia, dysphagia following cerebral infarction, left flaccid hemiplegia, Stage 3 pressure ulcers, vascular dementia, cognitive communication deficit, osteoarthritis, and the presence of tendon and bone implants. The Quarterly MDS (Minimum Data Set) assessment, dated 7/10/23, indicated the resident was severely cognitively impaired. She required extensive assistance of 2 staff members for bed mobility and transfers. The care plan, dated 8/19/19 and last revised on 7/15/23, indicated the resident had an unstageable pressure area to the sacrum, which was a Stage 3. The interventions included, but were not limited to, turn and reposition the resident every two hours with while in bed to avoid direct pressure to the at-risk areas and bony prominences (dated 5/7/21), apply heel boots while in bed (dated 5/8/23), and apply a pressure reduction wedge while in bed (dated 5/13/20). The nurse's note, dated 2/25/23 at 8:58 a.m., indicated the resident required total assistance with care. The nurse's note, dated 5/3/23 at 2:27 p.m., indicated the CNA (Certified Nurse Aide) called the nurse into the resident's room. The resident had at large blister on the right heel. The blister measured 8 cm (centimeters) long by 5 cm wide. The area was cleansed with normal saline and covered with a 4 by 4 dressing. The Wound Observation Tool, dated 5/5/23, indicated the resident had a facility acquired pressure ulcer to the right heel and was a SDTI (suspected deep tissue injury). The preventative measure was for new heel lift boots. There was 20% (percent) non-granular and 80% intact blister with a small amount of bloody drainage. The wound measured 5 cm long by 3.6 cm wide by 0.1 cm deep. The peri wound was intact, ecchymosis tissue. The current wound was to cleanse the wound with normal saline and apply calcium alginate, place an ABD (abdominal gauze pad) pad, and wrap the heel in kerlix daily on Monday, Wednesday, and Friday. The new order was for new heel lift boots to be obtained and to place the resident on the wound MD consult list. The dietitian and therapy were notified. The nurse's note, dated 5/7/23 at 12:15 p.m., indicated the resident had an area to her right heel and the treatment was to be continued. Heel protectors were to be kept on and the feet elevated related to the area on the heel. The Wound Observation Tool, dated 5/11/23 indicated the wound doctor saw the facility acquired SDTI and classified the heel wound as unstageable. The wound was worsening with necrotic tissue present and measured 8 cm long by 5 cm wide by 0.1 cm deep. There was 10% granulation tissue and 90% eschar. The Wound Observation Tool, dated 5/31/23, indicated the facility acquired unstageable pressure ulcer to the sacrum was first observed on 5/26/23. The preventative measures were a low air loss mattress. The wound had 100% slough tissue present (yellow, tan, white, stringy). The wound measured 2 cm long by 0.7 cm wide by 0.1 cm deep. The new pressure ulcer was noted on the sacrum, a low air loss mattress was ordered, a pressure reduction wedge was obtained for the patient, the Wound MD was to follow up Thursday, and therapy and the dietitian were notified. The Wound Observation Tool, dated 6/8/23, indicated the resident's Stage 3 pressure would to the right heal measured 0.4 cm long by 1.7 cm wide by 0.1 cm deep. There was a new order for treatment to cleanse the wound with normal saline, apply Medi-honey, and place a silicone foam border dressing daily. The wound was stalled. The Wound Observation Tool, dated 6/16/23, indicated the sacral wound was improving and measured 1 cm long by 0.4 cm wide by 0.1 cm deep. There were no new orders and indicated to cleanse the wound with normal saline and to apply Medi-honey, and cover with a 4 by 4 silicone foam border dressing daily. The wound was stalled, and the preventative measures were for low air loss mattress, and pressure reduction wedge. The nurse's note, dated 6/26/23 at 12:59 p.m., indicated the resident's air boots were to be always on, when in bed. The Wound Observation Tool, dated 6/30/23, indicated the Stage 3 wound to the sacrum had 90% granulation tissue and 10% slough. The wound measured 0.7 cm long by 0.2 cm wide by 0.1 cm deep. The wound was healing. The nurse's note, dated 6/30/23 at 10:20 a.m., indicated the resident was continued on the air mattress for healing of the sacral wound to the coccyx and therapy had been involved with e-stim treatment as well. when in bed she wore heel boots from the area to the right heel which had healed and looked good. The Wound Observation Tool, dated 7/7/23, indicated the Stage 3 wound to the sacrum had 100% granulation tissue. The wound measured 0.4 cm long by 0.2 cm wide by 0.1 cm deep. The Wound Observation Tool, dated 7/21/23, indicated the facility acquired pressure ulcer to the sacrum was now a Stage 3 with 100% granulation tissue and measured 0.5 cm long by 0.4 cm wide by 0.1 cm deep. The current treatment orders were to cleanse the wound with normal saline and apply Medi-honey, cover with a 4 by 4 silicone foam border every day and were to be continued. The wound was almost closed. During an observation on 7/27/23 at 1:36 p.m., with the wound nurse and wound doctor, the wound doctor indicated the wound hadn't improved and her orders were for dressing changes daily and as needed, the low air loss mattress, supplements for liquid protein, and Med Pass. The resident had been on e-stim for a little while. The staff turned and repositioned the resident, she could not do it on her own. The wound measured 0.7 cm long by 0.5 cm wide by 0.1 deep. It was a little bigger in size from her previous observation. The new order would be for a cream to be applied daily and left open to air, because it was a little sloughy. A pillow was under the resident's feet with her heels resting directly on the pillow. No lift boots were observed on the resident. An air mattress was on the bed. The resident had a bowel movement, and a CNA was obtained by the wound nurse to clean the resident before the dressing treatment could be applied. The CNA placed the resident's heels back, directly on the pillow and did not float the heel or apply any heel boots. During an observation of incontinence care on 7/27/23 at 1:45 p.m., CNA 16 provided care on the resident. The Wound Nurse assisted the CNA with the care. A brief was placed on the resident. Upon completion of the care, the resident was rolled onto her left side and a wedge was applied behind the resident's back. A blanket was placed between her knees, and her heels were placed directly on the pillow again. No lift boots were observed. During an interview on 7/28/23 at 9:06 a.m., QMA (Qualified Nurse Aide) 17, indicated the resident required a mechanical lift, due to her inability to turn and reposition. She was not able to roll herself. During an observation on 7/28/23 at 9:08 a.m., the resident's right ankle was crossed over her left ankle with her right heel resting directly on the pillow. Her left heel was resting on the mattress. She had no lift boots on. During an interview on 7/28/23 at 10:01 a.m., LPN (Licensed Practical Nurse) 12, indicated the resident would be turned from side to side for pressure ulcers. They would use a wedge pillow to cushion the bony prominences. The heels would be kept elevated above the mattress. The resident had boots available. Her feet rubbed together. During an interview on 7/28/23 at 10:41 a.m., CNA 18 indicated residents with pressure ulcers would be turned from side to side while in bed. During meals, they would be placed on their backs. The heels would be floated with a pillow between the ankles. Their heels would be floated by hanging them over the pillow. The Prevention of Pressure Injuries policy, last revised January 2023, was provided by the Director of Nursing on 7/28/23 at 11:40 a.m. The policy included, but was not limited to, . Prevention . 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries . Mobility/Repositioning . 3. Provide devices and assistance as needed . 3.1-40(a)(1)

Based on record review and interview, the facility failed to ensure residents received behavioral health services as required for 1 of 3 resident's reviewed for behavioral health services. This deficient practice resulted in a resident with ineffective behavior interventions and uncontrollable behaviors. (Resident 86) Findings Include: The record for Resident 86 was reviewed on 7/26/23 at 11:37 a.m. The diagnoses included, but were not limited to, developmental disorder of speech and language, anxiety disorder, altered mental status, and lack of expected normal physiological development in childhood. The Quarterly MDS (Minimum Data Set) assessment, dated 6/15/23, indicated the resident was moderately cognitively impaired. The MDS indicated the resident did not exhibit behavioral symptoms such as hitting, kicking, pushing, scratching, and grabbing. The care plan, dated 7/21/21 and last revised on 2/1/23, indicated the resident had behavior problems of expressing frustration, agitation, anxious and restless by throwing items and making disruptive sounds. The interventions included, but were not limited to, administer medications as ordered and monitor and document for side effects and effectiveness. Caregivers were to provide opportunities for positive interaction and attention. Staff were to stop and talk with him when passing by, encourage activities of resident's interest, provide supplies and assistance as needed for self-directed activities and pursuits, encourage family conversations and visits as feasible, explain all procedures to the resident before starting and allow the resident adequate time to adjust to changes, intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, and remove the resident from the situation and take to an alternate location as needed. Meet the resident's needs, monitor behavior episodes, and attempt to determine underlying cause, consider the location, time of day, persons involved, and situations and document behavior and potential causes. Provide a program of activities that is of interest to the resident and accommodate the resident's status, provide one on one attention, and engage in conversation with the resident, provide redirection as needed and remove from overly stimulating areas and situations. The resident was to deescalate in his room with activities of choice and television programs to help him calm down. The nurse's note, dated 7/20/22 at 4:47 p.m., indicated the resident was yelling out, throwing objects at other residents, and trying to hit the other residents and staff. The nurse's note, dated 8/25/22 at 4:57 p.m., indicated the resident threw a chair and a trash can in the common area. The resident was returned to his room to decrease stimulation. The resident then smacked and kicked the nurse and pinched and smacked the CNA (Certified Nurse Aide) assisting the nurse. Staff decreased bright lighting, offered snacks and a drink, turned on the TV to a show of the his choice, provided perineal care, and gave PRN (as needed) Tylenol in case the resident was in pain and could not communicate it. The interventions were not effective. When asked resident what was upsetting him, he shrugged his shoulders. The DON was notified, and a note was given to social services for possible evaluation from psychiatric services. The nurse's note, dated 9/30/22 at 5:34 p.m., indicated the resident was throwing his cup and dinner plate tray. When asked what was bothering him, he pointed across hallway to another resident's room who was yelling out. The interventions were ineffective. The resident then attempted to hit the nurse. He was not easily redirected at that time. His behavior was unchanged. The nurse's note, dated 10/29/22 at 4:56 p.m., indicated the resident hit another resident in the right arm. She could not get out of the resident's way. Resident 86 had a history of combative behavior towards staff and other residents, throwing objects into the hallway and was currently screaming. He was not easily redirected. Staff provided a less stimulating environment, removed harmful objects he had thrown into the hallway for his and the other residents' safety. The nurse's note, dated 10/30/22 at 3:15 p.m., indicated the resident was witnessed by staff pinching another resident. The CNAs separated Resident 86 from the other residents for safety and the resident scratched and pinched the CNAs right arm and left red marks on the CNAs forearm. The resident was non-compliant with education. The interventions to decrease stimuli, assess for pain, and administer medications were ineffective. The resident was not easily redirected. The on-call NP (Nurse Practitioner), on call manager, and the DON (Director of Nursing) were notified and spoke about sending the resident out to a behavioral facility. The nurse's note, dated 11/17/22 at 5:15 p.m., indicated the resident was throwing objects into the hallway, at staff, and into his roommate's side of the room and hitting staff. The nurse's note, dated 11/25/22 at 9:33 a.m., indicated during morning rounds, staff informed the nurse that the resident had behaviors the night before. The resident had pulled both closet doors off the tracks and threw them, the resident managed to break the bedside table, nightstand, and threw water all over his room. The nurse's note, dated 11/25/22 at 10:48 a.m., indicated a call was placed to the resident's family member related to the resident behaviors. The family member indicated she had been aware and was unsure what the cause or reason for behaviors was. The nurse's note, dated 3/7/23 at 3:35 p.m., indicated the resident was upset due to the ice cream parlor being closed, not being able to get a haircut, and not being able to get fast food for lunch. The resident started grabbing supplies off the nurse's cart and throwing them. The resident was asked to stop and offered snacks and diet pop. The resident continued to throw things and tried to swing at the employee who took him to his room to provide incontinent care. The resident continued to throw all items in his room including trash cans, books, remote, his glasses, and anything that he could grab to throw across the room. The resident hit and pinched two employees. The resident was asked to stop and to talk or write down what was wrong. The resident continued to throw everything. Staff called the resident's family member in hopes of de-escalation of behaviors', and he seemed to deescalate while talking to his family member. The resident was able to calm down and wanted to come back out to the living room. Moments later the resident took off his glasses and threw them across the room. While throwing his glasses they hit another resident in the face. The resident's family member, unit manager and social services was made aware. The nurse's note, dated 3/8/23 at 11:26 a.m., indicated the resident threw ink pens at two residents, pinched another, and tore up the nurse's medication cart. The nurse's note, dated 3/21/23 at 6:35 p.m., indicated the resident was in bed, dry, and watching television at 4:00 p.m. The resident started having behaviors. He started throwing items to the other side of the room. The resident stated he was upset about not having a haircut and wanted one. Staff cleaned his room up. The resident continued to throw his glasses, call light, and other items across the room. The nurse's note, dated 3/22/23 at 4:32 p.m., indicated the resident hit, slapped, and punched a CNA while providing care. The nurse's note, dated 3/29/23 at 6:55 p.m., indicated the resident had behaviors in the living room. He started flipping off the other residents and throwing anything that he could grab, including throwing a remote across the living room. The remote didn't hit anyone. He was taken to his room and put in bed with the call light in reach. He continued to have behaviors in his room. He tore the call light out of the wall and threw everything that he could reach across the room. The nurse's note, dated 4/17/23 at 6:14 p.m., indicated the CNA reported that the resident threw a notepad and pen towards another resident. The nurse took the resident to his room. He hit the nurse and CNA. He was placed in his room alone. He continued to throw anything that he could reach across his room. He then came out into the hallway and continued to throw walkers, canes, bedside commodes, and medical supplies across the hallway. The nurse called the resident's family member in hopes to attempt to de-escalate the resident's behaviors. He calmed down enough to apply the cream and ten minutes later he ate his dinner in his room. He continued to throw items in his room and items in the hallway including his glasses. Nursing management, the night shift nurse, and the resident's family member were made aware. The nurse's note, dated 5/5/23 at 6:43 p.m., indicated the resident was in the common area on the 100/400 unit, and went behind a resident who was sitting in a chair watching television) and tried to hit the CNA. The CNA removed the resident from 100/400 Unit. She took him back to the 600 Unit. He attempted to hit another resident on the way back to the 600 Hall. The nursing management and the resident's family member was made aware of the resident's behaviors. During an interview on 7/26/23 at 11:00 a.m., Social Services indicated her social service notes on follow-up with the residents would be documented in the computer under the general note section. The facility did not have any resident charting on paper form. The clinical record lacked documentation indicating the resident was evaluated and treated at a behavioral health facility for his behaviors or followed up by Social Services for the resident's psychological needs after his behaviors. During an interview on 7/27/23, at 10:30 a.m., QMA 7 indicated Resident 86 was nonverbal. He would make noises, but he could make his needs known. He would write on paper. He did have behaviors. The resident had a difficult time controlling his emotions. The staff used interventions but sometimes they were ineffective. He was mostly destructive with his own personal items. Some interventions that were effective was sitting and talking with the resident. Calling his family member usually calmed him down. When the resident got out of control staff would take him to his room and turn on the television. The QMA indicated he thought how a staff member approached the resident made a difference. The resident could get aggressive with his behavior. He was not sure why there wasn't a follow up on sending the resident to a behavior facility. The nursing staff would report his behavior and received orders to send the resident to a behavioral facility to the Unit Manager and the Social Service Director and they were responsible for making the arrangements and following up. During an interview on 7/27/23 10:45 a.m., LPN (Licensed Practical Nurse) 13 indicated she was aware the resident had behaviors. The Unit Manager, or Social Services should follow-up on the behavioral referrals. Once the nursing staff receive the order to send the resident to a behavioral facility, they would make the arrangements. During an interview on 7/27/23 at 2:08 p.m., VPCO (Vice President of Clinical Operations) indicated a behavioral health facility declined to admit the resident because of his mental disabilities. The resident did need to go to a behavioral health facility. A follow-up should have been done. There were facilities that accepted residents like Resident 86. The resident functioned at a five-year-old level. The resident's MDS indicated he was moderately cognitively impaired, which surprised her because she thought it would be lower. She did not know if other agencies were contacted. The clinical record did not indicate there was documentation indicating a follow-up was done. A reevaluation of the interventions should have been, and Social Services should have followed-up on the resident's behaviors. During an interview on 7/28/23 at 10:18 a.m., the DON indicated staff should follow the residents care plan. Staff should always make attempts to prevent the behaviors. They should be monitoring for agitation and what issues upset the resident. The resident would be taken back to his room for his outburst and to protect the other residents. The private room worked out well for the resident. The DON indicated she could not locate documentation regarding a follow-up. During an interview on 7/28/23 at 10:30 a.m., the ED (Executive Director) indicated staff should identify what triggered the resident and try to prevent the behavior. He indicated the unit could keep ice cream stocked if the ice cream shop was closed. The resident was impatient and wanted things done when he indicated he needed something. He felt like prevention would decrease the resident behaviors. The Behavior Assessment and Manage policy provided on 7/28/23 by the VPCO, included but was not limited to, . It is important to understand causes of behavior problems in our residents . Behaviors may be related to physical discomfort, overstimulation, unfamiliar surroundings, complicated tasks and frustrating interactions. 1. Examine the behavior; What was the behavior? Was it harmful to the individual or others? What happened just before the behavior occurred? Did something trigger it? What happened immediately after the behavior occurred? How did you react? Could something be causing the person pain? Consult a physician to identify any causes related to medications or illness. 2. Explore potential solutions; What are the needs of the resident? Are they being met? Can adapting the surroundings comfort the person? How can you change your reaction or approach to the behavior? Are you responding in a calm and supportive way? 3. Try different responses; Did your new response help? Do you need to explore other potential causes and solutions? If so, what can you do differently? .Understanding the nature of the issue/condition and addressing the underlying causes have the potential to improve the quality of the resident's life and lives of those with whom the resident interacts. Once behaviors have been assessed, the next step is to develop a resident-specific care plan base directly on the conclusion/underlying cause. If behaviors place the resident or others at risk for harm, immediate action is required to prevent any harm. The focus of the care plan should be to address the underlying cause or causes, reversing the daily display of troubling behaviors, and preventing any harm from occurring . 3.1-37(a) 3.1-43(a)(1)

Based on observation, interview, and record review, the facility failed to ensure appropriate fall interventions were implemented to prevent falls, which resulted in a fall with fracture for 1 of 6 residents reviewed for accidents. (Resident 114) Findings include: During an observation on 7/12/22 at 10:01 a.m., Resident 114 was sitting in her wheelchair by her bed. Her room curtain was pulled and her door was partially closed. She could not be seen from the hallway in passing. Her call light was clipped to the table in front of her. The resident could not indicate when asked what the call light was, she shrugged her shoulders and gave a puzzled look. She indicated she took herself to the restroom. The clinical record for Resident 114 was reviewed on 7/7/22 at 8:18 a.m. The diagnoses included, but were not limited to, fracture of unspecified part of right clavicle, orthopedic surgery, unspecified fall, urinary tract infection, anxiety disorder, major depressive disorder, dementia, [CONDITION(S)], cerebellar ataxia, chronic fatigue, [CONDITION(S)] disease of nervous system, overactive bladder, and muscle weakness. The Quarterly MDS (Minimum Data Set) assessment, dated 12/9/21, indicated the resident's cognition was severely impaired. The 5-day scheduled MDS assessment, dated 6/23/22, indicated the resident's cognition was severely impaired. The care plan, dated 2/2/22 and last revised on 7/5/22, indicated the resident was at risk for falls related to new environment, dementia, weakness, [CONDITION(S)] (chronic obstructive pulmonary disease), cerebral ataxia, pseudobulbar effect, medication use, and fractured clavicle. The goals indicated the resident would not have any unidentified fall related injuries through next review. The interventions dated 2/2/22, included, but were not limited to, bed in low position at all times, call light or personal items available and in easy reach or provide reacher (tool to reach), footwear to prevent slipping; dated 2/23/22, staff to encourage and assist resident to toilet before meals and at bed time; dated 3/22/22, assist to bed late evening per resident preference and toilet prior to bed; dated 4/2/22, encourage resident to lay down after meals to allow for rest periods as desired; dated 4/5/22, refer to urologist related to overactive bladder and presence of bladder stimulator; dated 5/4/22, encourage non-skid socks while abed as resident allowed and encourage to call for and await assist prior to transfer; dated 6/7/22, assist resident to chair prior to meals; dated 6/15/22, perimeter mattress to bed. The nurse's note, dated 1/21/22 at 11:53 p.m., indicated the resident was alert to self, forgetful, aware of city but not name of facility, unaware of month, year, and season. She was calm, pleasant, and her speech was unclear. She had tremors and jerking movements, required assist of 1 for transfers, used a wheelchair for locomotion, was continent of bowel and bladder. Her skin was warm and dry, with no skin issues. Her call bell was changed out for a soft touch call bell due to the resident being unable to push regular call button. The nurse's note, dated 2/23/22 at 5:45 a.m., indicated upon routine rounds the resident was observed sitting on her buttocks near the commode. She stated she did not fall, denied pain or any discomfort, and her vitals were within normal limits. The patient was educated to ask for assistance and verbalized understanding. The post fall assessment, dated 2/23/22 at 5:45 a.m., indicated resident fell from toilet to floor, stated she did not fall but was observed sitting on floor in front of commode, the immediate intervention was to reduce the risk of reoccurrence of fall with patient education encouraging the resident to ask for assistance. The nurse's note, dated 3/9/22 at 2:37 a.m., indicated the resident had multiple requests for staff to take her to the toilet repetitively and would ask again for help within minutes of returning from toilet. Staff observed she had gotten out of bed on her own and had a very large bowel movement on the floor at the foot of her bed. The nurse's note, dated 3/22/22 at 12:30 a.m., indicated the resident was heard yelling and found sitting in the floor right outside of her room. She had fallen trying to get out of bed to go to the bathroom. She had two linear abrasions to the right upper back from the fall. The resident was assisted to the bathroom after assessment and informed to use her call light for assistance with transfers and toileting. She voiced understanding. The post fall assessment, dated 3/22/22 at 12:30 a.m., indicated the resident fell from the bed to the floor trying to get up to go to the restroom. The resident had impaired judgement/ does not call out for assistance. Her last fall was on 2/23/22. The immediate intervention was to place her call light in resident's hand and encourage her to use it if she needed to use the restroom. The care plan was updated with a new intervention to assist the resident to bed in late evening per resident preference, toilet prior to bed. The nurse's note, dated 3/23/22 at 10:35 p.m., indicated the resident's family member stated that she hadn't been acting right that day, that something was off. Staff offered to contact the NP (nurse practitioner), and the family member was ok with that. The family member then assisted resident to bed, and stated that she did not assist in bearing weight, that he had to lift her into bed. After the resident being in bed approximately 10 minutes, the resident was no longer alert, would not open her eyes or answer simple questions, call placed to NP, and a new order was received to send to ER (emergency room ) for evaluation and treatment. The nurse's note, dated 3/23/22 at 11:59 p.m., indicated the resident was admitted to the hospital with a urinary tract infection. The nurse's note, dated 4/2/22 at 7:00 p.m., indicated the nurse heard the resident yelling out, entered the resident's room and observed the resident laying on the floor in front of her wheelchair and in front of the bed. She had no injuries noted, and neurological checks were within normal limits. She had not used call bell for assistance. The post fall assessment, dated 4/2/22 at 6:45 p.m., indicated the resident fell from her chair to the floor when going to bed. The care plan was updated with a new intervention to encourage resident to lay down after meals to allow for rest periods as desired. The nurse's note, dated 4/5/22 at 1:53 a.m., indicated the nurse heard the resident grunting and moving around in her room. She walked in to see her take a step away from her bed and sit down hard on the floor. She told this nurse she wanted to go pee! She had no shoes on, a cup in her hand, and denied new pain. She had been very agitated most of the shift, was not easily redirected. She had been screaming at staff to get her cane that she was going for a walk. She refused pain medication. She was assisted to her wheelchair then taken to toilet. Her cup was filled, call light was tied to bedrail within reach. She voiced understanding on use of call light. A fall mat would be added to bedside. The post fall event, dated 4/5/22 at 6:00 p.m., indicated the resident fell from her bed to the floor. No immediate interventions were listed. The care plan was updated with the following interventions: Medication review related to multiple antibiotic treatments, and refer to urologist related to over active bladder and presence of bladder stimulator. The clinical record lacked documentation of any attempts to contact a urologist, communication with the resident's family regarding a urology consult, or any attempts to schedule a urology consult. The nurse's note, dated 4/13/22 at 7:00 p.m., indicated the resident did not use the call light system, but would often start a shrill screaming to get staff attention. The nurse's note, dated 5/4/22 at 2:44 a.m., indicated the resident was found sitting in the floor beside her bed, and stated she sat down too soon after going to restroom. She yelled out to get staff attention, her call light was off and hanging on the bed. Non-skid socks were applied and a night light was turned on. The post fall event, dated 5/4/22 at 2:30 a.m., indicated the resident fell from her bed to the floor. and stated she sat down too soon after going to restroom, it appeared she was pushing her wheelchair. A urinalysis was pending. The resident complained of urgency, her urine looked like pancake syrup with a large amount of grey sediment. the immediate action indicated for staff to turn on nightlight and apply socks, return to bed, assess for pain. The care plan was updated with an intervention to encourage to call for and await assist prior to transfer. The nurse's note, dated 6/6/22 at 11:12 a.m., indicated the resident fell from bed while attempting to self-transfer. The post fall evaluation, dated 6/6/22 at 11:07 a.m., indicated the resident fell from her bed to the floor. The immediate action listed was assess for injury, returned to bed assist of 2 staff. The care plan was updated with an intervention to assist the resident to her chair prior to meals. The nurse's note, dated 6/8/22 at 8:49 p.m., indicated the resident did not use the call light system and often just started a shrill screaming to get staff attention. The nurse's note, dated 6/13/22 at 5:31 a.m., indicated the resident had hollered on and off all night, she had transferred herself numerous times, she was assisted to the bathroom numerous times. Staff encouraged the resident to use her call bell and educated the resident on where her call bell was and how to use it. She stated ok each time, but had not used her call bell to call for assistance. The nurse's note, dated 6/15/22 at 10:23 p.m., indicated the resident was in bed for the evening, she was attempting to self-transfer to her wheelchair. Her call light was not used. The CNA (Certified Nurse Aide) was in her room 10 minutes prior. Staff found the resident on floor, and slightly under edge of bed. The nurse's note, dated 6/15/22 at 10:30 p.m., indicated the resident fell in her room unwitnessed and was in an extreme amount of pain. The NP gave orders to send the resident to the hospital. The nurse's note, dated 6/16/22 at 12:43 a.m., indicated the resident would be returning to the facility and was diagnosed with a right clavicle fracture and would need to follow up with an orthopedic surgeon. The nurse's note, dated 6/17/22 at 5:29 a.m., indicated the resident was having increased pain, pain medication was administered. She made one attempt to transfer herself and did not use her call bell. During an interview, on 7/5/22 at 11:14 a.m., the resident's family member indicated if she was left alone long enough she would take herself to the restroom. She was a huge fall risk. They'd done a million things to try and get her to hit the call light. She had good days and bad days. They decided to move her closer to the nurses station so they could keep a better eye on her, but that did not work. A few weeks ago she tried to self-transfer and broke her collarbone. She won't hit the call light. She's supposed to be a 2 hour check and change. All of her falls have been related to her self transferring to the bathroom. During an interview on 7/11/22 at 12:19 p.m., Unit Manager 9 indicated she had tried several times last week to set up a urology appointment and several times that morning. She had been trying since July 5th. She believed the resident had a history of having a lot of urinary tract infections. She had asked the resident's family member before who she saw and he said he would have to look it up and they never did let the facility know. They could have referred her to any urologist for overactive bladder. There were some things she could understand, but as far as any teaching was concerned they had to follow that up with a visual reminder. They couldn't get it through to her that she's supposed to call them. She really didn't think she understand a whole lot of what they were trying to explain to her. She didn't think they let them do fall mats anymore. Sometimes someone may think she would understand things, but other times they thought maybe she didn't understand. They had moved her closer to the nurse's station but she didn't think it helped. Everyone was trying to get her to understand she couldn't transfer by herself. She knew they were supposed to be checking on her every two hours but they hadn't done a one hour toileting schedule. With her cognition it was hard to tell if she understood or not. They were always going to try to educate her, but as far as interventions as far as the fourth or fifth fall they were running short, other than to possibly check on her every hour. They were talking about the bladder stimulator thinking maybe that was the cause of her wanting to go to the bathroom so often. It took a little while to get the doctors name. They tried to do a root analysis, they worked with the MDS coordinator where everyone can bounce it back and forth and see what can be effective for each patient. During an interview on 7/11/22 at 9:52 a.m., LPN (Licensed Practical Nurse) 6 indicated he was familiar with the resident. He had worked with her some. She was alert and oriented fine, but she had neurological deficits that mimicked a stroke. She was understanding but couldn't quite get the words out, her speech wasn't clear. She'd had several falls. She thought she could do it alone. During an interview on 7/11/22 at 9:57 a.m., CNA 10 indicated the resident did not consistently use her call light. They would tell her to use it but she wouldn't, she yelled out. She tried to transfer herself. They had not used a fall mat. Staff were encouraging her to use the call light, but that did not seem to help. During an interview on 7/11/22 at 10:04 a.m., CNA 11 indicated the resident had problems communicating when she needed to use the restroom. She didn't think she'd ever seen the resident's call light turn on. She was encouraged to use it but she had good days and bad days with her memory. She'd asked her multiple times to use a call light and it never seemed to happen. She was not aware of any other fall interventions specific to the resident. During an interview on 7/11/22 an 10:30 a.m., the DON (Director of Nursing) indicated the resident was going to the urologist because she had a bladder stimulator, they moved her closer to the nurse's station but they wanted her to follow up with the urologist. Unit Manager 9 was making the appointment, and the family would take her. During an interview on 7/12/22 at 10:00 a.m., the DON indicated they were waiting on the family to give them the name of the urologist. They didn't know who she had seen. She put a note in the day prior about the appointment. She had several new interventions, but it was their right to fall. The family was responsible for letting them know what doctor they wanted to see. She felt something needed to be done with the resident's bladder stimulator because maybe it was causing her discomfort or making her want to get up. The Falls policy, dated 2/2017, provided on 7/12/22 at 8:15 a.m., by the DON, included, but was not limited to, . Post Fall . The fall evaluation is completed to assist in developing interventions to prevent future falls . The fall event and intervention is recorded on 24 Hour Report, patient's care plan, and caregiver guide . Implement intervention identified . IDT reviews post fall investigation and summarizes the team recommendations for interventions . 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure appropriate interventions were in place for residents resulting in an unstagable and a Stage III pressure ulcer for 2 of 3 residents reviewed for pressure ulcers. (Resident D and Resident K) Findings include: 1. The clinical record for Resident D was reviewed on 3/7/22 at 2:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment, dated 1/26/22, indicated the resident's cognition was severely impaired. The resident required the assistance of two physical staff for bed mobility. The baseline care plan, dated 1/19/22, indicated the resident's skin was intact. The comprehensive care plan, dated 1/21/22, indicated the resident had a deep tissue pressure injury to the right buttock, upon admission, and to complete treatments as ordered, weekly skin inspections, weekly wound assessment, pressure reducing cushion to wheelchair, and pressure reducing mattress to the bed. The Braden Scale for Predicting Pressure Ulcers, dated 1/19/21, indicated the resident had slightly limited sensory perception, very moist skin, was chairfast, had very limited mobility, and a potential problem with friction/shearing. The 1/19/22 weekly skin assessment indicated the resident had no new wounds. The progress note, dated 1/19/22 at 3:16 p.m., indicated the resident had no skin related issues. The progress note, dated 1/19/22 at 3:18 p.m., indicated the resident's skin was warm, dry, and intact. The progress note, dated 1/21/22 at 11:20 a.m., created as a late entry on 1/24/22 at 11:21 a.m., indicated the resident had a new DTPI (deep tissue pressure injury) on the right buttock, a new treatment order was put in place, and the resident was placed on the wound physician list. The physician and resident were notified. The wound evaluation report, dated 1/21/22, indicated the in-house acquired DTPI measured 4.8 cm (centimeters) in length, 3.1 cm in width with no depth. The physician order, dated 1/21/22, indicated to apply skin prep to the DTPI of the right buttock and cover with silicone foam border every day shift on M/W/F. The wound evaluation report, dated 2/7/22 indicated the unstageable area to the left buttock measured 10.8 cm in length, 6.5 cm in width with a depth of 0.2 cm. The would evaluation report, dated 2/7/22, indicated the unstageable area to the right buttock measured 5.5. cm in length and 3.7 cm in with and was covered in 100% slough. The wound physicians initial would evaluation, dated 1/27/22, indicated the following: -Unstageable (due to necrosis) of the left buttock, full thickness, which measured 10 cm in length, 7 cm in width with a depth of 0.1 cm. -Unstageable (due to necrosis) of the right buttock, full thickness, which measured 6 cm in length, 6 cm in width with a depth of 0.1 cm. The progress note, dated 1/27/22 at 4:20 p.m., indicated the wound physician had ordered a low air loss mattress (distributes air flow to pressure points During an interview on 3/10/22 at 12:15 p.m., Wound Nurse 7 indicated the resident was admitted with the area to the right buttock and was missed. The resident obtained the area to the left buttock due to staff were focused on keeping pressure off of the right buttock. 2. The clinical record for Resident K was reviewed on 3/7/22 at 4:42 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS admission assessment, dated 5/24/21, indicated the resident required an extensive one person physical assistance with bed mobility. The Braden Scale for Predicting Pressure Ulcers, dated 5/19/21, indicated the resident had slightly limited sensory perception, was occasionally moist, was bedfast, very limited mobility, and a problem with friction/shearing. The care plan, dated 6/10/21, indicated the resident was at risk for pressure ulcers with an actual pressure ulcer. Interventions included a low air loss mattress (implemented 6/14/21) and to encourage eating in bed at a 90 degree angle, tilted towards side of coccyx (implemented 6/17/21). The skin evaluation report, dated 6/11/21, indicated the resident had an in-house acquired stage 3 pressure ulcer to the coccyx which measured 3.4 cm in length, 4.0 cm in width with a depth of 0.2 cm. The physician wound evaluation, dated 6/11/21, indicated the resident had a stage 3 pressure ulcer to the coccyx which measured 2.2 cm in length, 3 cm in width with a depth of 0.1 cm. During an interview on 3/10/22 at 12:15 p.m., Wound Nurse 7 indicated due to an aspiration risk, the resident had to be at a 90 degree angle which caused the breakdown. On 3/11/22 at 2:23 p.m., the Director of Nursing provided a current copy of the document titled Skin Care Guideline dated July 2018. It included, but was not limited to, Purpose .Provide a system .to identify risk and identify individual interventions to address risk and a process for care of .disruption in skin integrity .Initiate positioning schedule .meet individual needs This Federal tag relates to Complaints IN 511 and IN 571 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a resident's plan of care was followed, which resulted in a stage 3 (full thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer to the right buttock, and to complete treatments as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Findings include: The clinical record for Resident C was reviewed on 4/23/21 at 1:18 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment, dated 4/28/20, indicated the resident required an extensive two person physical assistance with bed mobility and the resident had no pressure ulcers on admission. The Braden Scale for Predicting Pressure Sore Risk, dated 4/22/20, indicated the resident was a high risk for pressure ulcers due to having slightly limited sensory perception, being constantly moist, bedfast, very limited mobility, inadequate nutrition, and a potential problem with friction/shearing. The care plan, dated 9/5/18, indicated the resident was at risk for pressure ulcers due to required assistance with bed mobility, impaired range of motion, and [CONDITION(S)] (right sided). Interventions included, but were not limited to, complete treatments as ordered (initiated on 9/5/18), skin assessments to be completed per facility policy, and to turn and reposition the resident four times daily and avoid direct pressure on the buttocks. The April 2020 treatment administration record indicated the resident was to be turned and repositioned four times daily at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. The April 2020 treatment record lacked documentation of turning/repositioning on the following dates and times: -4/25/20 at 6:00 a.m. -4/26/20 at 12:00 p.m. and 6:00 p.m. -4/27/20 at 12:00 a.m., 6:00 a.m., and 6:00 p.m. -4/28/20 at 6:00 p.m. -4/29/20 at 12:00 a.m. and 6:00 a.m. The clinical record lacked documentation of a weekly skin assessment which should have been completed on 4/28/20. The change of condition note, dated 5/1/20 at 5:15 a.m., indicated the resident had an open area to the right buttock which measured 2 cm (centimeters) in length with a width of 3 cm. The wound evaluation report, dated 5/1/20 at 10:44 a.m., indicated the resident had a stage 3 pressure ulcer to the right buttock which measured 5.66 cm in length, 4.84 cm in width with a depth of 0.2 cm. The May 2020 treatment administration record indicated staff were to cleanse the stage 3 pressure ulcer with normal saline or wound cleanser, apply [MEDICATION(S)]/[MEDICATION(S)] ointment to the wound bed, and to cover the wound with a silicone foam border or sterile border gauze dressing every day and evening shift. The May 2020 treatment administration record lacked documentation of the treatment completed on the following dates: -5/1/20 - evening shift -5/2/20 - day shift and evening shift -5/3/20 - day shift -5/4/20 - day shift -5/5/20 - day shift -5/6/20 - evening shift -5/7/20 - day shift The wound evaluation report, dated 5/8/20 at 10:48 a.m., indicated the stage 3 pressure ulcer was 3.96 cm in length, 2.71 cm in width with a depth of 0.2 cm. On 5/13/20, the wound measured 3.72 cm in length, 2.76 cm in width with a depth of 0.2 cm. During an interview on 4/26/21 at 4:10 p.m., RN 3 indicated the area could have been a direct cause from COVID-19, the resident being heavy wetter, or being in bed more than normal due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 4/26/21 at 5:17 p.m., LPN (Licensed Practical Nurse) 4 indicated when a treatment has been completed, it should be initialed off as completed and weekly skin assessments should be completed weekly. On 4/26/21 at 5:15 p.m., the Director of Nursing provided a current copy of the document titled Skin Care Guideline dated July 2018. It included, but was not limited to, Purpose .To provide a system of evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity .Process .Weekly review of the patient's/resident's skin will be completed by the nurse and documented in the electronic medical record .When an open area is identified .Implement resident specific interventions immediately On 4/26/21 at 5:15 p.m., the Director of Nursing provided a current copy of the document titled General Dose Preparation and Medication Administration dated 12/1/07. It included, but was not limited to, Procedure .Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications .Document necessary .treatment information .on appropriate forms This Federal tag relates to Complaint IN 607 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident's transfer device/gait belt was used to prevent an injury during a transfer which resulted in a fracture for 1 of 3 residents (Resident B) reviewed for accidents. Findings include: The clinical record for Resident B was reviewed on 3/24/21 at 1:22 p.m. [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) Assessment, dated 12/30/20, indicated the resident required extensive assistance of one staff member with transfers. The care plan, initiated on 11/12/18 and last revised on 11/24/20, indicated the resident had a physical functioning deficit and required extensive assistance of one staff member for transfers. The nurse's note, dated 3/4/21 at 8:32 p.m., indicated CNA (Certified Nursing Aide) 4 had reported to the nurse that during a routine transfer from the wheelchair to the bed, she'd heard a popping sound in the resident's right shoulder. The resident complained of discomfort with movement of the right arm. The resident was transported to a local hospital. The handwritten statement by CNA 5, dated 3/5/21, indicated she was caring for the resident and was doing a routine transfer, the resident was pivoting and her knee gave out. The resident started to go down and her shoulder popped. The CNA managed to get her on the bed and notified the nurse. The statement did not indicate the use of a gait belt or any transfer devices. The nurse's note, dated 3/5/2021 at 4:00 a.m., indicated the resident had returned to the facility with a sling on her right arm. The resident had a fractured humerus and would be non weight baring to the right humerus for six weeks. The Care Plan, initiated on 3/5/21, indicated the resident had a fracture to the right arm The follow-up statement, dated 3/5/21, indicated CNA 5 was transferring the resident from the wheelchair to the bed and the resident slipped and went down. The resident was assessed and sent out to the hospital. She returned with a right humerus fracture with no dislocation. The resident was placed in sling and swath. During an interview, on 3/24/21 at 3:05 p.m., CNA 5 indicated she was getting ready to put the resident to bed. She put her arms around her waist and stood her up to pivot and her knee gave out. When that happened, the resident went down and her arms went up and she heard an . awful pop . She was not using any kind of transfer devices or a gait belt. At 3:24 p.m., CNA 5 indicated the resident did not have a transfer/gait belt. At the time, she did not have a gait belt on her to use for the resident. She probably did not think about using the transfer belt at the time, but should have used a gait belt to transfer the resident. During an interview, on 3/24/21 at 3:17 p.m., the DON (Director of Nursing) indicated the facility utilized transfer belts. The resident was not independent with transfers and the lift policy was in place at the time of the incident. At 4:22 p.m., the DON indicated the resident was definitively required the assistance of one staff member and would have been at the assistance level of needing a transfer belt prior to the incident. AT 4:35 p.m., the facility had to do a whole audit on every single person to ensure they had transfer lift evaluations, which were supposed to be done for every resident upon admission. She could not locate a transfer lift evaluation for Resident B prior to the incident on 3/4/21. The review of in-service and plan of correction documentation provided on 3/24/21 by the facility indicated all staff were in-serviced on the Lift 4 Care Safe 4 All Program and all residents had a Lift Evaluation completed by 3/8/21. The undated Overview of Lift 4 Care Safe 4 All Program Policy, which the DON indicated at 3:15 p.m. on 3/24/21 was the current policy in place at the time of the incident, included, but was not limited to, . Residents are evaluated at the time of admission, readmission, and any significant change, anytime needed utilizing the Lift Transfer Evaluation form .(electronic health record system) . There are four ways we transfer Independent- this is the resident that can do it all by themselves . Transfer Belt- This is the resident that can do it but may require assistance maintaining balance while performing the transfer . If a resident is evaluated for the transfer belt, one should be placed in the room so it is accessible to all team members . The deficient practice was corrected on 3/8/21, after the facility implemented a systemic plan that included the following actions: all staff were in-serviced on the lift program, audits were completed for every resident to ensure they had a transfer lift assessment, all residents had a Lift Evaluation completed by 3/8/21, all required transfer devices/gait belts were available for the residents, care plans were updated, and the facility's four point plan of correction was completed prior to the start of the survey. This Federal tag relates to Complaint IN 139. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place when a cognitively impaired resident (Resident G), with exit seeking behaviors exited the building, without staff knowledge, and was found by non-personnel with the back of his wheel chair wheels over the white line in the road of a high volume traffic area for 1 of 3 residents reviewed for accidents. The past noncompliance Immediate Jeopardy began on 11/3/19 when a cognitively impaired resident (Resident G), with exit seeking behaviors exited the building, without staff knowledge, and was found by non-personnel with the back of his wheel chair wheels over the white line in the road. The resident propelled himself 125 feet, from the facility chapel to the front doors and exited the facility. The resident went left and propelled himself another 155 feet through the parking lot to the entrance/exit and up to the road. He was found by non-personnel with the back wheel chair wheels over the white line in the road. There was a 40 foot gradual decline in the parking lot. At the bottom of the decline there was a 1 1/2 foot by 1 1/2 foot storm drain with broken concrete around the edges of the drain. There was a 1 foot by 1 foot pot hole 5 feet to the right of the storm drain. There was a gradual incline that lead to the entrance/exit and then onto the side of road. The road has high volume traffic with a speed limit of 50 miles per hour. The Administrator, Director of Nursing, Director of Clinical Operations and the Transition Specialist were notified of the Immediate Jeopardy on 11/21/19 at 2:12 p.m. Findings include: The clinical record for Resident G was reviewed on 11/20/19 at 3:51 p.m. [DIAGNOSES REDACTED]. The 10/25/19 interim payment MDS (Minimum Data Set) assessment indicated impaired cognition. The plan of care, dated 10/31/19, indicated the resident was at risk for elopement related to attempts to leave center, verbal comment of wanting to go home, and wandering. Interventions included to allow the resident to contact family when wandering behaviors begin, assess for risk of elopement per center policy, wander guard placed on left ankle, offer diversional activities, and redirect patient from doors. The progress note, dated 10/31/19 at 12:00 a.m., indicated the resident was alert to self and believed he could walk home from the facility and was visually observed to exit seek. The progress note, dated 10/31/19 at 9:20 p.m. (created as a late entry on 11/3/19 at 6:24 p.m.) , indicated the resident was propelling self in his wheel chair in the common area by the door and continually stated he needed to go home. The elopement risk evaluation, dated 10/31/19 at 9:24 p.m., indicated the resident was capable of leaving on his own; was cognitively impaired; had impaired decision making skills; made repetitive statements about going home; had a history of [REDACTED]. The progress note, dated 11/1/19 at 1:59 a.m., indicated the resident was alert to self only, confused of surroundings, exit seeking at times, and believed he could walk home from the facility. A wander guard was in place. The progress note, dated 11/2/19 at 11:00 a.m., indicated the resident continued with continuous confusion, unable to comprehend where he was most of the day, did not recognize room or dining room, and was hard to redirect. The progress note, dated 11/3/19 at 3:23 p.m., indicated a wanderguard was placed to the resident's left ankle. During an interview on 11/20/19 at 2:35 p.m., the Complainant indicated on 11/3/19, around noon, she and her husband were driving down the road when they came upon the nursing home and there was an elderly man in his wheel chair, pushing himself backwards towards the road. The back of his wheel chair was across the white line of the road. Her husband stopped in the road in order to stop traffic since church had just let out. She assisted the man back into the nursing home. She could not find anyone at the first nurse's station she came across. At the second nurse's station, she found two staff members behind the desk on their phones. She asked for the charge nurse and was told there were several nurses here. She said she told them she needed to speak with the DON (Director of Nursing) and was told she was not there. She told them she found a gentleman out by the road, in a wheel chair and brought him back in because he said he lived here. The outside air temperature, on 11/3/19, was a high of 57 degrees Fahrenheit and low of 32 degrees on the day of the elopement. During an interview on 11/20/19 at 4:05 p.m., LPN (Licensed Practical Nurse) 3 indicated on Sunday, 11/3/19, around 11 a.m., she was alerted the resident was found up by the road and a family member had brought him back due to they were concerned for him. He said he was trying to get across the road to go to church. Staff were unaware the resident was outside because he had been to mass in the facility's chapel. When the resident was assessed, he did not have a wander guard on and one was re-placed at that time to his left ankle. The resident was wearing a long sleeved shirt, casual pants, and tennis shoes. During an interview on 11/20/19 at 4:13 p.m., LPN 4 indicated a woman came in and said she saw the resident going up towards the road and brought him back into the facility. She notified the DON and took the resident back to LPN 3. During an interview on 11/20/19 at 4:19 p.m., the DON indicated the resident had gone to church, self-propelled himself to the front doors, which took about 15 minutes, and went out the door which were not locked at that time of day. During an interview on 11/21/19 at 11:49 a.m., the Administrator indicated staff did not have eyes on the resident while he was outside. During an interview on 11/22/19 at 11:14 a.m., the Administrator indicated the front doors locked down when a resident with a wanderguard approached the front doors. A sensor in-between the 200 and 300 halls detects the wanderguard and automatically locks the front doors and sounds an alarm. On 11/20/19 at 5:52 p.m., the Administrator provided a copy of the document titled Wandering, Unsafe Resident dated 8/22/2010. It included, but was not limited to, Policy Statement .The facility will strive towards preventing unsafe wandering of residents .Residents' unsupervised exit from the facility will be prevented On 11/21/19 at 4:40 p.m., the Director of Clinical Operations provided a current copy of the document titled Wanderguard Bracelets dated (MONTH) 2019. It included, but was not limited to, Policy .Residents who are identified as at risk for leaving the center unaccompanied by the elopement risk assessment or by actions, will have a Wanderguard bracelet applied for safety. Bracelets will cause doors to alarm and notify the team that a resident is attempting to leave through a door. Wanderguard bracelets will be checked for placement every shift and for function once per shift The past noncompliance Immediate Jeopardy began on 11/3/19. The Immediate Jeopardy was removed and the deficient practice was corrected on 11/5/19, prior to the start of the survey, when the facility completed staff education on elopement guidelines, abuse, neglect, prevention of accidents and supervision of residents, elopement drills conducted, and verification of code alert placement and functionality. This Federal tag relates to Complaint IN 486 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide care for [DIAGNOSES REDACTED] (low blood sugar) for 2 of 5 resident reviewed for diabetes (Resident B and C), which resulting in a resident being admitted to the hospital (Resident B), and failed to monitor for fluid intake for 1 of 2 residents reviewed for [MEDICAL TREATMENT] (Resident H). Findings include: 1. The clinical record for Resident B was reviewed on 4/27/17 at 10:00 a.m. [DIAGNOSES REDACTED]. The Initial/Admission at Risk Care Plan, dated 6/14/16, indicated to observe for signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. The nurse's note, dated 6/17/16 at 12:12 a.m. indicated the resident's wife was concerned the facility was not monitoring his blood sugars and the physician was notified with a new order to check the blood sugars before meals and at bedtime. The meal intake record for June 2016 indicated the resident consumed the following: 6/17/16 - 50% at breakfast, 25% at lunch, and no documentation for supper. 6/18/16 - 25% at breakfast, 25% at lunch, and 0% at supper. 6/19/16 - 25% at breakfast, 25% at lunch, and 0% at supper. The Medication Administration Record [REDACTED]. The nurse's note, dated 6/20/16 at 7:15 a.m., indicated the nurse was called to the resident's room and the resident was sweating, difficult to arouse, and had a blood sugar of 43. Orange juice and sugar was given, but the resident was not swallowing well. Glucose gel was pulled from the pyxis (emergency drug dispenser) and half was given with sugar. The physician was notified and gave a new order to send the resident to the emergency room . During an interview on 4/27/17 at 9:58 a.m., LPN (Licensed Practical Nurse) 1 indicated she assumed she gave the resident orange juice with sugar, but did not remember if she poured sugar directly in the resident's mouth. She could not recall if the resident was responsive or unresponsive, and the only thing she remembered was how hysterical the wife was. The EMS (emergency medical service) record, dated 6/20/16, indicated they were dispatched to the facility at 8:23 a.m. The resident's blood sugar was 33 at 8:31 a.m. and 40 at 8:50 a.m. The resident was very diaphoretic, and oral glucose was not administered due to the his mental status. The hospital emergency department note, dated 6/20/16, indicated the resident was found to be seriously ill, and was given a half amp ([MEDICATION NAME]) of D50 ([MEDICATION NAME]) for his [DIAGNOSES REDACTED] which was likely related to his insulin from the night before and not eating well. During an interview on 4/27/17 at 3:20 p.m., the DON (Director of Nursing) indicated there was no policy in place for [DIAGNOSES REDACTED] prior to March 2017, and the nurses just followed the physicians orders. On 4/27/17 at 3:20 p.m., the DON provided a current copy of the document titled Acute Management: Diabetic Resident, effective March 2017. It included, but was not limited to, the following: .[DIAGNOSES REDACTED] .Glucose Gel 15 grams .If unresponsive or unable to swallow position on side and give: [MEDICATION NAME] 1 mg (milligram) IM (intramuscularly) .Inform primary care practitioner if blood sugar less than 70 or as directed by blood glucose parameters . 2. On 04/26/17 at 12:47 a.m., the Admission [DIAGNOSES REDACTED]. The review, on 05/01/17 at 9:55 a.m., of the ACC (accu check) MONITORING (Administration Record) for April, 2017 indicated, but was not limited to, the following: On 04/01/17 at 11:30 a.m., a blood sugar of 567. On 04/02/17 at 4:30 p.m., a blood sugar of 502 and at 8:00 p.m., a blood sugar of 513. On 04/03/17 at 8:00 p.m., a blood sugar of 545. On 04/05/17 at 4:30 p.m., a blood sugar of 452. On 04/06/17 at 8:00 p.m., a blood sugar of 488. On 04/07/17 at 12:00 a.m., a blood sugar of 490, and at 4:30 p.m., a blood sugar of 451. On 04/14/17 at 8:00 p.m., a blood sugar of 430. On 04/19/17 at 4:30 p.m., a blood sugar of 509. On 04/22/17 at 8:00 p.m., a blood sugar of 417. On 04/27/17 at 8:00 p.m., a blood sugar of 405. On 04/29/17 at 11:30 a.m., a blood sugar of 410. The review, on 04/26/17 at 12:53 p.m., of the Care Plan indicated, but was not limited to, .is at risk for hypo/[MEDICAL CONDITION] R/T diabetes. (03/01/16). Interventions indicated AccuChecks as ordered. Administer medications as ordered. Monitor for effectiveness. Provide diet and fluids as ordered. Monitor for signs/symptoms of hypo/[MEDICAL CONDITION]. Notify MD as needed. Offer snacks. Obtain lab work as ordered, if family or resident wishes. Report results to MD. On 04/28/17 at 2:15 p.m., the DON provided a copy of the physician's orders [REDACTED].=2UNITS 151-200=4UNITS 201-250=8UNITS 251-300=12UNITS 301-350=14UNITS 351-401=16UNITS. ABOVE 401 GIVE 20 UNITS & CALL MD. [MEDICATION NAME] Flextouch 100 Units/mL Inject 27 Units SubQ Daily. On 05/01/17 at 10:15 a.m., the DON (Director of Nursing) provided a copy of the Departmental Notes for April, 2017 which indicated on 04/14/17 at 10:20 p.m. Residents 8pm blood sugar was 430. Dr .(name) notified ok to give max dose of sliding scale insulin. 20 Units given. No other Nurse's Notes for physician notification could be located. The review, on 05/02/17 at 8:30 a.m., of the ACC MONITORING (Administration Record) sheet, for May, 2017 indicated on 05/01/17 at 8:00 p.m., a blood sugar of 455. During an interview on 05/01/17 at 10:47 a.m., the DON indicated the nurse should follow the parameters for MD notification by the physician's orders [REDACTED]. She could not find any other nurse's notes for informing the MD of the elevated blood sugars in April, except for April 14th. On 04/25/17 at 1:50 p.m., the DON provided a copy of the policy for blood sugar monitoring which indicated to follow MD orders. 3. On 04/28/17 at 8:30 a.m., Resident H was observed in bed waiting on therapy before he left the facility for [MEDICAL TREATMENT]. He had already eaten breakfast and his coffee cup was empty. On 04/27/17 at 12:29 p.m. during an interview with CNA (Certified Nursing Assistant) 5, she indicated Resident H was on a fluid restriction and was noncompliant. The CNA's were told to give him what he wanted and to tell the nurses, so they could document his noncompliance. He goes to [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays around 10:15 a.m. On 04/28/17 at 8:30 a.m. during an interview with Resident H, he indicated, he goes to [MEDICAL TREATMENT] 3 times a week, was picked up at 10 a.m., and had been on [MEDICAL TREATMENT] for a year. The facility sends a lunch with him. The [MEDICAL TREATMENT] shunt was in his right arm. He stated he would do better with his fluid restriction because they were increasing the amount he could have. On 04/28/17 at 8:50 a.m. during an interview with the Dietary Manager, she indicated she was aware of his fluid restriction and included the ordered amount of fluids on his meal trays. On 04/28/17 at 10:25 a.m. during an interview with LPN 3, she indicated and provided the intake and output record for Resident H for April 2017, dated from 4/10/17 to 4/22/17. The resident's intake and output was only documented for the 1st shift on the following dates: 4/13, 4/14, 4/16 and 3rd shift for 4/10, 4/20, and 4/21. All other dates were left blank. On 04/28/17 at 1:09 p.m., during an interview with the DON and Administrator, they indicated there was no facility policy/protocol for fluid restriction, whether the patient was on [MEDICAL TREATMENT] or not. On 04/26/17 at 10:39 a.m., the review of the admission [DIAGNOSES REDACTED].[MEDICAL CONDITION], end stage [MEDICAL CONDITION], dependence on [MEDICAL TREATMENT], and malignant neoplasm of kidney. The review of the physician orders [REDACTED].pre and post [MEDICAL TREATMENT] weights, check fistula to right upper extremity for bruit/thrill every shift, .(name) [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 10:45 a.m. On 04/11/17 a physician orders [REDACTED]. On 04/27/17 at 12:08 p.m., the review of the care plan indicated but was not limited to, .requires [MEDICAL TREATMENT]-coordinate transportation to the [MEDICAL TREATMENT] center, monitor fluid intake, . labs as ordered, monitor dietary/fluid intake, educate resident on importance of dietary restrictions, .resident at risk for alteration in hydration status related to need for [MEDICAL TREATMENT], complicated by [DIAGNOSES REDACTED].ensure access to fluids. Resident is resistant to recommendation of his fluid restriction-approach him slowly and calmly, if resistive try to approach later, administer fluids as ordered. Alteration in nutrition related to increased protein needs related to Resident on [MEDICAL TREATMENT], weights are expected to fluctuate related to end stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. On 04/28/17 at 9:32 a.m., the review of the MDS (Minimum Data Set) dated 4/15/17 indicated a BIMS (Brief Interview for Mental Status) score of 11 (moderately impaired cognitively). The Special Treatments indicated, but was not limited to, .[MEDICAL TREATMENT] while a patient and while not at facility. The MDS dated [DATE] indicated a BIMS score of 13 (cognitively intact). On 04/28/17 at 9:53 a.m., the review of the nurses notes, dated 04/11/17 at 7:06 a.m., indicated, but was not limited to, .patient asked for water throughout night. On 04/16/17 at 9:05 a.m., . is on a fluid restriction of 1500ml/day, patient continuously asking for water and ice chips and ice cream, when explained to him about his fluid restriction and its importance he started yelling patients rights, patient remains noncompliant with fluid restriction. On 04/17/17 at 10:20 a.m., patient remains noncompliant to fluid restriction, attempted to educate patient but will not listen, will talk over staff. On 04/18/17 at 2:50 a.m., patient remains non compliant with fluid restriction, educated on fluid restriction, cont to ask for ice chips, prune juice. On 04/21/17 patient given meds with small amount of water but continues to ask for more, currently on a 1500ml fluid restriction daily but is noncompliant at present. On 04/22/17 at 4:26 a.m., patient cont to request extra fluids and remains noncompliant with 1500ml/day fluid restriction. On 04/23/17 at 3:27 p.m., resident continues to ask for extra fluids. On 04/28/17 at 10:14 a.m., the review of the Nurse Practitioner's progress note, dated 04/12/17, indicated 1500 fl (fluid)-patient noncompliant. On 05/01/17 at 8:33 a.m., the review of the physician's orders [REDACTED]. This Federal tag relates to Complaint IN 216 and IN 046 3.1-37(a) 3.1-37(b)

Based on interview and record review, the facility failed to provide care for [DIAGNOSES REDACTED] (low blood sugar) for 2 of 5 resident reviewed for diabetes (Resident B and C), which resulting in a resident being admitted to the hospital (Resident B), and failed to monitor for fluid intake for 1 of 2 residents reviewed for [MEDICAL TREATMENT] (Resident H). Findings include: 1. The clinical record for Resident B was reviewed on 4/27/17 at 10:00 a.m. [DIAGNOSES REDACTED]. The Initial/Admission at Risk Care Plan, dated 6/14/16, indicated to observe for signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. The nurse's note, dated 6/17/16 at 12:12 a.m. indicated the resident's wife was concerned the facility was not monitoring his blood sugars and the physician was notified with a new order to check the blood sugars before meals and at bedtime. The meal intake record for June 2016 indicated the resident consumed the following: 6/17/16 - 50% at breakfast, 25% at lunch, and no documentation for supper. 6/18/16 - 25% at breakfast, 25% at lunch, and 0% at supper. 6/19/16 - 25% at breakfast, 25% at lunch, and 0% at supper. The Medication Administration Record [REDACTED]. The nurse's note, dated 6/20/16 at 7:15 a.m., indicated the nurse was called to the resident's room and the resident was sweating, difficult to arouse, and had a blood sugar of 43. Orange juice and sugar was given, but the resident was not swallowing well. Glucose gel was pulled from the pyxis (emergency drug dispenser) and half was given with sugar. The physician was notified and gave a new order to send the resident to the emergency room . During an interview on 4/27/17 at 9:58 a.m., LPN (Licensed Practical Nurse) 1 indicated she assumed she gave the resident orange juice with sugar, but did not remember if she poured sugar directly in the resident's mouth. She could not recall if the resident was responsive or unresponsive, and the only thing she remembered was how hysterical the wife was. The EMS (emergency medical service) record, dated 6/20/16, indicated they were dispatched to the facility at 8:23 a.m. The resident's blood sugar was 33 at 8:31 a.m. and 40 at 8:50 a.m. The resident was very diaphoretic, and oral glucose was not administered due to the his mental status. The hospital emergency department note, dated 6/20/16, indicated the resident was found to be seriously ill, and was given a half amp ([MEDICATION NAME]) of D50 ([MEDICATION NAME]) for his [DIAGNOSES REDACTED] which was likely related to his insulin from the night before and not eating well. During an interview on 4/27/17 at 3:20 p.m., the DON (Director of Nursing) indicated there was no policy in place for [DIAGNOSES REDACTED] prior to March 2017, and the nurses just followed the physicians orders. On 4/27/17 at 3:20 p.m., the DON provided a current copy of the document titled Acute Management: Diabetic Resident, effective March 2017. It included, but was not limited to, the following: .[DIAGNOSES REDACTED] .Glucose Gel 15 grams .If unresponsive or unable to swallow position on side and give: [MEDICATION NAME] 1 mg (milligram) IM (intramuscularly) .Inform primary care practitioner if blood sugar less than 70 or as directed by blood glucose parameters . 2. On 04/26/17 at 12:47 a.m., the Admission [DIAGNOSES REDACTED]. The review, on 05/01/17 at 9:55 a.m., of the ACC (accu check) MONITORING (Administration Record) for April, 2017 indicated, but was not limited to, the following: On 04/01/17 at 11:30 a.m., a blood sugar of 567. On 04/02/17 at 4:30 p.m., a blood sugar of 502 and at 8:00 p.m., a blood sugar of 513. On 04/03/17 at 8:00 p.m., a blood sugar of 545. On 04/05/17 at 4:30 p.m., a blood sugar of 452. On 04/06/17 at 8:00 p.m., a blood sugar of 488. On 04/07/17 at 12:00 a.m., a blood sugar of 490, and at 4:30 p.m., a blood sugar of 451. On 04/14/17 at 8:00 p.m., a blood sugar of 430. On 04/19/17 at 4:30 p.m., a blood sugar of 509. On 04/22/17 at 8:00 p.m., a blood sugar of 417. On 04/27/17 at 8:00 p.m., a blood sugar of 405. On 04/29/17 at 11:30 a.m., a blood sugar of 410. The review, on 04/26/17 at 12:53 p.m., of the Care Plan indicated, but was not limited to, .is at risk for hypo/[MEDICAL CONDITION] R/T diabetes. (03/01/16). Interventions indicated AccuChecks as ordered. Administer medications as ordered. Monitor for effectiveness. Provide diet and fluids as ordered. Monitor for signs/symptoms of hypo/[MEDICAL CONDITION]. Notify MD as needed. Offer snacks. Obtain lab work as ordered, if family or resident wishes. Report results to MD. On 04/28/17 at 2:15 p.m., the DON provided a copy of the physician's orders [REDACTED].=2UNITS 151-200=4UNITS 201-250=8UNITS 251-300=12UNITS 301-350=14UNITS 351-401=16UNITS. ABOVE 401 GIVE 20 UNITS & CALL MD. [MEDICATION NAME] Flextouch 100 Units/mL Inject 27 Units SubQ Daily. On 05/01/17 at 10:15 a.m., the DON (Director of Nursing) provided a copy of the Departmental Notes for April, 2017 which indicated on 04/14/17 at 10:20 p.m. Residents 8pm blood sugar was 430. Dr .(name) notified ok to give max dose of sliding scale insulin. 20 Units given. No other Nurse's Notes for physician notification could be located. The review, on 05/02/17 at 8:30 a.m., of the ACC MONITORING (Administration Record) sheet, for May, 2017 indicated on 05/01/17 at 8:00 p.m., a blood sugar of 455. During an interview on 05/01/17 at 10:47 a.m., the DON indicated the nurse should follow the parameters for MD notification by the physician's orders [REDACTED]. She could not find any other nurse's notes for informing the MD of the elevated blood sugars in April, except for April 14th. On 04/25/17 at 1:50 p.m., the DON provided a copy of the policy for blood sugar monitoring which indicated to follow MD orders. 3. On 04/28/17 at 8:30 a.m., Resident H was observed in bed waiting on therapy before he left the facility for [MEDICAL TREATMENT]. He had already eaten breakfast and his coffee cup was empty. On 04/27/17 at 12:29 p.m. during an interview with CNA (Certified Nursing Assistant) 5, she indicated Resident H was on a fluid restriction and was noncompliant. The CNA's were told to give him what he wanted and to tell the nurses, so they could document his noncompliance. He goes to [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays around 10:15 a.m. On 04/28/17 at 8:30 a.m. during an interview with Resident H, he indicated, he goes to [MEDICAL TREATMENT] 3 times a week, was picked up at 10 a.m., and had been on [MEDICAL TREATMENT] for a year. The facility sends a lunch with him. The [MEDICAL TREATMENT] shunt was in his right arm. He stated he would do better with his fluid restriction because they were increasing the amount he could have. On 04/28/17 at 8:50 a.m. during an interview with the Dietary Manager, she indicated she was aware of his fluid restriction and included the ordered amount of fluids on his meal trays. On 04/28/17 at 10:25 a.m. during an interview with LPN 3, she indicated and provided the intake and output record for Resident H for April 2017, dated from 4/10/17 to 4/22/17. The resident's intake and output was only documented for the 1st shift on the following dates: 4/13, 4/14, 4/16 and 3rd shift for 4/10, 4/20, and 4/21. All other dates were left blank. On 04/28/17 at 1:09 p.m., during an interview with the DON and Administrator, they indicated there was no facility policy/protocol for fluid restriction, whether the patient was on [MEDICAL TREATMENT] or not. On 04/26/17 at 10:39 a.m., the review of the admission [DIAGNOSES REDACTED].[MEDICAL CONDITION], end stage [MEDICAL CONDITION], dependence on [MEDICAL TREATMENT], and malignant neoplasm of kidney. The review of the physician orders [REDACTED].pre and post [MEDICAL TREATMENT] weights, check fistula to right upper extremity for bruit/thrill every shift, .(name) [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 10:45 a.m. On 04/11/17 a physician orders [REDACTED]. On 04/27/17 at 12:08 p.m., the review of the care plan indicated but was not limited to, .requires [MEDICAL TREATMENT]-coordinate transportation to the [MEDICAL TREATMENT] center, monitor fluid intake, . labs as ordered, monitor dietary/fluid intake, educate resident on importance of dietary restrictions, .resident at risk for alteration in hydration status related to need for [MEDICAL TREATMENT], complicated by [DIAGNOSES REDACTED].ensure access to fluids. Resident is resistant to recommendation of his fluid restriction-approach him slowly and calmly, if resistive try to approach later, administer fluids as ordered. Alteration in nutrition related to increased protein needs related to Resident on [MEDICAL TREATMENT], weights are expected to fluctuate related to end stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. On 04/28/17 at 9:32 a.m., the review of the MDS (Minimum Data Set) dated 4/15/17 indicated a BIMS (Brief Interview for Mental Status) score of 11 (moderately impaired cognitively). The Special Treatments indicated, but was not limited to, .[MEDICAL TREATMENT] while a patient and while not at facility. The MDS dated [DATE] indicated a BIMS score of 13 (cognitively intact). On 04/28/17 at 9:53 a.m., the review of the nurses notes, dated 04/11/17 at 7:06 a.m., indicated, but was not limited to, .patient asked for water throughout night. On 04/16/17 at 9:05 a.m., . is on a fluid restriction of 1500ml/day, patient continuously asking for water and ice chips and ice cream, when explained to him about his fluid restriction and its importance he started yelling patients rights, patient remains noncompliant with fluid restriction. On 04/17/17 at 10:20 a.m., patient remains noncompliant to fluid restriction, attempted to educate patient but will not listen, will talk over staff. On 04/18/17 at 2:50 a.m., patient remains non compliant with fluid restriction, educated on fluid restriction, cont to ask for ice chips, prune juice. On 04/21/17 patient given meds with small amount of water but continues to ask for more, currently on a 1500ml fluid restriction daily but is noncompliant at present. On 04/22/17 at 4:26 a.m., patient cont to request extra fluids and remains noncompliant with 1500ml/day fluid restriction. On 04/23/17 at 3:27 p.m., resident continues to ask for extra fluids. On 04/28/17 at 10:14 a.m., the review of the Nurse Practitioner's progress note, dated 04/12/17, indicated 1500 fl (fluid)-patient noncompliant. On 05/01/17 at 8:33 a.m., the review of the physician's orders [REDACTED]. This Federal tag relates to Complaint IN 216 and IN 046 3.1-37(a) 3.1-37(b)

Based on interview and record review, the facility failed to maintain proper hydration for a dependent resident, requiring assistance with fluid intake, resulting in the resident becoming dehydrated and requiring hospitalization for 1 of 3 residents reviewed for hydration. (Resident #B) Findings include: The closed clinical record for Resident #B was reviewed on 5/15/15 at 9:00 a.m. and indicated the following: [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) assessment, dated 2/27/15, indicated Resident #B required the physical assistance of one staff person for eating and drinking. Registered Dietician Evaluation, dated 9/02/14, indicated the daily fluid/water requirement for Resident #B was 1325 ml (milliliters) per day. Weekly nursing note, dated 1/05/15, indicated Resident #B's skin was warm, dry and intact with no [MEDICAL CONDITION] (swelling) noted. Weekly nursing note, dated 1/12/15, indicated resident had slight swelling in bilateral (both) lower extremities. The swelling was described as non-pitting (skin did not stay indented if pushed in). Weekly nursing note, dated 1/26/15, indicated, 3+ pitting (skin remained indented deeply, when pushed in) [MEDICAL CONDITION] to bilateral lower extremities. [MEDICATION NAME] (medication to reduce fluid/swelling) started today. physician's orders [REDACTED]. This order was discontinued on 01/06/15. physician's orders [REDACTED]. This order was discontinued on 3/11/15. physician's orders [REDACTED]. On 2/02/15, this medication was increased to [MEDICATION NAME] 20 mg, once daily in the morning and [MEDICATION NAME] 10 mg in the afternoon at 4:00 p.m. This order was discontinued 3/11/15. physician's orders [REDACTED]. The clinical record for Resident #B indicated the resident was on 3 different diuretics to remove excess fluid due to swelling from 2/9/15 through 3/8/15, when the resident was discharged from the facility due to hospitalization . The weekly nursing note for Resident #B, dated 2/23/15, indicated swelling has went down. The weekly nursing note for Resident #B, dated 3/02/15, had the No box checked for [MEDICAL CONDITION], in the skin section of the assessment, indicating the resident did not have any swelling. The Physician's Progress Notes, dated 3/4/15, indicated Resident #B had no [MEDICAL CONDITION]. The clinical record for Resident #B did not contain any indication of an attempt to reduce the resident's diuretic use in response to the noted absence of [MEDICAL CONDITION] by the nursing staff. The clinical record for Resident #B did not contain any documentation regarding monitoring of daily fluid intake and output. The laboratory record for Resident #B indicated labs were monitored for diuretic use and hydration status. Labs reported as follows: 1/5/15 - Results were: Sodium 140, Potassium 4.9, Chloride 102, BUN 46, Creatinine 1.0, Calcium 10.5, GFR 52. Normal values for these labs included: Sodium 135-145, Potassium 3.5-5.3, Chloride 96-110, BUN 7-25, Creatinine 0.6-1.3, Calcium 8.4-10.2, GFR greater than 60. 1/26/15 - Results were: Sodium 140, Potassium 4.7, Chloride 107, BUN 21, Creatinine 0.9, Calcium 10.0, GFR 59. 2/5/15 - Results were: Sodium 138, Potassium 4.4, Chloride 101, BUN 24, Creatinine 1.0, Calcium 10.3, GFR 52. 2/6/15 - Results were: Sodium (not tested ), Potassium 4.6, Chloride (not tested ), BUN 25, Creatinine 1.0, Calcium (not tested ), GFR 52. 2/16/15 - Results were: Sodium 138, Potassium 4.5, Chloride 94, BUN 26, Creatinine 1.1, Calcium 10.6, GFR 46. The clinical record for Resident #B did not contain any further labs to monitor hydration status related to diuretic use between 2/16/15 and 3/06/15. A lab dated 3/06/15 indicated Resident #B had a magnesium level of 2.9 (normal values were 1.5-2.5). This lab test was ordered by the physician on 3/06/15 as a response to a recommendation from the consulting Pharmacist on 2/18/15 who noted the resident was on a magnesium supplement and did not have a current lab to monitor the serum (blood) magnesium level. During an interview on 5/14/15 at 8:10 p.m., Resident #B's POA (Power of Attorney), indicated the family had concerns about the care of the resident. The POA indicated the resident had been showing signs of dehydration for at least 3 weeks prior to being sent to the hospital on [DATE]. The POA indicated the resident had a dry mouth, raspy voice, eyes were sunken in, and temples were sunken in. The POA also indicated the resident showed in increase in confusion and had significant weight loss related to the use of the diuretics. The POA also indicated the family had voiced their concerns to the facility staff and there were no changes in the resident's care. The clinical record for Resident #B lacked interventions and physician notification regarding the family concerns. Review of the Nurses Notes documented in the clinical record for Resident #B, included the following: 3/8/15 12:25 p.m. At approximately 1130AM (sic) CNA (Certified Nursing Assistant) notified this nurse that resident had a brief episode of being non responsive, BP (blood pressure) 92/58, Pulse 116, 02 Sat (oxygen saturation) 95% on room air, resident is noted to (sic) lethargic, call placed to MD (medical doctor), Daughter requested that MD call her personally to discuss treatment and medications. 3/8/15 10:37 p.m. At 1:00 pm resident transferred via (name of ambulance company) to (name of hospital) ER due to non-responsive episode per daughter request, report call to ER nurse. 3/8/15 10:39 p.m. Resident admitted to (name of hospital) due to dehydration, UTI (urinary tract infection), and renal (kidney) insufficiency. Review of the hospital document titled, (name of hospital) ED Evaluation dated 3/8/15, included, but was not limited to, the following: Medical Decision.Comments: Patient is severely dehydrated.She will be admitted for further hydration therapy and evaluation. Review of the hospital document titled, (name of hospital) Renal Progress Note, dated 3/14/15, included, but was not limited to, the following: Assessment/Plan: CKD III ([MEDICAL CONDITION], stage 3) - from overdiuresis (excess release of water from the body by urination) .[DIAGNOSES REDACTED]. and .dehydration. Review of the hospital document titled, (name of hospital) Hospitalist History and Physical, dated 3/08/15, indicated the following laboratory results for Resident #B: Sodium 137 (normal value 136-144) Potassium 3.4 (normal value 3.6-5.1) Chloride 87 (normal value 101-111) Carbon [MEDICATION NAME] 37 (normal value 22-32) BUN 116 (normal value 8-20) Creatinine 2.6 (normal value 0.4-1.0) Calcium 10.8 (normal value 8.9-10.3) These labs were drawn on 3/08/15 at 2:37 p.m. in the hospital emergency department. During an interview on 5/14/15 at 2:56 p.m., the Director of Nursing (DON) indicated the staff do not know how much a resident drinks because they do not keep track. During an interview on 5/15/15 at 9:05 a.m., the Facility Administrator indicated the facility did not have a policy and procedure for intake of fluids less than dietary recommendations. During an interview on 5/15/15 at 2:30 p.m., the DON indicated the facility did not have a policy and procedure for the monitoring of fluid intake and output. This Federal tag relates to Complaint IN 945. 3.1-46(b)

Based on interview and record review, the facility failed to provide ongoing monitoring and evaluation of diuretic medications to prevent adverse consequences resulting in hospitalization for 1 of 3 residents reviewed for unnecessary medications. (Resident #B) Findings include: The closed clinical record for Resident #B was reviewed on 5/15/15 at 9:00 a.m. [DIAGNOSES REDACTED]. The clinical record also indicated the following: The current MDS (Minimum Data Set) assessment, dated 2/27/15, indicated Resident #B required the physical assistance of one staff person for eating and drinking. The February, 2015 and March, 2015 Medication Administration Records, indicated Resident #B was receiving the following diuretics (medications to reduce fluid/swelling): [MEDICATION NAME], 25 mg (milligrams) daily. This medication was ordered by the physician on 1/23/15. [MEDICATION NAME], 20 mg every morning and 10 mg every afternoon. This medication was ordered by the physician on 2/02/15 as in increase to the previous [MEDICATION NAME] order (10 mg once daily-ordered 1/26/15). [MEDICATION NAME], 2.5 mg on Monday, Wednesday and Friday. This medication was ordered by the physician on 2/09/15. The clinical record for Resident #B indicated the resident was on 3 different diuretics to remove excess fluid due to swelling from 2/9/15 through 3/8/15, when the resident was discharged from the facility due to hospitalization . The weekly nursing note for Resident #B, dated 2/23/15, indicated swelling has went down. The weekly nursing note for Resident #B, dated 3/02/15, had the No box checked for [MEDICAL CONDITION], in the skin section of the assessment, indicating the resident did not have any swelling. The Physician's Progress Notes, dated 3/4/15, indicated Resident #B had no [MEDICAL CONDITION]. The clinical record for Resident #B did not contain any indication of an attempt to reduce the resident's diuretic use in response to the noted absence of [MEDICAL CONDITION] by the nursing staff. Resident #B's clinical record contained labs to monitor diuretic use and hydration status for the following dates: 1/5/15 - Results were: Sodium 140, Potassium 4.9, Chloride 102, BUN 46, Creatinine 1.0, Calcium 10.5, GFR 52. 1/26/15 - Results were: Sodium 140, Potassium 4.7, Chloride 107, BUN 21, Creatinine 0.9, Calcium 10.0, GFR 59. 2/5/15 - Results were: Sodium 138, Potassium 4.4, Chloride 101, BUN 24, Creatinine 1.0, Calcium 10.3, GFR 52. 2/6/15 - Results were: Sodium (not tested ), Potassium 4.6, Chloride (not tested ), BUN 25, Creatinine 1.0, Calcium (not tested ), GFR 52. 2/16/15 - Results were: Sodium 138, Potassium 4.5, Chloride 94, BUN 26, Creatinine 1.1, Calcium 10.6, GFR 46. Normal values for these labs included: Sodium 135-145, Potassium 3.5-5.3, Chloride 96-110, BUN 7-25, Creatinine 0.6-1.3, Calcium 8.4-10.2, GFR greater than 60. The clinical record for Resident #B did not contain any further labs to monitor possible fluid imbalance, related to diuretic use, after 2/16/15. One further lab was noted in Resident #B's clinical record, a lab dated 3/06/15 for a magnesium level. The lab was ordered by the physician on 3/06/15 as a response to a recommendation from the consulting Pharmacist on 2/18/15 who noted the resident was on a magnesium supplement and did not have a current lab to monitor the serum (blood) magnesium level. This lab result was: Magnesium 2.9 (normal values were 1.5-2.5). Resident #B's clinical record did not contain any pharmacy consults related to diuretic medications. The document titled Care Plan Conference Summary, dated 3/5/15, included, but was not limited to, the following: Plan of Care reviewed with (c with line over it) family via tele-conference. Discussed (resident name) medications and concerns regarding fluid intake and [MEDICATION NAME]''. The clinical record for Resident #B lacked documentation of interventions and physician notification related to the family concerns until 2 days after the care plan conference, on 3/7/15 at 8:36 p.m. A nursing note, documented on 3/7/15 at 8:36 p.m. indicated, POA (Power of Attorney) voiced concerns regarding amount of diuretics resident is receiving (sic). POA states she does not want resident receiving [MEDICATION NAME] or 4pm [MEDICATION NAME] dosage anymore. Notified (physician's name) and per family request medications D/C'd (discontinued). Will continue to monitor. The clinical record of Resident #B indicated the resident was discharged from the facility on 3/8/15 and admitted to the hospital for evaluation and treatment. A nursing note, documented on 3/8/15 at 12:25 p.m., indicated, At approximately 1130AM (sic) CNA (Certified Nursing Assistant) notified this nurse that resident had a brief episode of being non responsive, BP (blood pressure) 92/58, Pulse 116, 02 Sat (oxygen saturation) 95% on room air, resident is noted to (sic) lethargic, call placed to MD (medical doctor), Daughter requested that MD call her personally to discuss treatment and medications. A nursing note, documented on 3/8/15 at 10:37 p.m., indicated, At 1:00pm resident transferred via (name of ambulance company) to (name of hospital) ER due to non-responsive episode per daughter request, report call to ER nurse. A nursing note, documented on 3/8/15 at 10:39 p.m., indicated, Resident admitted to (name of hospital) due to dehydration, UTI (urinary tract infection), and renal (kidney) insufficiency. Review of the hospital document titled (name of hospital) Renal Progress Note, dated 3/14/15, included, but was not limited to the following: .Assessment/Plan:.CKD III ([MEDICAL CONDITION], stage 3) - From overdiuresis (excess release of water from the body by urination).dehydration. and .[DIAGNOSES REDACTED]. During an interview on 5/15/15 at 9:05 a.m., the Facility Administrator indicated the facility did not have a policy and procedure for the monitoring of residents on diuretics. This Federal tag relates to Complaint IN 945. 3.1-48(a)(6)

Based on record review and interview, the facility failed to increase the direct supervision of the resident when the approaches of call light in reach and alarms were ineffective to prevent unassisted transfers and unsupervised ambulation resulting in a fall when the resident repeatedly attempted to rise without assistance. The resident was not supervised when diuretic and laxative medications were added to the medication regimen, and when the resident was emotionally upset. The deficient practice affected 1 of 3 residents reviewed related to falls in a sample of 3. (Resident C) Resident C experienced a fall after unassisted rising, which resulted in a laterally displaced type-3 odontoid fracture to the cervical spine and a laceration at the eyebrow requiring repair with sutures. Findings include: The clinical record for Resident C was reviewed on [DATE] at 1:30 p.m. The record indicated the resident was admitted to the facility on [DATE] from a rehabilitation hospital following aftercare for pelvic fracture and [DIAGNOSES REDACTED]. The "Morse Fall Scale" used to assess risk for falls, with a score equal to or greater than 25 indicating risk for fall, indicated the following assessments: [DATE]: 45; [DATE]: 60; [DATE]: 45; [DATE]: 60; and [DATE]: 60. All of the assessments indicated a history of falling, with an immediate fall or history of falling within three months and impaired gait/transferring. The assessments on [DATE], [DATE], and [DATE] also indicated, "Mental status: Forgets limitations." Nurse's Notes on [DATE] at 5:05 p.m., indicated, "Visitor approached desk & advised Res (resident) in (room number) was lying on floor, entered room, res supine at foot of bed on floor, advised she was going to trailer....Late Entry @ 5:20 p.m. alarms checked turned off by resident, stated she wasn't sure. (sic)" The Admission Fall Care Plan, dated [DATE], indicated the following approaches were check marked as applicable: "Keep call light and frequently used items in place, Non-skid footwear, Complete Fall Risk Assessment, Use of Alarm/Equipment (Type) Pressure sensor alarm @ all X's (times), Therapy or Restorative as indicated, Dycem sheets layered above & below alarm while (arrow pointing up) in chair/W/C (wheel chair)." Nurse's Notes for [DATE] indicated the following: [DATE] at 9:41 p.m., "...Several attempts to self ambulate this p.m. (evening) (symbol for with) alarms in place & funct (functioning). Ignores all alarms & verbal education on the importance of alarms & amb (ambulation) (symbol for with) assist - Call lt (light) (symbol for with) in reach makes (symbol for no) attempt to use it." [DATE] at 9:40 p.m., "...Res (resident) confused this shift @ times, transferred self (symbol for without) use of call light, pt (patient) teaching given in regards to assist (symbol for with) transfers...." [DATE] at 9:21 p.m., "...Self ambulated X (times) 2 this p.m....Non-compliant to alarms stated 'I'm trying.'" [DATE] at 6:45 a.m., "...Res slept all noc (night) (symbol for without) diff (difficulty). Res did get (arrow pointing up) OOB (out of bed) X i (one) (symbol for without) assist, alarm was sounding and res had walked self to the bathroom this nurse waited for res to finish and walked (symbol for with) her back to bed. Gait slow/steady. Alarm in place & funct. (functioning) properly. Call light (symbol for with) in reach...." [DATE] at 1:31 p.m., indicated the physician was contacted related to "3+ edema to BLE (bilateral lower extremities), and a new order was received for Lasix (diuretic) daily. [DATE] at 9:30 p.m., indicated the resident complained of no bowel movement and discomfort in the rectal area. The physician was contacted and orders were received for enemas and Dulcolax suppositories as needed and a stool softener daily. The Note indicated, "Prune juice given X 2 - enema given tolerated well (symbol for with) med (medium) soft bowel...." [DATE] 8:00 p.m. "...Res cont (continues) to have +2 edema BLE (bilateral lower extremities)...XL (extra large) bowel movement this shift...Sensor alarm on & functioning properly. Several attempts to stand up. Re-educated about using call light." The Medication Administration Record indicated the diuretic was administered on ,[DATE] and [DATE] at 4:00 p.m., and Miralax (stool softener) was administered on [DATE] at 8:00 a.m. The Physical Therapist Progress Report and Discharge Summary, dated [DATE], indicated the following: "Gait tasks: Assistive Devices - Current Level of Function: The patient requires front wheeled walker and CGA (contact guard assist) to SBA (stand by assist) for safe ambulation for 100 feet X 2 with cues for safety technique; Standing Balance: General - The patient demonstrates standing balance of poor to fair dynamic and maintains for 5 - 10 minutes requiring CGA to SBA; Transfer: General - The patient is able to safely complete all functional transfers requiring CGA to SBA." "Patient/Caregiver Training" indicated, "Res needed cont (continuous) verbal cues for safety." "Impact on Burden of Care/Daily Life: Needed CGA to SBA for safety." "Precautions: Fall risk, WBAT (weight bearing as tolerated)." The Social History and Assessment, dated [DATE], indicated the resident was alert to person and time, had good to fair long term memory, and poor short term memory. Social Service Progress Notes indicated the following: [DATE] (untimed), "...She has struggled with unsafe transfers when she feels staff do not respond quick enough to her call light...." [DATE] (untimed) , "Resident's behaviors continue with...unsafe transfers...." Social Service Progress Notes for [DATE] at 11:30 a.m., indicated the social worker met with the resident and her power of attorney (POA) about the resident's plans for discharge. The resident was told by her POA that she would be unable to afford to return home and pay for full time caregivers. The Notes continued, "Res. was worried about d/c (discharge) plan & upset that she couldn't return hm (home). Sat (symbol for with) res (resident) 1:1 (one on one) for 15 min (minutes) (symbol for with) (name of POA) @ other side of bed until she stopped crying & began to go to sleep. (Name of POA) was in rm (room) when this writer left. Alerted the nurse of resident's concerns & requested a f/u (follow up)...." Nurse's Notes on [DATE] at 12:55 p.m. indicated, "Res call light sounded. This nurse left desk to answer call light . As this nurse approached room, alarm sounding. As this nurse approached room, res found laying on bathroom floor (symbol for with) pants pulled down, head on floor laying on L (left) side. Asked CNA to call supervisor office. Supervisor arrived to assess situation." The Notes were signed by LPN #7. Nurse's Notes on [DATE] also at 12:55 p.m. indicated the following: The resident was lying face down with arms at side and blood on the floor. The resident closed the eyes tightly when her name was called. The floor nurse was asked to call 911. During assessment, the resident stopped breathing and had no pulse. The resident was log rolled to her back, and pulse and respirations were absent. CPR was initiated. Emergency technicians (EMTs) arrived, a pulse was detected, and an endotracheal tube was placed. The resident was transferred to the local hospital. The Emergency Department report, dated [DATE] indicated, "...CT (computerized tomography) scan of cervical spine reveals evidence of laterally displaced type-3 odontoid fracture....The wound to the patient's eyebrow was...closed with running ,[DATE] Ethilon suture." The report indicated the resident was to be transferred to an out of state hospital for further evaluation. During interview completed on [DATE] at 2:05 p.m., LPN #7 indicated the following: She was caring for Resident C on [DATE] when the resident fell . The resident used her call light, and she (LPN #7) left the nurse's desk to answer the call light. She heard the alarm sounding, and the resident was on the floor in the bathroom. She asked the CNA to call the supervisor who came immediately and began assessing the resident. LPN #7 left the room to call 911. LPN #7 indicated Resident C was the type of resident who used the call light and then immediately got up out of her chair instead of waiting for assistance. This federal tag relates to Complaint IN 601. 3XXX,[DATE](a)(2)