Every finding on record at Chateau Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member (CNA 2) for 1 of 3 residents reviewed (Resident B).Findings includeAn investigation file was provided by the Administrator on 5/4/26 at 11:39 AM. The file indicated, on 4/28/26, Resident B and CNA 2 were yelling and arguing at the nurse's station. The file statements indicated the following:LPN 4's statement, dated 4/28/26, indicated Resident B spoke with her at the nurse's station regarding CNA 2. Resident B indicated he was upset due to the way CNA 2 talked to him. Resident B indicated CNA 2 came into his room and told him to go to the dining room. While Resident B was expressing his feelings to LPN 4, CNA 2 came around the corner and said I'm not going to argue with you and you aren't going to call me a piece of sh**. Resident B responded with you are a piece of sh**. Resident B and CNA 2 continued to yell at each other until other staff arrived.The Administrator's statement, dated 5/1/26, indicated on 4/28/26, both she and the Regional Nurse Consultant spoke with CNA 2. CNA 2 indicated Resident B was yelling at her and she was tired of being treated that way. CNA 2 indicated she yelled at the nurse's station where Resident B was present. The Administrator indicated CNA 2 was educated that yelling at the nurse's station was inappropriate and if she needed to talk or vent she could go to an office and close the door to do so.The Regional Nurse Consultant's statement, dated 4/28/26, indicated on 4/28/26 she heard yelling coming from nurse's station. Regional Nurse Consultant indicated she arrived in the area where she observed CNA 2 standing near the nurse's station speaking loudly. Regional Nurse Consultant indicated she heard CNA 2 make statements, including it's too much, I just want to go home and I don't want to be yelled at anymore. CNA 2's undated statement indicated, on 4/28/26, she went into Resident B's room and informed both him and his roommate it was time for lunch and to head to the dining room. CNA 2 indicated Resident B began to argue with her. CNA 2 indicated she responded with: I'm not arguing with you. CNA 2 indicated she then overheard Resident B complaining about her at the nurse's station. CNA 2 indicated Resident B indicated he was not a child, then CNA 2 responded to Resident B that she was not a piece of sh** for him to talk to her however he wanted. Resident B kept saying yes, yes, you are.The Assistant Director of Nursing (ADON)'s statement, dated 4/28/26, indicated she overheard CNA 2 yelling from the nurse's station. The ADON indicated she observed CNA 2 tell Regional Nurse Consultant I don't even know who the f*** you are. The ADON indicated the floor staff indicated CNA 2 had been yelling after a disagreement with a resident.The Social Service Director (SSD)'s statement indicated she overheard yelling coming from the nurse's station. The SSD indicated CNA 2 was yelling and cursing and Resident B was yelling back at CNA 2. The SSD indicated she interviewed Resident B, who indicated he thought CNA 2 was yelling at him, so he yelled back.During an interview, on 5/4/26 at 9:42 AM, the Regional Nurse Consultant indicated, on 4/28/26, she overheard yelling from the hallway. The Regional Nurse Consultant indicated when she arrived in the area, she observed CNA 2 visibly upset, cursing and arguing with Resident B.During an interview, on 5/4/26 at 10:36 AM, Qualified Medication Aide (QMA) 7 indicated staff should never yell, curse or argue with or around residents.During an interview, on 5/4/26 at 10:50 AM, Licensed Practical Nurse (LPN) 4 indicated, on 4/28/26, Resident B indicated CNA 2 upset him. Resident B indicated CNA 2 told Resident B to go to the dining room for lunch and Resident B was upset about how he was treated. LPN 4 indicated CNA 2 overheard Resident B talking about CNA 2 and then CNA 2 told Resident B she was not going to argue with him, and she wasn't a piece of sh**. LPN 4 indicated Resident B responded with yes yes you are and Resident B and CNA 2 continued to argue. LPN 4 indicated staff should not argue or use foul language around residents. During an interview, on 5/6/26 at 9:54 AM, Resident B indicated on 4/28/26 CNA 2 entered his room and told him and his roommate to go to the dining room. Resident B indicated he responded to CNA 2 that he and his roommate don't go to the dining room but rather eat in their room. Resident B indicated CNA 2 responded with I don't want to hear it. Resident B indicated later that day he spoke with LPN 4 at the nurse's station about the incident. Resident B indicated he was confused about how CNA 2 acted. Resident B indicated during this conversation CNA 2 appeared and began to argue with Resident B. Resident B indicated CNA 2 indicated she wasn't going to be treated this way and she was not a piece of sh**. Resident B indicated he never called CNA 2 a piece of sh** but CNA 2 kept arguing with Resident B.Resident B's record was reviewed on 5/6/26 at 10:44 AM. Diagnosis included adjustment disorder.A quarterly Minimum Data Set (MDS) assessment, dated 3/31/26, indicated Resident B had a brief interview of mental status score of 13/15 (cognitively intact).A policy, dated 12/1/2013, titled Abuse Prevention and Prohibition was provided by the Administrator on 5/6/26 at 11:13 AM. The policy indicated residents should be free from abuse treatment.Past non-compliance existed related to auditing for like circumstances, staff reeducation completed on 4/30/26, and quality monitoring initiated on 5/1/26. This finding relates to Intake 2999159.410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure treatments to pressure injuries were completed as ordered for 2 of 4 residents reviewed with pressure injuries (Resident D and Resident E). Findings include:1. On 2/17/26 at 10:15 A.M., Resident D's record was reviewed. Diagnoses included paraplegia and pressure related wounds. An in-house wound Nurse Practitioner (NP) progress note, dated 12/31/25, indicated Resident D was seen for chronic wounds. The resident had a wound to her left ischium. The wound, located on the left ischium (lower back part of hip bone), was unstageable and measured 20 centimeters (cm) x 16 cm x 1 cm with 50% epithelial tissue, 20% granulation, and 30% slough with a moderate amount of bloody, serous drainage. The wound had improved with a decrease in wound size and wound drainage. There was no odor. Orders were to clean the wound and apply Calcium Alginate with Santyl (removes dead tissue in a wound) to the base of the wound and secure with a bordered dressing. The wound treatment was to be done 3 times per day. A Treatment Administration Record (TAR), dated January 2026, indicated on 1/1/26 through 1/5/26, Santyl was applied to the left buttock wound topically every morning. The left ischium was treated with Santyl and Calcium alginate and covered with a bordered gauze every day shift. The NP note didn't indicate there was a wound on Resident D's left buttock. The TAR had not indicated dressings to the ischium had been completed 3 times per day as ordered on 12/31/25. A Wound Clinic progress note, dated 1/5/26, indicated Resident D had 2 wounds. A wound to her left buttock, and a wound to her sacrum. The progress note did not indicate measurements of the 2 wounds but provided treatment orders for the wounds as follows: -Left buttock wound: wash wound with baby soap and water, pat dry. Place Santyl nickel thick and cover with gelling fiber Ag (silver), ABD pad, kerlix and tape. Change dressing daily.-Sacral wound: wash wound with baby soap and water, pat dry and cover with gelling fiber Ag, ABD pad, kerlix and tape. Change dressing daily (Santyl was not ordered for this wound). A TAR, dated January 2026, indicated on 1/6/26 through 1/11/26, Santyl was applied to the left buttock wound topically every morning. The left ischium was treated with Santyl, covered with Calcium alginate and a bordered gauze every day shift. The TAR had not indicated treatment was provided as ordered by the wound clinic on 1/5/26. On 1/8/26, an NP note indicated the area to the sacrum was 20 cm x 16 cm x 1 cm. The NP note didn't indicate there was a wound on Resident D's left buttock. In an interview, on 2/17/26 at 10:40 AM, LPN 2 indicated the measured area indicated in the NP note included the left buttock. 2. On 2/18/26 at 10:53 A.M., Resident E's record was reviewed. Diagnoses included chronic sacral wound and diabetes. A wound clinic note, dated 1/7/26, indicated Resident E had been seen for a stage 4 pressure injury of the sacral region with chronic osteomyelitis (bone infection) of the coccyx. The wound measured 2.2 cm x1 cm x 0.1 cm. Orders for wound care included to follow up with the wound clinic in 2 weeks; wash the wound with baby soap and water, and pat dry. Staff were to place Endoform AM (antimicrobial) and cover with Superabsorber with border. The dressing was to be changed every other day. Information regarding Endoform dressing was retrieved from the manufacturer's website, www.aroa.com, on 2/18/26. Endoform dressings were used to treat acute and chronic wounds. The dressings helped to protect against infection and helped to build new tissue/skin. Endoform antimicrobial (AM) could last from 1 to 7 days in the wound and dressings were to be changed as ordered by the physician. Endoform AM had been shown in studies to heal and close a wound significantly faster than collagen with silver alone. A Treatment Administration Record (TAR), dated January 2026, indicated between 1/1/26 through 1/31/26, Resident E's sacral wound was treated with collagen with silver, cut to size and placed in the wound bed on Monday, Wednesday, and Friday. Every day, staff were to place Vashe soaked gauze in the wound and cover with a bordered gauze. When using collagen, staff were to place the collagen first then the Vashe soaked gauze over it every day shift. The TAR did not indicate treatment was provided as ordered by the wound clinic on 1/7/26. A Wound NP note, dated 1/24/26, indicated the wound measurements were 2.2cm x 1 cm x 0.1 cm. On 2/17/26 at 2:02 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The ADON indicated resident's with wounds may be seen by the facility in-house wound NP, the wound clinic or both depending on the resident's choice. She indicated the wound NP could not visit the resident during the same week they were seen at the wound clinic. The DON indicated orders for wound care were to be followed as ordered, either by the wound NP or wound clinic. The ADON indicated orders from the wound clinic should be placed on the TAR and completed as ordered. On the NP's next visit, they could decide if they wanted to change the treatment ordered by the wound clinic and staff would be expected to follow those orders when written. On 2/18/26 at 9:50 A.M., the Administrator indicated staff should have followed treatment orders as written by the wound NP or by the wound clinic when the orders were given. She indicated staff had missed changing the wound treatments as ordered. A current facility policy, titled Wound Care, was provided by the Administrator on 2/18/26 at 10:07 A.M. The policy indicated wound care was to be done as ordered by the physician. This Citation relates to Intake 2736099. 3.1-40

Based on interview and record review, the facility failed to ensure necessary assessments and monitoring of catheter care were completed for 1 of 4 residents resulting in hospitalization for sepsis (Resident D). Findings include:A report, dated 2/4/26, alleged Resident D had not been assessed or provided assistance with catheterization of her Indiana pouch (internal urinary reservoir after removal of the bladder) when she became acutely ill. Resident D was hospitalized for profound urinary retention, acute kidney injury, electrolyte imbalance, and sepsis. Information obtained on 2/17/26 from www.medicine.iu.edu, Indiana University where the Indiana pouch was developed, indicated the pouch was a continent urinary reservoir. It was created out of the colon and fashioned into a pouch with an opening through the skin called a urostomy. The pouch could hold up to 600 milliliters of fluid and required routine self-catheterization through the opening of the skin, every 4-6 hours to empty out urine. Routine care included preventing and monitoring for infection of the urine such as strong-smelling, cloudy, dark urine, foul odor, little output, or changes in mental status. On 2/17/26 at 10:15 A.M., Resident D's record was reviewed. Diagnoses included paraplegia, Indiana pouch, pressure related wounds, and chronic pain syndrome treated with routine pain medications. A care plan, dated 6/9/25, indicated Resident D required some assistance with her activities of daily living (ADL) due to paraplegia, muscle wasting, and intermittent catheterization. An intervention, dated 8/25/25, indicated the resident required straight catheterization of her Indiana pouch every 4 hours. The care plan indicated the resident was competent to catheterize herself. Staff were to offer her assistance with catheterization, every 4 hours, especially at night, and document urine output. Staff were to observe for signs and symptoms of urinary tract infection (UTI) such as pain, burning, abnormal urine color, frequency, and mental status changes. A physician order, dated 8/6/25, was to straight catheterize the Indiana pouch at the right iliac crest every 4 hours. Resident D may self-catheterize. Staff were to continue to offer assistance, especially at night. A Treatment Administration Record (TAR), dated January 2026, indicated on 1/11/26 at 8:00 a.m. and 12:00 p.m., the catheterization was not done and there was no output recorded. The nurse's initials and number indicated to refer to progress notes for further information. There were no progress notes written on 1/11/26 between 8:00 a.m. and 12:00 p.m. to indicate why the catheterization was not done or why no output recorded. A progress note, dated 1/11/26 at 3:56 p.m., indicated Resident D had been lethargic during the day. The nurse went to Resident D's room to change her dressings and observed the resident's abdomen to be distended. The resident complained of pain in her swollen abdomen. The nurse tried to help Resident D catheterize her pouch but was unsuccessful. The on-call Nurse Practitioner (NP) was notified and orders received to send the resident to the ER for mental status change, distended abdomen, inability to catheterize, and wound changes. Hospital records, dated 1/11/26, indicated Resident D was seen in the emergency room for abdominal pain. The resident indicated she started having abdominal pain around lunchtime and her appetite had been decreased over the past few days. The resident indicated she self-catheterized her Indiana pouch but hadn't gotten out any urine on 1/11/26. She indicated she hadn't been able to remove any urine since last night. The resident's abdomen was distended. After gentle dilation of the urostomy, a catheter was placed into the pouch where a profound amount of urine was removed. The resident had 2 liters of urine with large amounts of mucous and blood drained from the pouch. Blood work done in the ER indicated a highly elevated white blood count (WBC) of 34.4 (Reference Range: 3.4 - 10.5) indicating infection. A urine sample taken was positive for blood, white blood cells, and bacteria. Her blood sodium level was low at 124 (Reference Range: 134 - 146) and kidney function tests were elevated with a creatinine level of 1.16 (Reference Range: 0.60 - 1.10). The resident was admitted to the hospital for leukocytosis (elevated WBC), acute kidney injury, urinary retention and hyponatremia (low sodium). On 2/17/26 at 11:15 A.M., Resident D's family member was interviewed. They indicated while the resident usually was able to self-catheterize her Indiana pouch, with any changes in condition, she would require staff's assistance. They indicated Resident D had been having lethargy since changes in her pain medication a few days before being hospitalized . On 2/17/26 at 2:02 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The DON indicated she was not aware the resident had not been catheterized either by the resident or the nurse on 1/11/26 at 8:00 a.m. or 12:00 p.m. There should have been documentation in the TAR or progress notes related to why the catheterization wasn't done. The ADON indicated she had specifically written in the care plan for staff to offer assistance with catheterization every 4 hours as scheduled. The ADON indicated staff had been instructed to always ask regardless of how many times the resident refused the offer of assistance. A current facility policy, provided on 2/18/26 at 10:07 A.M., and titled Indiana Pouch (Continent Urinary Diversion) Management Policy indicated: Residents with an Indiana pouch could perform self-catheterization and pouch emptying when they demonstrated the ability and desire to do so. The facility would support the resident's independence while ensuring appropriate monitoring; the resident's ability to perform self-care would be assessed with any change in condition; and nursing staff would monitor changes in continence, signs of infection or complications. This Citation relates to Intake 2736099 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident's physicians were notified of a change in condition and refusal of treatment for 1 of 3 residents reviewed (Resident D). Findings include:A report, dated [DATE], alleged Resident D had been in poor shape one day and was sent to the hospital where he later died. It was alleged staff ignored his condition and assumed he had been drinking alcohol as the cause of his decline. On [DATE] at 1:08 P.M., Resident D's record was reviewed. Diagnoses included end stage renal disease with dependence on dialysis, chronic low back pain, and diabetes. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview Mental Status (BIMS) score of 9 indicating Resident D had moderately impaired cognition. He had chronic moderate pain which would occasionally cause disruption with his daily activities. He was prescribed opioid medications to manage his pain. Care plans indicated Resident D received kidney dialysis at the facility. He was scheduled for 4 hours of dialysis at 4:00 p.m. on M-W-F. Staff were to perform pre and post dialysis care which was communicated to dialysis staff. Resident D was at risk for side effects related to use of opioids and staff were to observe for and report side effects to the physician. There was no care plan indicating Resident D had current or past issues with substance or alcohol abuse. A nurse progress note, dated [DATE] at 6:57 a.m., indicated Resident D had spoken with Licensed Practical Nurse (LPN) 2. During the conversation, LPN 2 indicated the resident smelled of alcohol. The medical Nurse Practitioner (NP) and Unit Manager were notified. At 12:18 p.m., new orders were given for a drug and alcohol screen to be done. The nurse progress notes nor assessments indicated the drug and alcohol screen had been completed as ordered. There was no follow up documentation completed indicating the residents' condition on 11/3 or [DATE]. A Change in Condition form, dated [DATE] at 8:00 p.m., indicated Resident D refused his scheduled dialysis appointment on [DATE] at 4:00 p.m. The resident was not socializing in his normal manner and had refused his evening medications. He slept most of the evening and would fall asleep while sitting up. The Director of Nursing, NP, Unit Manager and dialysis nurse were aware, and orders given by dialysis. An NP progress note, dated [DATE], indicated Resident D was seen for a chronic care visit. Staff had reported him to have altered level of consciousness and refusing dialysis the day before ([DATE]). He refused dialysis treatment yesterday, telling staff he wasn't feeling well. He was observed sitting on the side of his bed, slow to answer questions, and needed assistance to reposition in bed and lay down. He appeared awake, alert, and slow to respond and his cognition was unable to be assessed. The NP ordered labs to be drawn today including blood alcohol level. Staff were to monitor his condition and report any changes. A Medication Administration Record (MAR), dated [DATE], indicated Resident D's medications, scheduled to be administered on [DATE] at 8:00 p.m., including insulin, blood pressure medication, and pain medications, were not given due to the resident sleeping.There was no documentation of nursing assessment done on the resident due to sleepiness and holding of medications. There was no documentation indicating the NP or dialysis team had been notified of the medications being held due to Resident D's sleepiness. A transfer form, dated [DATE] at 8:40 a.m., indicated Resident D was sent to the hospital due to a very low oxygenation saturation level of 68% (normal >90%).On [DATE] at 2:50 P.M., the Director of Nursing (DON) was interviewed and was asked for results of the drug and alcohol screen ordered on [DATE]. The DON indicated the resident had refused the testing however, it had not been documented in the resident's medical record. When asked if the NP or dialysis team had been notified of the resident's refusal, she indicated the NP and dialysis team should have been notified and notification documented in the resident's medical record.On [DATE] at 10:12 A.M., LPN 2 was interviewed. He indicated on [DATE], Resident D had called him to his room. The resident was out of sorts and smelled of alcohol. He notified the medical NP and got an order for a drug and alcohol screen. He asked the resident if he would take the test and the resident refused. He indicated, thinking he had notified the NP of the refusal but hadn't charted it. LPN 2 indicated, Resident D continued to be out of sorts on [DATE] and stayed in his room most of the day. He was not aware of the resident's condition on 11/5 or [DATE]. When questioned he indicated he wasn't sure if nurses were to notify the dialysis team of a resident's drinking or refusals of drug and/or alcohol tests. On [DATE] at 3:47 P.M., the Nephrologist (kidney doctor) was interviewed. She indicated she had not been notified nor had her staff of the resident's possible intoxication with alcohol on [DATE]. Resident D received dialysis on [DATE] and indicated it would be important for the dialysis team to be made aware of any changes with dialysis patients including possible substance abuse prior to the treatment. The Nephrologist indicated she had not been notified of the altered level of consciousness he was observed to have beginning on [DATE] and continuing until his hospitalization. She indicated any altered level of consciousness in a dialysis patient was an opportunity to intervene to prevent complications. A current facility policy, titled Guidelines for Notifying Physicians of Clinical Problems and provided by the Executive Director on [DATE] at 4:47 P.M., indicated guidelines to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. Immediate Notification (Acute) Problems such as Rapid decline or continued instability should be reported after an appropriate nursing evaluation. This Citation relates to Intake 2681866. 3.1-5(a)(2)

Based on observation, interview and record review the facility failed to ensure safe and sanitary food storage and serving practices for 3 of 3 observations. Food prepared in the kitchen was consumed by 90 of 90 residents who lived in the facility. Findings include: During a continuous observation on, 7/22/25 from 09:15 AM-10:15 AM, the following was observed:A dining room pantry had about a cupful of colorful O shaped cereal in an open tray below the cereal dispensers. A second tray contained about a cupful of tan O shaped cereal underneath the dispensers. There was no label on the trays.The dry food storage had an open bag of white granules visible in a bulk sized bag labeled salt. There was no label on the bagThe walk-in freezer had an ice cream tub with the lid partially covering the ice cream. There was no open date on the ice cream tub.In the B Hall pantry, a container of berry fruit juice expired on 7/6/25. The ice scoop was in the ice of the unit ice machine. A broken hook was observed next to the scoop.In The Garden Unit refrigerator, a container of thickener liquid was open, without a lid or cover. In an interview, on 7/22/25 at 09:20 AM, the Dietary Manager indicated the salt should be sealed and dated.In an interview, on 7/22/25 at 09:40 AM, the Dietary Manager indicated the hook for the ice scoop was broken. She indicated the resident and the resident's family wouldn't be happy if we threw away the expired berry juice.During a continuous observation, on 7/23/25 from 10:35 AM to 11:30 AM, the following was observed:Two about cup full of tan flakes, colorful and tan O shaped cereal was found under the dispensers in the dining room pantry. Two paper towel holders in the kitchen had paper towel rolls on top of the holder. Moisture drops on the paper towel rolls were observed after tearing paper off the roll.The wall behind the sink had a missing tile opening, exposing the wall. The tile was sitting on the sink behind the hot water tap.Stacked serving items had moisture in 3 trays, 3 warming lids, and one plate in approximately 3 observations of each item during lunch service. Staff continued to use trays and lids. When the moisture on the plate was addressed by surveyor, the [NAME] removed the moist plate.In an interview, on 7/23/25 at 10:45 AM, the Dietary Manager indicated the missing tile at sink had been entered into maintenance software program. She indicated Housekeeping had not been putting the paper towels in the holders.An observation on 7/28/25 at 12:58 PM, in the dining room pantry, about two cup full of tan flakes, colorful and tan O shaped cereal was found under the dispensers.In an interview, on 7/28/25 at 1:00 PM, [NAME] 5 indicated 90 of 90 residents residing in the facility ate food provided by the kitchen.A current policy undated, provided by the Administrator, indicated opened bulk foods should be sealed or in a sealable container. All foods should be covered. All foods will be checked to assure food will be consumed by use-by date or discarded.A current policy undated, provided by the Administrator, indicated dishes should be air dried on dish racks. Dishes are inspected for complete dryness before being nested. 3.1-21(i)(3)

Based on observation, interview and record reviewed, the facility failed to maintain clean, intact ceiling tiles in 4 of 6 hallways where residents reside. Findings include: During an observation, on 7/24/25 10:18 AM, a ceiling tile outside room [ROOM NUMBER] had a round brown stain approximately 15 inches in diameter. A ceiling tile outside room [ROOM NUMBER] had 2 irregularly shaped brown stains, about 7 inches in diameter and 5 inches in diameter. Ceiling tiles outside room [ROOM NUMBER] were stained with approximately a 15 inch diameter round brown stain, a 20 inch round brown stain and a 6 inch round brown stain. A ceiling tile outside room [ROOM NUMBER] had an approximately 12 inch round stain and a crack about 14 inches long. A long brown stain was observed above the countertop of the 300 hall end of the nurses station covering the entire length of 2 ceiling tiles. A large crack the width of ceiling tile was observed outside medical records office in a common hallway. 2 ceiling tiles outside the activity room had stains approximately 6 inches in diameter and 4 inches in diameter. A large brown stain, about 8 inches by 4 inches was observed on the ceiling tile outside the social services office. A large brown stain was observed in a ceiling tile above the aquarium near the B-wing nurses station about 12 inches by 24 inches. Outside room [ROOM NUMBER] a ceiling tile had dark brown stains about 12 inches by 4 inches. A brown stain about 5 inches in diameter was observed on a ceiling tile outside room [ROOM NUMBER]. Outside room [ROOM NUMBER] a large crack about 7 inches long was observed on a ceiling tile. Ceiling tiles outside room [ROOM NUMBER] had large grey stains approximately 8 inches by 5 inches, 12 inches by 8 inches and 12 inches by 4 inches. A brown stain about 8 inches by about 6 inches was observed on a ceiling tile outside room [ROOM NUMBER]. A large crack about 6 inches long was observed in a ceiling tile outside room [ROOM NUMBER]. A ceiling tile outside room [ROOM NUMBER] around a return air vent had five cracks on each side of the tile from about 4 inches to about 12 inches in length.Documents titled Touch Up Paint schedule, Deep Clean Schedule, and printout of maintenance work orders for the last 30 days, provided by the Administrator 7/25/25 at 9:25 AM, did not include any current plan for replacement of soiled or damaged ceiling tiles.During an interview, on 07/25/25 at 2:04 PM, the Administrator indicated ceiling tiles should be intact and free of stains. She indicated she would initiate tile replacement for damaged tiles.A document titled Ceiling Tile Replacements, provided by the Administrator on 7/25/25 at 2:27 PM, indicated ceiling tiles for the hall including rooms 114 through 129 were scheduled to be replaced by 7/25/25.During an observation, on 7/28/25 at 9:40 AM, observations of ceiling tiles throughout the facility remained unchanged.During an interview, on 7/28/25 at 1:45 PM, the Regional Director of Operations indicated some ceiling tiles had been replaced in April, 2025, but other pressing financial matters had slowed the process of tile replacement.During a review of facility quality assurance and performance improvement plans with the Administrator on 07/28/25 at 1:26 PM, a performance improvement plan for ceiling tile replacement was not available for review.3.1-19(a)(4)

Based on interview and record review the facility failed to ensure that 1 of 5 residents reviewed received insulin as ordered. (Resident 83) Findings include:Resident 83's record was reviewed on 7/23/2025 at 9:46 AM. Diagnoses included Diabetes mellitus type 2, hemiplegia or hemiparesis, anxiety, and cerebrovascular accident (stroke).A review of Resident 83's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated the resident received insulin 7 days a week. In an interview, on 7/25/25 at 11:05 AM, Resident 83 indicated the staff had missed insulin doses because Resident 83 did not go out to the nurse's station to receive the doses.A review of the Medication Administration Record, or MAR, dated June 2025 on 7/28/25 at 9:30 AM, indicated there was missing documentation for blood glucose measurements on 6/4/25 at 10:00 PM, 6/10/25 at 11:30 AM, and on 6/26/25 at 11:30 AM. A review of physician orders, dated 2/28/25 at 7:30 AM, indicated blood glucose was to be checked and entered into the record before meals. A review of physician orders, dated 5/21/25 at 10:00 PM indicated blood glucose was to be checked and entered into the record at bedtime (scheduled at 10:00 PM). A new order placed (discontinuing the previous order) on 6/20/25 at 9:35 AM indicated a new sliding scale order was to check blood sugar more than 2 hours (8:00 PM) after the last dose of Novolog and give the listed sliding scale amounts.A review of physician orders, dated 6/25/25 at 2:40 PM, indicated to give Novolog 15 units when blood glucose was between 111-149 before meals. A review of the Medication Administration Record (MAR), dated June 2025, indicated the following insulin administration documentation was missing from the record:Lantus 52 units subcutaneous administrations on 6/4/25 at 8:00 AM, 6/28/25 at 8:00 PM, and 6/30/25 at 8:00 PM.Routine Novolog 25 units subcutaneous before meals on 6/3/25 at 11:30 AM, 6/4/25 at 7:30 AM, and 6/10/25 at 11:30 AM.Novolog Sliding Scale subcutaneous coverage with meals and at bedtime on 6/3/25 at 11:30 for no additional coverage, 6/4/25 at 8:00 AM for 2 units, 6/4/25 at 10:00 PM for an unknown amount of units, 6/10/25 at 11:30 AM for an unknown amount of units, and 6/27/25 at 4:00 PM for 15 units.A review of progress notes, on 7/28/25 at 10:35 AM, indicated Resident 83 had refused doses of Novolog insulin on 6/5/25 at 11:30, 6/17/25 at bedtime, and 6/30/25 at bedtime.The June 2025 MAR was missing documentation on 6/5/25, 6/17/25, and 6/30/25. Refusals were to be indicated with a code 2 and the staff identifier on the MAR.In an interview, on 7/28/25 at 10:51 AM, LPN 2 indicated when a medication was refused, a call should be placed to the provider, documented in electronic health record, and in the medication administration record, with a code # for refused, and the NP notified. There should not be missing information on the MAR.A current policy titled Documentation of Medication Administration, dated 11/2022, provided by the Administrator, indicated documentation must include a reason why medication was withheld, not administered, or refused. 16.2-3.1-37(b)

Based on observation, interview and record review, the facility failed to notify the physician of abnormal catheter assessment findings in 1 of 3 residents reviewed (Resident 12).Findings include:During an observation, on 07/23/2025 at 10:56 AM, Resident 12 was seated near the nurses station in a Broda chair. Her catheter tubing contained yellow cloudy fluid with sediment. During an observation, on 07/24/2025 at 1:19 PM, Resident 12 was seated in a Broda chair near the nurses station. Catheter tubing had whitish sediment covering more than half of the tubing. Some light yellow, cloudy fluid was observed in the tubing. During an observation, on 07/25/2025 at 9:10 AM, Resident 12's urine was light yellow and very cloudy with large amounts of sediment. Resident 12's record was reviewed on 07/25/2025 at 11:46 AM. Diagnoses included chronic kidney disease and Kennedy ulcer of the coccyx. During an interview, on 07/25/2025 at 9:11 AM, Registered Nurse (RN) 5 indicated abnormal urine assessments could include dark or discolored urine, cloudiness or sediment. She indicated upon discovering such findings nurses should check for orders to flush the catheter or contact the provider to report assessments. She indicated physician's orders should be followed. She indicated the color and clarity of Resident 12's urine in catheter tubing was normal for her. She indicated she did not know if this condition was documented. Resident 12's current Significant Change in Status Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident 12 had a Basic Interview for Mental Status (BIMS) score of 1 (severe cognitive impairment). The MDS indicated Resident 12 used an indwelling catheter. A current physician's order, dated 3/18/25, indicated staff should irrigate Resident 12's catheter with 30 milliliters (ml) normal saline every six hours as needed for clogging or sediment. A current physician's order, dated 3/12/25, indicated Resident 12's indwelling catheter and urine should be monitored for color, clarity and patency every shift. The order indicated the physician should be notified of abnormal findings. A current care plan titled chronic conditions with risk for discomfort indicated Resident 12 had a problem of risk for decline due to chronic kidney disease, stage 2 with a goal date of 12/9/25. The care plan indicated Resident 12's catheter should be flushed as needed. There was no documentation in the care plan cloudy urine was normal for the resident. A review of medication and treatment administration records, dated July 2025, did not include any signed administration of a catheter flush. No abnormal urine assessments were recorded on the administration record. A review of July 2025 progress notes did not include any abnormal urine assessments or physician notifications of abnormal assessments. During an interview, on 07/25/2025 at 9:34 AM, the Director of Nursing (DON) indicated normal urine would appear clear, light yellow with no sediment or cloudiness. She indicated abnormal findings should be reported to the nurse practitioner. She indicated Resident 12 always had cloudiness and sediment in her urine. She indicated a nurse would know this because it would be passed on in report. She indicated she didn't know if this was documented anywhere a nurse could readily access the information. A current policy, titled Physician's Services and Orders, dated 12/1/23 indicated all physician orders should be followed as prescribed and if not followed, the reason should be recorded in the resident's medical record during that shift. 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure trauma informed care was provided for 2 of 3 residents reviewed (Resident 11 and Resident 17).Findings include: 1. In an attempted interview, on 7/23/25 at 11:10 AM, Resident 11 was observed rubbing their hands together. Resident 11 avoided eye contact when greeted. Resident 11 turned their head away when spoken to.Resident 11's record was reviewed on 7/28/25 at 10:27 AM. Diagnoses included major depression, insomnia, nicotine dependence and anorexia nervosa.Resident 11's Annual Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 (no cognitive loss). Resident 11's Preadmission Screening and Resident Review, (PASRR) dated 10/5/20, indicated the resident had attempted suicide in the past. The PASRR indicated pain was a trigger for increased depression. The PASRR indicated Resident 11 had a substance disorder related to alcohol abuse or dependency.A physician order, dated 4/4/25, indicated Resident 11 could be administered 45 milliliters of rum at bedtime as needed for prophylaxis.Resident 11's care plan, dated 8/1/23, indicated the resident had a history of alcohol abuse. The target goal was to have minimal risk for complications and maintain the highest level of wellbeing by 12/5/24. An intervention included providing a safe environment if the resident displayed symptoms of substance abuse.Resident 11's care plan, dated 8/1/23, indicated the resident was at risk for impaired psychosocial wellbeing. The target goal was to follow the recommendations through 12/5/24. Interventions included encouragement of socializing with others and the implementation of the PASRR recommendations.Resident 11's care plan, dated 8/1/23, indicated the resident had a diagnosis of anorexia nervosa. The target goal was meeting needs, honoring preferences, following PASRR recommendations and remaining free of psychosocial complications through 12/5/24. An intervention included avoiding any discussions related to diets and losing weight.Resident 11's care plan did not indicate the resident had a history of attempted suicide.Resident 11's care plan did not indicate pain was a trigger for increased depression.Resident 11's care plan summary for direct care staff (Kardex) indicated a trauma trigger to avoid speaking about diets or weight loss.Resident 11's Kardex did not indicate pain was a trigger for increased depression.Resident 11's Kardex did not indicate the resident had a history of attempted suicide.In an interview, on 7/28/25 at 11:56 AM, the Social Service Director (SSD) indicated each resident was screened for trauma upon admission. The SSD indicated trauma was assessed with either a Psychosocial Assessment or an Abuse and Neglect Screening. The SSD indicated the trauma screening results were added to each resident's care plan according to their PASRR recommendations.On 7/28/25 at 12:11 PM, a Psychosocial Assessment was not documented in Resident 11's record. An Abuse and Neglect Screening was not documented in Resident 11's record.In an interview, on 7/28/25 at 1:55 PM, the Director of Nursing (DON) indicated Resident 11's record did not include a Psychosocial Assessment. The DON indicated Resident 11's record did not include an Abuse and Neglect Screening. The DON indicated each resident should be screened for a history of trauma upon admission.2. On 7/22/25 at 9:40 AM, Resident 17 was observed propelling their wheelchair in the hall. Resident 17 introduced themselves. Resident 17 was smiling and spoke highly of staff members, addressing them by name.In an interview, on 7/23/25 at 11:20 PM, Licensed Practical Nurse (LPN) 4 indicated Resident 17 had a very bad day yesterday. LPN 4 indicated Resident 17 was out with their mom today.Resident 17's record was reviewed on 7/28/25 at 5:57 AM. Diagnoses included cerebral palsy, down syndrome, depression, bipolar disorder, affective mood disorder and impulse disorder.Resident 17's Annual MDS, dated [DATE], indicated their BIMS score was 12 (minimal cognitive impairment). The MDS indicated Resident 17 had depression, bipolar disorder, affective mood disorder, impulse disorder, cerebral palsy, down syndrome and unspecified lack of physiological development in childhood. The MDS indicated Resident 17 did not have anxiety. The MDS indicated Resident 17 had not displayed any disruptive behaviors.Resident 17's PASRR, dated 1/3/25, indicated the resident had a diagnosis of intellectual disability. The PASRR indicated Resident 17 had experienced seeing and hearing things that were not real. The PASRR indicated Resident 17's BIMS score was 7.A Psychosocial Assessment, dated 7/29/24, indicated Resident 17 had increased anxiety. Stressful triggers were rapid movement or contact.A Psychosocial Assessment, dated 8/5/24, indicated Resident 17 had a physical altercation with another resident. Resident 17 became agitated due to their mom not being able to take them home. Stressful triggers were rapid movement or contact.An Abuse and Neglect Screening, dated 7/22/25, indicated Resident 17 had a moderate problem with aggressive and agitated behavior. Resident 17 had a moderate problem with abuse or neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior. Resident 17 had a moderate problem of psychotic symptoms such as delusions, hallucinations, misinterpretation of events or intentions of others. Resident 17 had a moderate problem with denial of mental health and psychosocial issues.Resident 17's care plan, dated 7/26/24, indicated the resident was at risk for psychosocial impairment. The care plan indicated Resident 17 displayed episodes of verbal aggression, physical aggression, repetitive questions, repetitive demands and repetitive calls to their mom. The target goals were to be free from psychosocial complications and to follow the PASRR recommendations through 7/6/25. An identified trigger was Resident 17's mom not answering the phone. Interventions included providing simple and structured activities, administering medications as ordered, providing simple and direct communication and following the PASRR recommendations.Resident 17's care plan did not indicate they had a history of delusions or hallucinations.Resident 17's care plan did not indicate triggers were rapid movement or contact.Resident 17's Medication Administration Record, dated 7/1/25 through 7/31/25, indicated the resident had been administered an antipsychotic medication (haloperidol) injection on 7/14/25 at 4:56 PM.Resident 17's Medication Administration Record, dated 7/1/25 through 7/31/25, indicated the resident had been administered an injection of haloperidol on 7/22/25 at 3:16 PM.A progress note, dated 6/25/25 at 5:40 PM, indicated Resident 17 had been disruptive in the dining room. Resident 17 told staff they did not know why they were upset, then the resident said they had an appointment tomorrow.A progress note, dated 6/25/25 at 6:18 PM, indicated Resident 17 had been swearing and attempting to hit staff members. When the resident was asked why they were upset, the resident said they don't know and then said they have an appointment in the morning.A progress note, dated 7/14/25 at 4:44 PM, indicated Resident 17 had an injection of haloperidol administered due to screaming, swearing, kicking the medication cart, throwing items and grabbing items from the nurse station.A progress note, dated 7/20/25 at 8:59 PM, indicated Resident 17 had been agitated and broke their glasses.A progress note, dated 7/21/25 at 9:53 AM, indicated Resident 17 had been in the lobby yelling and demanding to go to their 2:30 PM medical appointment immediately.A progress note, dated 7/21/25 at 7:30 PM, indicated Resident 17 had been yelling loudly and said they hated the doctor. Resident 17 calmed down after numerous attempts to calm the resident.A progress note, dated 7/22/25 at 8:38 AM, indicated Resident 17's mom had reported the rod in the resident's leg had separated from the bone. Resident 17 was scheduled to have more tests and was referred to the wound clinic.A progress note dated 7/22/25 at 1:10 PM, indicated Resident 17 had been agitated and had bitten a staff member. 3 attempts to redirect the resident were not successful.A progress note, dated 7/22/25 at 4:19 PM, indicated Resident 17's mom was going to transport the resident to an appointment on 7/23/25.Resident 17's Kardex indicated PASRR recommendations should be followed. The Kardex indicated attempts should be made to determine the underlying cause for the behaviors. The Kardex did not indicate Resident 17 had a history of delusions or hallucinations.In an interview, on 7/28/25 at 1:55 PM, the DON indicated Resident 17 could possibly be triggered by upcoming medical appointments. The DON indicated Resident 17 could possibly have medical trauma.A current facility policy, titled Trauma Informed Care, dated 1/26/23, indicated the facility must identify triggers that could possibly re-traumatize residents. The policy indicated residents would be assessed for trauma by observation, interview and the use of screening tools.A current facility policy, titled Behavior Policy, dated 12/26/24, indicated behavioral documentation should be specific. The policy indicated documentation should include the time, duration and frequency of the behaviors. The policy indicated observations of possible triggers for specific behaviors should be included in the documentation.3.1-42(a)(1)

Based on observation, interview and record review, the facility failed to ensure medications were stored and adequately labeled for 1 of 1 medication room observed and 2 of 5 residents reviewed (Resident 3 and Resident 71) Findings include: During an observation, on [DATE] at 10:57 AM, the B wing medication room was observed. In a drawer was an open bag of 30 insulin syringes. The bag had no label to indicate when the pharmacy had sent them to the building and had no expiration date. A separate drawer held three staple removal kits. Two kits had no label to indicate when the facility received the kits and had no expiration date on the kit. One kit had an expiration date of 2-28-25. In a storage container under the shelf, two catheter irrigation kits were observed to be without expiration dates, and no labeling to indicate when the kits had been sent to the facility. In an interview, on [DATE] at 11:24 AM, Registered Nurse (RN)10 indicated she reviewed the medication room each Friday for expired and unlabeled supplies, and pharmacy double checked the room for the audit about every other month. During an observation, on [DATE] at 11:34 AM, Resident 3's Nitroglycerin tablets 0.3mg were open with no open date noted on the label. The date filled on the pharmacy label was [DATE]. In the top drawer, were 2 clear cups with 3 unidentified pills in the top cup and 4 unidentified pills in the bottom cup. the bottom cup was labeled with Resident 71's room number. In an interview, on [DATE] at 11:40 AM, QMA 11 indicated the medications were not set up by him, and the medications should have been discarded. He indicated the nurse on shift prior to his indicated the resident had already left the building for an appointment, so the nurse was unable to administer the medications she had set up. An undated policy titled Medication labeling and storage provided by the Administrator on [DATE] at 2:54 PM indicated under Medication Labeling 5. medications that were opened or accessed would be dated and discarded with 30 days of opening . and 11. Medications would not be transferred between containers . 3.1-25 (j)(m)

Based on observation, interview and record review, the facility failed to ensure a mechanically altered diet was served as ordered for 1 of 12 residents reviewed (Resident 31).Findings include: During a dining observation on the dementia unit, on 07/23/2025 at 12:01 PM, Resident 31 reached into an unattended meal tray cart, partially pulled out a tray, lifted the plate cover, pulled out a bratwurst sausage on a bun and began to eat. The bratwurst was whole and not chopped or ground. Registered Nurse (RN) 10 approached Resident 31 read the tray card, assisted him to the table and placed the remaining items on the tray on the table in front of Resident 31. During an interview, at on 07/23/25 at 12:03 PM, RN 10 indicated the tray served to Resident 31 was prepared for another resident. She indicated it was not an issue because both residents were on the same diet.During an observation, on 07/23/25 at 12:04 PM, RN 10 pulled the tray prepared for Resident 31. The tray contained a bun filled with ground bratwurst. The tray card with Resident 31's name indicated Resident 31 should receive a mechanical soft diet with ground meat.During an interview, on 7/23/25 at 12:05 PM, RN 10 indicated the tray cart should not have been unattended and accessible to Resident 31. She indicated Resident 31's tray card should have been checked prior to serving the tray, and Resident 31 should have received ground meat as ordered.Resident 31's record was reviewed on 07/28/2025 11:26 AM. Diagnoses included dementia and dysphagia. Resident 31's current annual Minimum Data Set assessment, dated 4/13/25, the a Basic Interview for Mental status was not conducted due to Resident 31's inability to make himself understood. The MDS indicated Resident 31 received a mechanically altered diet. A physician's order, dated 8/22/24, indicated Resident 31 should receive a regular diet, double portions with mechanical soft texture. A physician's order, dated 5/22/25, indicated Resident 31's food should be served in individual bowls. Food should given to Resident 31,one bowl at a time. A current care plan titled at nutritional risk indicated Resident 31 was at risk for malnutrition due to dementia and dysphagia and received a mechanical soft textured diet. The care plan had a goal date of 10/12/25. Interventions included serving Resident 31's diet as ordered and providing assistance as needed. A nurses note, dated 07/23/25 at 1:25 PM, indicated Resident 31 ate a hot dog that was not ground up (belonging to another resident) off of the hall cart. A current policy titled Select Menus, undated, indicated nursing staff should check the tray card for to ensure the correct meal is delivered to the correct resident. 3.1-21(a)(3)

Based on interview and record review, the facility failed to ensure a resident received assessment, treatment, and individualized interventions to prevent worsening of a pressure injury to the coccyx. This resulted in the resident developing an unstageable (wound bed is obscured by dead tissues) pressure injury (Resident P). The Immediate Jeopardy began on 1/16/25 when the facility failed to assess an identified pressure injury and provide appropriate treatment and interventions The Administrator, Director of Nursing (DON), Regional Support Nurse and Chief Nursing Officer were notified of the Immediate Jeopardy on April 24, 2025 at 3:49 P.M. The immediate jeopardy was removed on 4/25/25. Findings include: On 4/22/25 at 12:34 P.M., Resident P's family member was interviewed. They indicated the resident resided at the facility from 12/11/24 until 1/21/25 when the family transferred her to another facility due to alleged care issues. Upon admission to the receiving facility, family alleged Resident P was observed with a deep wound on her bottom and her feet were red, swollen, and infected. The wound on the residents bottom was black with green drainage and had to be packed with gauze dressings. The family member indicated she nor other family members were aware of the resident's wound to her bottom or extent of wounds on her feet prior to admission at the receiving facility. The resident passed away on 1/27/25. On 4/22/25 at 1:00 P.M., Resident P's record was reviewed. Diagnoses included dementia with psychotic disturbance, major depressive disorder and chronic obstructive pulmonary disease. A Nurse Practitioner (NP) note, dated 12/12/24, indicated Resident P was seen for initial visit to establish care. The resident came from an inpatient psychiatric hospital after having confusion, hallucinations, and behaviors of walking non-stop with little sleep. She was admitted for long term care on the secured memory care unit. An admission Minimum Data Set (MDS) assessment, dated 12/20/24, indicated the resident had moderately impaired cognition without mood indicators or behaviors. She required set up help for eating, oral hygiene, upper body dressing and personal hygiene. She was independent with bed mobility, ambulation, transfers, and toileting. She was occasionally incontinent of bowel and bladder. She was assessed to not be at risk for developing pressure ulcers, had no current pressure ulcers and was not receiving any skin or ulcer treatments. She had 4 days of occupational therapy (OT) and 5 days of physical therapy (PT) during the assessment period. A skin assessment tool (Braden Scale), dated 12/11/24 at 5:03 p.m., indicated Resident P had no impairment responding to verbal commands and no sensory deficits to limit her ability to feel pain or voice pain; the resident's skin was rarely moist; she was able to walk outside her room [ROOM NUMBER] times per day and in her room at least once every 2 hours while awake; the resident had no limitation with mobility and could make major and frequent changes in position; the resident had a poor appetite and never ate a complete meal; and had no apparent problem moving in bed and while seated, with sufficient muscle strength to lift up completely during a move. The skin assessment tool indicated the resident had no risk for skin impairment. The skin assessment did not indicate the residnet had o skin impairment on admission. Care plans, initiated on 12/12/24, indicated: -Resident was at risk for decline in activities of daily living (ADL). The goal was to maintain her current level of functioning. Interventions included: No staff assist for bed mobility; Use walker during mobility; and 1 staff assist for dressing and bathing. -Resident was at risk for impaired skin integrity. The goal was to remain free of new skin breakdown. Interventions were: Assist resident with turning and repositioning as needed; complete skin inspection every 7-10 days and as needed; encourage good nutrition/hydration and assist as needed; encourage to reposition self if able; encourage/assist as needed to elevate heels off mattress as tolerated; labs per physician order; notify nurse/physician/NP of any new skin breakdown; provide pressure redistribution mattress to bed; and provide a non-irritating surface to reduce friction or shearing forces. -initiated 1/18/25, the resident had a urinary tract infection (UTI) and was at risk for complications. The goal was the UTI would resolve without complications. Interventions were: observe for antibiotic side effects; labs/cultures/diagnostic testing as ordered and report results to physician; and observe for worsening or lack of improvement in signs/symptoms of UTI. A Physical Therapy Progress Report, dated 1/8/25, the resident complained of pain on her feet when standing. She had generalized weakness and unsteady balance while standing. She required moderate assistance with bed mobility, transfers, and walking short distances. A Physical Therapy Discharge Summary indicated the resident received physical therapy services from 12/24 to 1/20/25. The summary indicated the resident's ability to perform bed mobility and transfers had declined due to presence of bilateral heel sores. An Occupational Therapy Progress Report, dated 1/8/25, indicated her functional skills assessment were: maximal assistance with eating and was dependent for toileting hygiene and toilet transfer. An Occupational Therapy Discharge Summary indicated the resident received occupational therapy services from 12/12/24 to 1/19/25. Her functional skills assessment indicated the resident required maximal assistance with eating and toileting transfers and was dependent for toileting hygiene. She declined in toilet transfer performance due to wounds on her feet. A weekly skin observation form, dated 1/1/25 at 12:04 p.m., indicated new foot concerns had been identified. The resident had large purple blisters on both heels. A Braden skin assessment tool dated 1/2/25 at 8:20 a.m., indicated Resident P had slightly limited impairment responding to verbal commands but couldn't always communicate discomfort or need to be turned; the resident's skin was occasionally moist; she was able to walk occasionally for very short distances and spent the majority of each shift in bed or chair; the resident had slightly limited mobility and could make frequent though slight changes in her body and extremity position independently; the resident's nutrition was probably inadequate as she rarely ate a complete meal and protein intake was only 3 servings per day; and had a potential problem for friction and shear due to moving feebly and requiring minimum assistance. During a move, skin probably skid against surfaces and she occasionally slid down while in bed or seated in a chair. The skin assessment tool indicated the resident was at risk for skin impairment. A Wound Nurse Practitioner's skin and wound note, dated 1/2/25 at 4:12 p.m., indicated Resident P was seen for skin and wound consultation. The resident was at the facility for rehabilitation and got around in a wheelchair. The resident had no history of a chronic wound or pressure ulcer. She had 2 new blisters to both heels. Physical examination indicated the resident had out of bed mobility with use of a wheelchair; she was awake and alert; confused at baseline. The resident had no lower extremity swelling (edema); had urinary incontinence; and intact skin with no open wounds. Wound assessment: Right heel had a stage 2 (Partial thickness loss of skin; may present as an intact or open/ruptured blister) pressure injury which measured 5 centimeters (cm) by 4 cm and was covered with 100% epithelial tissue (skin in the final stage of healing). The left heel had a stage 2 pressure injury measuring 4 cm by 4 cm, covered with 100% epithelial tissue. Treatment was to cleanse both heels with wound cleanser daily, followed by application of Skin Prep to base of the wounds and left open to air. Preventative treatments and recommendations were to apply moisturizer to resident's skin daily but not massage over bony prominences. The resident was to wear proper fitting footwear to prevent/minimize unwanted pressure and friction. The resident was incontinent and moisture barrier creams were to be provided after thorough skin care for each incontinent episode. The resident was at increased risk of skin breakdown and would recommend good hygiene and skin care to prevent skin breakdown. The wound NP recommended to continue with moderate assistance with adl's as needed; application of emollients daily; skin kept clean and dry; barrier cream as necessary; and avoidance of pressure on bony prominence by adhering to turning protocols and floating heels. The care plan on 1/2/25 was not updated to indicate changes in Resident P's condition with development of pressure injuries to both heels; decreased ability to walk; decreased ability to make major, frequent changes to her position; increased moisture due to incontinence and need for thorough skin care after each incontinent episode followed by application of barrier creams; need for interventions to address positioning and sliding down in bed or chair; and need for turning protocols. The care plan was not updated to include interventions reflected from the 1/2/25 skin (Braden) assessment and the 1/2/25 Nurse Practitioner findings. A nutrition/dietary note, dated 1/3/25 at 10:17 a.m., indicated the Interdisciplinary team (IDT) had met. Resident P had blisters to both heels; PT and OT were working with the resident; and there were no dietary recommendations. An IDT note, dated 1/3/25 at 1:58 p.m., indicated the wound NP had evaluated the resident on 1/2/25 and new orders received to cleanse wounds to both heels with wound cleanser followed by skin prep and leaving heels open to air. The resident was to wear foot booties while in bed to help protect her heels. Nursing staff were to monitor and update as needed. The care plan was not updated on 1/3/2025 to indicate the need to foot booties for heel protection. A weekly skin observation form, dated 1/8/25 at 9:16 a.m., indicated Resident P's skin was observed to be warm and dry with fair skin turgor. She had no foot concerns and her skin was intact without skin problems. A Wound NP skin and wound note, dated 1/9/25 at 5:14 P.M., indicated Resident P was seen for skin and wound consultation. Wounds to her heels were stable and staff were to continue Skin Prep daily to her heels. During the visit, she was assessed for reported redness to her buttocks which upon exam, was not observed. Staff were to continue use of protective creams. Wound assessment indicated the right heel remained a stage 2 pressure injury measuring 5 cm by 4 cm and covered with 100% epithelial tissue (tissue lining the surface of the wound). The left heel remained a stage 2 pressure injury measuring 4 cm by 4 cm and covered with 100% epithelial tissue. The documentation did not include the wound contained dead tissue. Treatment was to continue with with cleansing the heels with wound cleanser daily followed by application of Skin Prep to base of wounds and heels left open to air. Preventative treatments and recommendations were unchanged: staff were to apply moisturizer to resident's skin daily but not massage over bony prominences; the resident was to wear proper fitting footwear to prevent/minimize unwanted pressure and friction; and moisture barrier creams were to be applied after thorough skin care for each incontinent episode. The resident remained at increased risk of skin breakdown and recommendations remained to continue with moderate assistance with adl's as needed; application of emollients daily; skin kept clean and dry; barrier cream as necessary; and avoidance of pressure on bony prominence by adhering to turning protocols and floating heels. A physician order, dated 1/9/25, was for Triad Hydrophilic wound dress external paste (wound dressing) to be applied to buttocks topically every shift for redness. A Treatment Administration Record (TAR), dated January 2025, indicated by nurse initials, Triad Hydrophilic wound dressing was applied, as ordered, from 1/9/25 until 1/21/25. A change in condition form (SBAR), dated 1/11/25 at 8:11 a.m., indicated the resident had increased urinary incontinence and complained of burning and pain with urination. The form indicated the resident had no skin impairment. An order was received to obtain a urinalysis and culture to check for infection. A urine sample was collected on 1/11/25 and received by the lab on 1/14/25. The medical NP reviewed the results on 1/17/25 and ordered an antibiotic-Levofloxacin 500 milligrams (mg) by mouth, 1 time per day for urinary tract infection. A weekly skin observation form, dated 1/15/25 at 10:27 a.m., indicated Resident P's skin was observed to be warm and dry with good skin turgor. She had skin concerns to her right and left heels which were not new. The form indicated the resident had stage 2 pressure injuries to both heels but hadn't indicated measurements or description of the wounds. A Wound NP skin and wound note, dated 1/16/25 at 6:40 p.m., indicated Resident P was seen for skin and wound consultation. The resident's blisters to her right and left heels were flattened and firm to touch. Wound assessment indicated the right heel remained a stage 2 pressure injury measuring 5 cm by 4 cm and covered with 100% epithelial tissue. The left heel remained a stage 2 pressure injury measuring 3 cm by 3 cm and covered with 100% epithelial tissue. Treatment was to continue with with cleansing the heels with wound cleanser daily followed by application of Skin Prep to base of wounds and heels left open to air. Preventative treatments and recommendations were unchanged: staff were to apply moisturizer to resident's skin daily but not massage over bony prominences; the resident was to wear proper fitting footwear to prevent/minimize unwanted pressure and friction; and moisture barrier creams were to be applied after thorough skin care for each incontinent episode. The resident remained at increased risk of skin breakdown and recommendations remained to continue with moderate assistance with adl's as needed; application of emollients daily; skin kept clean and dry; barrier cream as necessary; and avoidance of pressure on bony prominence by adhering to turning protocols and floating heels. The progress note hadn't indicated condition of the resident's bottom; if there was new or continued redness to the area as reported on 1/9/25. A Pressure assessment form, dated 1/16/25 at 6:59 a.m., indicated the type of assessment was a weekly status report and not a new skin concern. The resident had a pressure injury to her coccyx, acquired in-house. There was no drainage or signs of infection and the wound bed and skin around the wound bed were intact. The wound had well defined edges and shape and the form was marked as unchanged in status. There were no measurements of the wound completed. A physician order, dated 1/16/25 at 11:00 p.m., was for Calmoseptine cream (Moisture barrier that prevents and Helps heal skin irritations from urine, diarrhea, perspiration or wound drainage) to be applied, every shift and as needed, for an open area on the coccyx. The resident was to be turned side to side with pillows to hold the resident in place and turned side to side every 2 hours. A TAR, dated January 2025, indicated by nurse initials, Calmoseptine cream had been applied as ordered on 1/16/25 through 1/21/25. There was no further documentation of the coccyx wound in the medical record. The care plan was not updated to indicate Resident P had developed a open pressure injury to her coccyx or the interventions put into place to prevent worsening of the wound until the day of discharge. A Discharge Instruction form, dated 1/21/25 at 9:55 a.m., indicated the resident was being discharged to another facility on 1/21/25 at 10:30 a.m. She was to be transported to the receiving facility by the receiving facilities transportation van. Her skin condition on discharge, indicated Resident P had a pressure injury to her right and left heels. The form hadn't indicated wound measurements, stage of wounds, nor treatments for the wounds. There were no other forms or notes to indicate the resident had any other wounds or open areas. A Discharge/Transfer/LOA note, dated 1/21/25 at 11:55 a.m., indicated the resident was being discharged to another facility on 1/21/25 at 11:00 a.m. Records from the receiving facility, were reviewed on 4/23/25 at 2:25 P.M., and indicated Resident P arrived to the receiving facility via their transportation van and nursing summary completed on 1/21/25 at 10:25 a.m. A nurse note, dated 1/21/25 at 12:45 p.m., indicated the resident was alert and oriented to self, president, year and knew she was at a new facility but unsure of the name. She was wheelchair bound and had heel protector boots with her sent from the transferring facility. Skin assessments were completed and indicated the follow wounds were identified: -1/21/25 at 2:56 p.m., right heel wound, black in color, measured 4.8 cm by 3.7 cm. -1/21/25 at 2:59 p.m., left heel wound, black in color, measured 3.3 cm by 2.9 cm. -1/21/25 at 3:02 p.m., an extensive, large and deep wound was observed to the coccyx area. The wound was unstageable and covered with 100% slough with surrounding tissue colored black, blue, and red. The wound had a strong foul odor and measured 5 cm by 3.6 cm and depth was unable to be determined due to slough covering the wound. The family was present and observed the wounds and were shocked at the extensive wounds on her heels and had no knowledge she had a wound on her bottom. The medical NP reviewed the wound assessment and pictures of the wounds and ordered treatment with Dakins solution (anti-septic containing diluted bleach), packing the wound followed by application of 4 x 4 dressing which was to be completed daily and as needed. On 1/23/25, in collaboration between the receiving facility's Medical Director and medical NP, a full assessment was completed which indicated the resident had been admitted to the facility with wounds. She was experiencing increased lethargy. New orders were given to administer Rocephin (antibiotic) intramuscularly STAT, start an IV for fluids, obtain labs, and STAT chest x-ray. A medical NP note, dated 1/23/25 at 8:35 p.m., indicated the resident had wounds which were suspected to have underlying infection. A medical NP note, dated 1/27/25 at 9:08 a.m., indicated the resident was lethargic and not speaking. Her coccyx wound was open and seeping foul, green/brown drainage. She had been on Rocephin and Bactrim (antibiotic). Her prognosis was guarded. Her coccyx wound was infected and she was referred to the wound clinic and was being followed by the facility wound NP. She was at high risk of decline and sepsis. A nurse note, dated 1/27/25 at 4:05 p.m., indicated the resident had passed away. On 4/23/25 at 9:56 A.M., Registered Nurse (RN) 5 from the sending facility was interviewed. She indicated Resident P had been prescribed Triad paste for her coccyx and at some point, had been changed to Calmoseptine but was unable to remember dates changed. When asked, she indicated a wound could be viewed through Triad paste and the resident's coccyx was observed daily. She was not aware of an open area being on the resident's coccyx. On 4/23/25 at 4:02 P.M., the Administrator from the sending facilitywas interviewed. She indicated, Resident P did not have an open wound on her bottom. When questioned about the order gotten on 1/16/25 for Calmoseptine, she repeated there was no open area and the nurse who obtained the order, was no longer employed at the facility. On 4/24/25 at 10:17 A.M., the wound NP from the sending facility was interviewed. She indicated she had last viewed Resident P's bottom/sacral/coccyx area on 1/9/25 after being told of redness on the residents bottom. She and the Unit Manager (UM) observed the residents bottom and saw no redness. She ordered Triad Hydrophilic wound dress external paste (wound dressing) to be applied to buttocks topically every shift for redness and protection. She indicated she had not been notified an open area had been found on the resident's coccyx on 1/16/25 or a new order had been given for Calmoseptine. When asked, the wound NP indicated Triad paste was white and non-transparent. The paste had to be removed with wound cleanser and re-applied. When asked if a wound could be viewed through the paste, she indicated absolutely not. Calmoseptine was pink in color and was required to be removed with wound cleanser and re-applied. Manufacturer's instructions for Calmoseptine indicated to use the cream around wounds and to not use the cream on deep wounds as a moisture barrier. Manufacturer's instructions Triad indicated the wound dressing be used for open wound with light exudate (drainage) and as a debriding (removal of dead skin) agent. There were no other pressure assessment forms or pressure tracking available for review. On 4/24/25 at 10:50 A.M., Certified Nurse Aide (CNA) 2 from the sending facility was interviewed. She indicated she provided care to Resident P during the day shift, Monday through Thursdays. When asked what kind of care the resident required, CNA 2 indicated it was all hands on care and she required assistance of 2 staff for transfers due to weakness and wounds on her heels. She indicated the resident used to have a pink cream applied to her bottom but hadn't been used recently prior to her discharge. When asked, she indicated she cared for the resident on 1/13, 1/14, 1/15, and 1/16/25 and 1/20 and 1/21/25. She had not seen any pink cream on the resident's bottom while providing incontinent care on those days. She indicated she toileted the resident approximately every hour and a half because the resident felt she had to go. On 1/21/25, she had another CNA assist her to transfer the resident onto the shower chair after breakfast, and she provided the resident's shower prior to her discharge. She indicated she saw some slight redness on her bottom but no open sores. On 4/24/25 at 12:35 P.M., the Director of Nursing (DON) and Unit Manager (UM) at the receiving facility were interviewed. They indicated Resident P arrived to their facility on 1/21/25 at 10:25 a.m. via their facility transport van. She arrived in a transport wheelchair which appeared small and was immediately transferred to a different wheelchair. She had been groggy but interacted with family present. She was in the wheelchair until after lunch and then put to bed. Skin assessments were completed at the times provided in their records. The UM indicated surprise when she assessed the wound on her coccyx because she nor the DON had been made aware of the wound prior to admission. The wound was extensive and deep. It was located on her coccyx right above the crack of her buttocks which was very dry. There was no barrier cream or paste observed on her buttocks or wound. The wound was black and covered with eschar (dead skin) and had a foul odor. The eschar appeared sunken and was not flush with the surrounding skin. When asked, the UM indicated the coccyx wound was not hidden in skin folds and had been immediately observed and smelled upon removal of her brief. Pictures of the wound on her coccyx and right and left heels were taken in addition to an area of redness and swelling on her left earlobe and all areas measured and documented. The medical NP, present in the facility, reviewed the pictures of the wounds and gave orders for Dakins solution, pack the wound and cover with a dressing. Both indicated the resident had increased lethargy, abnormal labs, and worsening of the wounds. She passed away on 1/27/25. Manufacturer's instructions for Dakins solution indicated to use on wounds with light to moderate drainage as a debriding agent. On 4/24/25 at 1:41 P.M., the Medical NP at the receiving facility was interviewed. She indicated she had not been aware of any diagnosis or condition the resident had which would have caused her skin breakdown. She observed pictures of the wounds, spoke with the resident and her family and ordered treatment to the wound on 1/21/25 and completed a full assessment with the Medical Director on 1/23/25. A current policy, titled Skin and Wound Management was provided by the DON on 4/24/25 at 11:57 A.M. indicated:Risk Assessment: Assess the resident on admission (within eight hours) .Inspect the skin on a daily basis when performing or assisting with personal care or ADL's .Identify any signs of developing pressure injuries (i.e., non-blanchable redness) .Inspect pressure points (sacrum, heels, buttocks, coccyx, etc) .Monitoring: Evaluate, report and document potential changes in the skin; Review the interventions for effectiveness on an ongoing basis .Assessment and Recognition .the nurse shall describe and document/report the following .pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; mobility status; current treatments including support surfaces; and all active diagnoses .the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing .dressings, and application of topical agents The Immediate Jeopardy that began on 1/21/25 was removed and the deficient practice corrected on 4/25/25 when the facility re-educated all licensed nurses on facility policies for Pressure ulcers/Skin breakdown, clinical protocol, prevention, assessment and wound staging, but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Citation relates to Complaints IN00457597, IN00457901 and IN00457935. 3.1-40

Based on observation, interview and record review, the facility failed to ensure ceiling return air ducts were free from debris for 3 of 10 vents observed. Findings include: During an environmental tour on 1-24-25 at 11:01 AM, the following was observed: On Hall 100 south of the dining room, the ceiling air intake had gray, feathery debris. On Hall 100 on the memory unit, the ceiling air intake had gray, feathery matter in strings across the grate. On Hall 100 by nurse's station, the ceiling air intake had gray feathery matter on the grate. In an interview on 1-24-25 at 11:21 AM, the Administrator indicated the ceiling air intake vents should be free of debris. A review of an undated Deep Clean List, provided by the Administrator on 1-24-25 at 11:32 am, did not indicate the ceiling air intakes should be cleaned. This citation is related to complaint IN00448990. 3.1-19(e)

Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment, evaluation and non-pharmacological approaches were identified and implemented, prior to decreasing a resident's anti-psychotic medication prescribed to treat behavior symptoms for 1 of 2 residents reviewed (Resident B). Findings include: An Indiana reported incident, dated 8/28/24 at 6:01 p.m., indicated Resident B was agitated while walking around in the dining room of the secured memory care unit (MCU), had thrown silverware at staff and then threw herself onto the floor. She was sent to the hospital and treated for a right hip fracture. On 9/24/24 at 2:35 P.M., Resident B was observed lying in bed in her room. She was confused but articulate and appeared to enjoy visiting. She indicated she had retired from a state hospital, had spent most of her life caring for children with mental illness and had always been a caregiver. When asked, she denied pain; she indicated some female doctor had cut open her hip and she had a huge wound. She was irritated with the doctor who operated on her because she hadn't spoken directly to her and hadn't come to see her since the surgery. She hadn't sounded angry but indicated she was leaving this place today because all she was doing was lying in bed and that wasn't her. She wasn't getting therapy and was caring for herself so believed she didn't need to be here and could go home. On 9/24/24 at 10:24 A.M., Resident B's record was reviewed. Diagnoses included, dementia with behavioral disturbances, anxiety disorder, and severe malnutrition. The resident had been hospitalized , prior to admission, with worsening confusion and fractured left ankle. A hospital note, dated 8/21/24 at unknown time, indicated the resident was seen for a psychiatric consult. The psychiatric physician indicated he had seen the resident during a previous hospital stay on 6/25/24 for evaluation of confusion and psychosis. At the time, she presented with cognitive impairment, visual hallucinations and paranoid delusions. On 7/30/24, the physician indicated he declared she hadn't the capacity to make decisions. She was tried on a low dose of Risperdal (anti-psychotic) without clear benefit so was started on Zyprexa 5 milligrams (mg) by mouth at bedtime approximately 2 weeks prior. She was hospitalized again on 8/16/24 for confusion, failure to thrive, poor appetite and not eating/drinking. He met with the resident and asked about her previous hallucination and paranoid delusion regarding strangers at home. She indicated nobody had bothered her recently. Psychiatric problems were: Personality disorder from 2013 to present time; major neurocognitive disorder due to multiple etiologies with psychotic and behavioral disturbance from 6/25/24 to present; and major depressive disorder from unknown time to present. Current psychiatric medications were: Pristiq (anti-depressant), Gabapentin (used for chronic pain), Hydroxyzine (sedating anti-histamine), and Zyprexa (an antipsychotic) 5 mg at bedtime. -Assessment and Recommendations: Resident presented with cognitive impairment, disorientation, poor memory, confabulation (memory error causing person to create false or distorted memories), reduced executive functioning and impaired judgement. She was, again, determined unable to make decisions about her health care based on cognitive impairment, poor self care and poor insight. She was to continue on Zyprexa 5 mg at bedtime for psychosis. It was recommended she be discharged to a memory care unit for dementia care. A nurse note, dated 8/24/24 at 6:18 p.m., indicated the resident had arrived to the facility with her family. She had a fractured left ankle with a boot in place for comfort when weight bearing. She complained of some pain in her shoulders and right arm and had a scabbed area over her left elbow from a previous fall. A physician order, dated 8/24/24 at 8:00 p.m., was for Zyprexa 5 mg by mouth at bedtime for schizophrenia [sic]. A Baseline Care Plan Meeting, dated 8/26/24 at unknown time, indicated a meeting was held with staff. Resident B's daughter attended by phone. Prior to her admission to the facility, she had lived by herself at home using a wheelchair for mobility, but since her hospitalization , her daughter believed she may require long term placement. The resident's goal was to remain in the facility as she was doing well, was adjusting to her roommate, socializing and participating in activities. Her cognitive assessment, indicated she had moderately impaired cognition. The resident smoked but would only do so when her daughter was present. Her medications were reviewed and indicated the resident was prescribed as-needed [sic] antipsychotic medication. According to her family, she could become verbally aggressive with them. There was no documentation of non-pharmaceutical interventions or behavioral health interventions put in place to be used in addition to antipsychotic medications to treat her behaviors. There was no documentation to indicate the need to decrease her antipsychotic medication at the time nor documentation of the daughter's knowledge of the plan to decrease the medication or agreement to do so. A Social Service note, dated 8/27/24 at 12:13 p.m., indicated a Gradual Dose Reduction (GDR) meeting was held to discuss the resident's use of anti-psychotic medication (Zyprexa). It was determined the dose should be reduced and a new order was received, per the Psychiatric NP, to decrease the dose of Zyprexa from 5 mg to 2.5 mg at bedtime for 14 days, then discontinue the medication. A nurse note, dated 8/28/24 at 5:11 p.m., indicated Resident B had been agitated, walking around in the dining room, wearing only socks, carrying a cup of coffee. She kept going back and forth to the beverage cart, attempting to pour a peer some coffee. Staff attempted to re-direct her without success. She was observed to yell at and throw silverware at staff and then threw herself to the floor. The resident immediately complained of pain to her right leg when on the floor. She was transported to the hospital where she was admitted for a fractured right hip. She underwent surgical repair of the hip fracture and returned to the facility on [DATE]. She was readmitted to a rehabilitation room not located on the secured MCU. A Medication Administration Record (MAR) dated August 2024 and initiated 8/26/24, indicated behaviors to be tracked for use of antipsychotic medication on each shift was delusions. There were no delusions documented on 8/26, 8/27, or 8/28/2024. On 9/2/24, Resident B's re-admission orders included, Zyprexa 5 mg by mouth at bedtime for dementia with behavioral disturbance. Behaviors of delusions were tracked on the MAR dated September 2024. On 9/4/24, during the evening shift, the resident had 4 delusions but there no other delusions documented through 9/23/24. The MAR hadn't indicated the resident had other behaviors which were to be monitored. A care plan, initiated 9/3/24, indicated the resident was at risk for impaired psychosocial well-being due to impaired cognition, sensory deficits, communication deficits, and displayed episodes of wanting to elope. She had behaviors of believing she was at a resort or country club. She had behaviors of flailing her arms, kicking, pinching, and spitting at staff, throwing herself on the floor while trying to be assisted, throwing dishes and silverware at staff; physical and verbal aggression towards staff; and making false accusations against others. Interventions included: monitor and document episodes of inappropriate behaviors and notify the NP when behaviors persist or won't deescalate; monitor behavior episodes and attempt to determine underlying cause. On 9/6/24 at an unknown time, a letter from Resident B's daughter was received by the facility. The letter indicated a request to have no further reductions made in the resident's psychotropic medications due to a history of catastrophic psychiatric reactions in prior attempts at medication reductions. A psychiatric NP note, dated 9/10/24 at unknown time, indicated the resident engaged in conversation but was easily distracted. Staff reported an increase in her behaviors of verbal and physical agitation not easily redirected. She was currently prescribed Zyprexa to be increased to target her increased symptoms. Her mental status exam indicated she was frail, underweight, oriented with impaired judgement and insight. She was anxious but had no delusions or hallucinations. The assessment and plan was to continue use of Pristiq for depression and increase the dose of Zyprexa from 5 mg at bedtime to Zyprexa 2.5 mg by mouth 2 times per day and Zyprexa 5 mg by mouth at bedtime. Resident B's baseline care plan didn't indicate she was prescribed Zyprexa to treat psychosis, delusions and hallucinations. There was no documentation of indications for withdrawing the antipsychotic medication nor non-pharmaceutical interventions put in place prior to decreasing the dose. There was no documentation to indicate the resident's family member had been notified and approved of the decrease in the use of Zyprexa. Hospital psychiatrist notes, dated 8/21/24, indicated Zyprexa was necessary to continue treatment for her delusions, hallucinations, and psychosis. The psychiatrist had treated the resident during prior hospital stays in June, July, and August 2024 and was familiar with her mental health needs. Progess notes, dated 8/28/24, indicated Resident B was at the facility for 4 days when she became agitated, wanting to help a fell ow peer, and acted out by throwing herself on the floor sustaining a hip fracture. Progress notes, dated 9/2/24 through 9/24/24, indicated Resident B returned to the facility, was placed in a non-secured room, and was prescribed the initial dose of Zyprexa 5 mg by mouth at bedtime. Since return from the hospital, she was reported to have behaviors of verbal and physical aggression towards staff and dose of Zyprexa increased to a total of 10 mg per day-double the initial dose. On 9/24/24 at 11:22 A.M., the Director of Nursing (DON), Regional Nurse Consultant (RNC), Social Service Director (SSD) and psychiatric NP were interviewed. The SSD and psychiatric NP indicated they were trying to see if the resident's dose of Zyprexa could be decreased hence the change in dosage. The psychiatric NP indicated information from the hospital had not been available to her prior to the attempted GDR and she had not seen the resident until after her fall and hospitalization . She indicated she had attempted to visit the resident but the resident had been asleep and wouldn't wake up to speak with her. There was no documentation to indicate the resident had been excessively sedated or attempts had been made to visit and evaluate the resident. The RNC indicated the Interdisciplinary team (IDT) hadn't determined the resident's fall had been due to a decrease in her medication however, her behaviors may have escalated due to the decrease in Zyprexa as well as being newly admitted to the facility. A current facility policy, titled Medication Management Psychotropic Agents was provided by the Administrator, on 9/24/24 at 11:00 A.M., and stated: The psychotropic medication regimen will be managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being in compliance with federal guidelines .A comprehensive regimen review will ensure the following regarding psychotropic agents .4. Gradual dose reductions must be assessed for appropriateness .5. Time frames and duration of attempts to taper any medication must be consistent with accepted standards of practice Standards of Practice for Behavioral/Psychological symptoms of Dementia was retrieved on 9/24/24 from psychiatryonline.org which indicated the following recommendations of the American Psychiatric Association: Patients with dementia should be assessed for the type, frequency, severity, pattern, and timing of symptoms; patients should be assessed for pain and other modifiable contributors to symptoms; patients with dementia with agitation or psychosis should have response to treatment assessed with a quantitative measure; patients should have a documented comprehensive treatment plan with appropriate person-centered nonpharmacological and pharmacological interventions .for patients who have shown a positive response to treatment, decision making about possible tapering of antipsychotic medication should be accompanied by a discussion with the patient (if clinically feasible) as well as with the patient ' s surrogate decision maker (if relevant) with input from family or others involved with the patient. The aim of such a discussion is to elicit their preferences and concerns and to review the initial goals, observed benefits and side effects of antipsychotic treatment, and potential risks of continued exposure to antipsychotic's, as well as past experience with antipsychotic medication trials and tapering attempts; for patients who show adequate response of behavioral/psychological symptoms to treatment with an antipsychotic drug, an attempt to taper and withdraw the drug should be made within 4 months of initiation; for patients with dementia whose antipsychotic medication is being tapered, assessment of symptoms should occur at least monthly during the taper and for at least 4 months after medication discontinuation to identify signs of recurrence and trigger a reassessment of the benefits and risks of antipsychotic treatment . This Citation refers to Complaint IN00442157. 3.1-37

Based on record review and interview the facility failed to ensure the qualified/registered dietician was licensed in Indiana. This deficient practice had the potential to affect 70 of 70 residents in the facility who received dietary services. Findings include: The employee records were reviewed on 8/18/24 at 11:40 AM. The employee records indicated Registered Dietician (RD) 6 was hired by the facility on 6/1/2024. Review of the Indiana Professional Licensing Agency website on 8/19/24 at 11:53 AM indicated, effective 7/1/2019, Dieticians would receive licensures instead of certifications through the Medical Licensing Board of Indiana. RD 6's undated resume indicated she provided Dietician coverage for Long Term Care/Rehabilitation facilities as needed remotely through a nationwide dietician staffing service since 4/2024. The RD 6's resume indicated she was a RD/Licensed Dietician/Nutritionist in the states of North Carolina, South Carolina, and Florida. On 8/19/24 at 11:55 AM the Indiana Professional Licensing Agency website, 2024, was used to search for and verify RD 6's license. No current Indiana Registered Dietician license was found for RD 6. In an interview on 8/19/24 at 11:45 AM, the Administrator indicated according to federal regulations the facility's registered dietician must be licensed or certified as a dietitian or nutrition professional by the State in which the services are performed unless the State does not provide certification or licensure. A current policy titled, Food and Nutritional Services, dated 11/2021, provided by the Director of Nursing on 8/19/24 at 12:18 PM, indicated a qualified dietician or other clinically qualified nutrition professional was one who .was licensed or certified as a dietician/nutritional professional in the State their services were performed unless the State does not provide certification or licensure. No current Indiana Registered Dietician license was provided for RD 6 by survey exit.

Based on observation interview, and record review the facility failed to ensure fall interventions were recorded and communicated for 1 of 6 residents reviewed (Resident 67). Findings include: Resident 67's record was reviewed on 8/13/24 at 11:48 AM. Diagnoses included Alzheimer's disease, major depressive disorder, and unilateral primary osteoarthritis, right hip. Resident 67's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was not conducted as he was rarely if ever able to make himself understood. The MDS indicated Resident 67 required assistance with activities of daily living and had fallen since admission to the facility. An admission fall risk assessment dated [DATE] indicated Resident 67 had fall risk factors including disorientation, 1-2 falls in the past 3 months, incontinence, decreased muscular coordination, use of medications that had side effects including drowsiness and dizziness, recent medication changes, and diagnoses predisposing a fall risk. A document titled Initial Occurrence Note dated 5/18/24 at 4:43 PM indicated Resident 67 was found lying on the floor after being seen walking toward the garden room. No fall interventions were recorded at the time of the fall. An interdisciplinary team (IDT) note dated 5/20/24 at 5:01 PM indicated an intervention of orienting Resident 67 to surroundings should be added. An IDT note dated 5/21/24 at 12:58 PM indicated an intervention of ensuring non-skid footing was in place. A document titled Initial Occurrence Note dated 6/23/24 at 6:40 AM indicated Resident 67 fell . No description of the fall or interventions added were available for review. A document titled Initial Occurrence Note dated 6/30/24 at 10:00 AM indicated Resident 67 was standing in the dining room with his hands on the back of a chair when he suddenly fell to the left landing on his left shoulder and arm. An intervention was assisting the Resident 67 to bed and lowering the bed to the floor. An IDT note dated 7/1/24 indicated staff should ensure proper footing when ambulating. A document titled Initial Occurrence Note dated 7/5/24 at 7:53 AM staff heard a noise in the dining room and found Resident 67 on the floor. An IDT note dated 7/8/24 at 4:25 PM indicated staff was educated on keeping the area bright, ensure toileting is completed, and offering snacks at bedtime. A document titled Initial Occurrence Note dated 7/26/24 at 5:00 PM indicated Resident 67 was walking in the dining room when he bent over to pick something up, lost his balance and fell . An IDT note dated 7/29/24 at 10:44 AM indicated staff should assist resident when bending over to pick items up off the floor. A document titled Initial Occurrence Note dated 8/9/24 at 2:30 PM indicated Resident 67 was found sitting on the floor of another resident's room. The intervention initiated was to assist the resident to lie down in his room. An IDT note dated 8/12/24 at 1:36 PM indicated Physical and Occupational therapy were initiated for weakness. During an observation and interview on 8/15/24 at 11:57 AM, Certified Nurse Aide (CNA) 11 indicated staff instructions for care of each resident were found in a book marked ADLS (activities of daily living), located in a cabinet in the pantry area of the dementia unit dining room. The book included printed care plan forms with care plan goal dates of 2022. The Dementia Care Director (DCD) indicated most of the care plans in the book were for residents no longer residing on the unit. She did not know why the book had not been updated. Resident 67's care plan was not found in the book. CNA 11 and the Dementia Care Director were not aware of any other place instructions for care for CNAs were located and accessible to the CNA staff. A document titled Visual Bedside Kardex provided by the Assistant Director of Nursing on 8/15/24 at 12:28 PM indicated Resident 67 had safety precautions including encouraging him to lay in his bed and not in the middle of the floor or sidewalk. A mat to the floor beside the bed while in bed was an additional intervention. No other interventions were listed. Resident 67's current Care plan titled .at risk for impaired safety/injury .indicated the resident had a problem of a risk for falls, with a goal date of 9/16/24. Interventions included the following: 1. Distract resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, book, etc. 2. Encourage resident to avoid secured doorways to avoid injury when staff are entering and exiting unit; periodically re-evaluate need for secured unit. 3. Keep bed in lowest position 4. Mat to floor at bedside while in bed. 5. Refer to psychiatrist/psychologist/behavior specialist. No additional interventions were listed. During an interview on 3/18/24 at 3:18 PM, the Director of Nursing (DON) indicated a new intervention should be put in place immediately after post fall care (vital signs, assessments, first aid, if applicable) has been provided for a resident who had fallen. Interventions should be passed on verbally in report, added to the care plan and the Kardex (document for CNAs detailing individual care interventions). A current policy, undated, titled Falls Management and Fall Risk provided by the Chief Nursing Officer indicated each resident will have a person-centered fall care plan. The fall care plan should be reviewed at a minimum of quarterly, post fall, annually and with significant changes. The policy indicated the fall care plan should address both prevention of falls as well as when applicable, specific interventions in response to a fall occurrence. The policy indicated staff should implement additional or different interventions. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a shared glucometer was cleaned between uses for 3 of 12 residents reviewed (Resident 19, Resident 29, and Resident 30). Findings include: During a medication pass observation on 8/16/24 at 8:37 AM, Licensed Practical Nurse (LPN) 9 removed a glucometer (handheld device designed to measure blood glucose levels), lancet (small needle designed to poke the skin to produce a drop of blood), a test strip, and an alcohol swab from the top drawer of the medicine cart on the 300-hall of the C-wing. LPN 9 entered the room of Resident 19, cleaned her finger with an alcohol swab, obtained a drop of blood, applied it to the test strip inserted in the glucometer and obtained a reading. After the test, LPN 9 placed the glucometer in the top drawer of the cart, completed her documentation, and proceeded to prepare medications for the next resident who required medicine at that time. The glucometer was not cleaned before or after use. Upon completion of the medication pass observation, the medicine cart for the 300 hall of the C-wing was inspected. The glucometer in the top right drawer was the only glucometer in the cart. LPN 9 indicated that glucometer was used for all the residents on the 300- hall requiring blood glucose monitoring. She indicated it should be cleaned with a disinfectant wipe for 3 minutes before and after each use. She thought another employee had cleaned it earlier and did not give a reason for not cleaning it after use. A document titled Glucometers, provided by the Director of Nursing on 8/16/24 at 12:32 PM indicated Resident 19, Resident 29, and Resident 30 used the glucometer in the 300-hall medication cart. Resident 19's record was reviewed on 8/16/24 at 1:04 PM. Diagnoses included type 2 diabetes without complications, chronic kidney disease, stage 4, and hypothyroidism. Resident 19's current significant change Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 7 (cognitively impaired). Physician orders dated 5/9/24 indicated Resident 19's blood sugar should be checked twice daily. Resident 29's record was reviewed on 8/16/24 at 12:02 PM. Diagnoses included type 2 diabetes without complications, end stage renal disease, and acute respiratory failure, unspecified whether hypoxia or hypercapnia. Resident 29's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 13 (cognitively intact). Physician's orders dated 3/5/22 indicated a glucometer check should be performed twice daily. Resident 30's record was reviewed on 8/16/24 at 11:28 AM. Diagnoses included type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, acute on chronic diastolic (congestive) heart failure. Resident 30's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). Physician orders dated 5/23/24 indicated blood glucose readings were needed to determine need for insulin coverage at mealtimes. In an interview on 8/16/24 at 10:19 AM, the Administrator indicated the glucometer should be cleaned before and after each use to prevent cross contamination. A current policy dated 6/11/24 provided by the Administrator on 8/16/24 at 9:46 AM indicated blood glucometers intended for reuse are cleaned and disinfected between use with a disinfectant. An undated document titled Medical and Commercial Disinfecting wipes provided by the Administrator indicated a wipe must keep the device thoroughly wet for 2 minutes to ensure disinfection. 3.1-18(a)

Based on observation, interview, and record review the facility failed to ensure flooring panels were complete and intact for 1 of 24 residents reviewed (Resident 11). Findings include: During an observation on 8/13/24 at 9:51 AM, an approximately 15 inch by 30 inch area of floor paneling was missing in front of the heating unit and near the end of Resident 11's bed. One floor panel was lying loose across a small portion of the uncovered area. Resident 11's record was reviewed on 8/14/24 at 9:49 AM. Diagnoses included multiple sclerosis, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and type 2 diabetes mellitus without complications. Resident 11's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). During an observation and interview on 8/13/24 at 12:16 PM, Registered Nurse (RN) 4, and Certified Nurse Aide (CNA) 5 and CNA 6 indicated they were not aware of the floor damage until that observation. CNA 5 indicated it likely just happened since one piece of flooring was lying in the middle of the patch of missing flooring. She was unable to identify where the other missing floor panels were located and indicated the additional damage must have happened at an earlier time. She indicated floor damage should be reported to maintenance immediately. During an observation and interview, on 8/13/24 at 12:18 PM, Maintenance 3 indicated this was the first he heard of floor damage. During an interview on 8/13/24 at 1:34 PM, the Administrator indicated floor damage should be reported through the facility maintenance system as soon as the damage is found. She indicated she was not aware the floor panels were missing until today. A Document titled Point Click Care Dashboard, dated 8/13/24, provided by the Administrator on 8/13/24 at 3:10 PM indicated staff should use an application called tells to generate a work order to notify maintenance staff of any concerns. She indicated this system was the facility's current method of communication regarding maintenance issues and there were no additional facility policies available for review. 3.1-19(a)(4)

Based on interview and record review, the facility failed to notify the Power of Attorney of a significant change in condition for 1 of 3 residents reviewed for notification (Resident C). Findings include: An Indiana report, dated 1/16/24, indicated Resident C had been sent to the hospital on 8/15/23 for a life threatening condition. The resident's POA (Power of Attorney) indicated the hospital had received no clinical information from the facility regarding the resident including his advanced directives or POA. They alleged an ICU (Intensive Care Unit) nurse was finally able to contact them the morning after he was transferred to the hospital after reviewing the resident's previous hospitalization s and POA contact information. On 2/2/24 at 2:27 P.M., Resident C's record was reviewed. Diagnoses included demyelinating disease of the central nervous system and neuromuscular dysfunction of the bladder. His face sheet indicated he was responsible for himself and had a family contact phone number listed. The face sheet did not have a POA listed nor their contact information. A quarterly MDS (Minimum Data Set) assessment, dated 7/3/23, indicated the resident had no cognitive impairment. He had an indwelling catheter and was always incontinent of bladder. An NP (Nurse Practitioner) progress note, dated 8/14/23, indicated the NP had tried to contact the resident's POA regarding the resident and had left a message for the POA to return her call. A nurse progress note, dated 8/15/23 at 10:27 p.m., indicated the resident complained of discomfort and leakage of urine. Unsuccessful attempts were made to flush his indwelling catheter . The NP was notified and an order was reveived to change the resident's catheter. When the old catheter was removed, there were blood clots on the catheter. The new catheter was inserted and urine returned. When the bulb of the catheter was inflated, the resident complained of pain so the catheter was removed. -At 10:48 p.m., the nurse called the NP and a family member. A physician order, dated 8/15/23 at unknown time, indicated it was okay to send the resident to the ER for evaluation and treatment. A nurse progress note, dated 8/16/23 at 5:32 a.m., indicated the hospital ER nurse called the facility to find out the resident's code status was and contact for the POA. A social services progress note, dated 8/16/23 at 5:04 p.m., indicated the resident had been transferred to the hospital, but the resident had been unable to sign the bed hold policy at the time. The note indicated the resident was responsible for himself and did not have a POA. The record contained no information regarding the resident's POA. The record indicated the resident was able to make daily decisions on his own but had a POA for when he was unable to do so. On 2/5/24 at 2:45 P.M., the Administrator indicated staff had searched the resident's records and found the resident's POA paperwork in the billing department. She indicated the resident's record should have listed the resident's POA and contact information. She indicated the POA should have been notified of his change in condition on 8/15/23. On 2/7/24 at 1:05 P.M., the Administrator provided a current copy of the facility policy titled Notification of Resident's Change in Condition which stated the following: Policy: To ensure that the facility immediately informs the resident; consults with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical, mental, and/or psychosocial status .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when .There is a significant change in the resident's physical, mental, or psychosocial status .It is necessary to transfer the resident to a hospital/treatment center The tag relates to Complaint IN00426219. 3.1-(a)(2)

Based on interview and record review, the facility failed to provide information to the hospital upon transfer for 1 of 3 residents reviewed. (Resident C). Findings include: An Indiana report, dated 1/16/24, indicated Resident C had been sent to the hospital on 8/15/23. The resident's POA (Power of Attorney) indicated the hospital had received no clinical information from the facility regarding the resident including his advanced directives or POA. On 2/2/24 at 2:27 P.M., Resident C's record was reviewed. Diagnoses included demyelinating disease of the central nervous system and neuromuscular dysfunction of the bladder. A nurse progress note, dated 8/15/23 at 10:27 p.m., indicated the resident complained of discomfort and leakage of urine. Unsuccessful attempts were made to flush his indwelling catheter. The NP (Nurse Practitioner) was notified and ordered to change the resident's catheter. When the old catheter was removed, there were blood clots on the catheter. The new catheter was inserted and urine returned. When the bulb of the catheter was inflated, the resident complained of pain so the catheter was removed. A review of progress notes, dated between 8/15/24 through 8/16/23 at 5:32 a.m., did not indicate bedhold or transfer paperwork had been given to the family.The record contained no information sent to the receiving hospital regarding need for emergency treatment, the resident's legal representative, advanced directive information, mental and functional status, recent vital signs, diagnoses, medications and when last given, drug allergies, and most recent labs and other diagnostic tests. On 2/5/24 at 1:17 P.M., the Administrator was interviewed. She indicated the facility usually used a transfer form to communicate information to the hospital or other provider residents are transferred to. She was unable to locate a transfer form for Resident C. On 2/5/24 at 1:48 P.M., the Administrator provided a current copy of the facility policy titled Transfer and Discharge Requirements which stated: Documentation: When the facility transfers or discharges a resident under any of the circumstances, the facility will ensure the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving institution or provider .3. Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident. b. Resident representative information including contact information. c. Advance Directive information. d. All special instructions or precautions for ongoing care, as appropriate. e. Comprehensive care plan goals. f. All other necessary information, including a copy of the resident's discharge summary and any other documentation, as applicable, to ensure a safe and effective transition of care. The tag relates to Complaint IN00426219. 3.1-12 (a)(3)

Based on interview and record review, the facility failed to appropriately transfer a resident who required the extensive assistance of two staff members. One staff member transferred the resident from chair to the bed using a bear hug and a short time later the resident was observed lying in bed with her foot/leg in an unnatural position facing the left leg, which resulted in the resident found with a right femur compression fracture for 1 of 3 residents reviewed for accident hazards. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/15/22 at 11:00 A.M. The resident's diagnoses included, but were not limited to, unspecified protein-calorie malnutrition, unspecified dementia with behavioral disturbance, disorder of bone density and structure, abnormal weight loss, and age-related [CONDITION(S)] without current pathological fracture. A progress note, dated 8/29/22, indicated the facility staff heard the resident yelling and they opened the resident's door. The staff observed the resident lying in bed, the bedding was off, and her right leg was in an unnatural position with her foot pointed to the left leg. They observed a discoloration (black), resident's right foot was cool to touch, and they were unable to obtain a pedal pulse. The staff notified the NP, DON, resident's sister, and called 911. An annual Minimum Data Set (MDS) Assessment, dated 8/25/22, indicated the resident required the extensive assistance of two staff members with transferring. A current care plan, dated 2/11/21, indicated The resident required two staff members physical assistance for transferring. The employee statements were provided by the Administrator on 9/15/22 at 12 P.M. The statements indicated the following: On 8/30/22, CNA (Certified Nurse Aide) 2 indicated CNA 3 had asked CNA 2 to assist with putting Resident B to bed. CNA 2 arrived in the resident's room and she was in her chair. CNA 2 indicated she helped put Resident B into bed and CNA 3 finished providing care. CNA 3 asked CNA 2 if Resident B was combative with care, CNA 2 indicated yes and to put the resident's hand on the bedrail when turning her. CNA 2 exited the room. On 8/30/22, CNA 3 indicated she took Resident B to her room, started to undress her and the resident was being combative. CNA 3 then asked CNA 2 for assistance. CNA 3 indicated CNA 2 picked up Resident B by herself and sat her in the bed. Resident B turned herself and laid down herself. CNA 2 instructed CNA 3 how to roll her and where to place her hand. CNA 3 placed her bed in lowest position, pulled up the covers and resident appeared to be falling asleep. On 8/29/2b2, LPN (licensed Practical Nurse) 4 indicated at 5 PM, Resident B was sat upright in her geri-chair fully clothed. The LPN assisted Resident B with dinner in the dining room. She then brought the resident out of the dining room and sat her beside the fish tank. Resident B's legs were in a sitting position with knees evenly bent. On 8/30/22, CNA 7 indicated he had assisted with ADL (activities of daily care) approximately at 6:30 P.M. and did not notice anything out of the ordinary. After performing ADL care, CNA 7 transferred the resident to her wheelchair without any complications. The statement did not indicate any other staff assisted with the transfer. On 9/7/22, QMA (Qualified Medication Assistant) 6 indicated she had observed CNA 2 and CNA 3 enter Resident B's room together. After a few minutes CNA 2 exited the room and shut the door while CNA 3 remained in the room. The resident was not screaming at the time. The QMA went to check on Resident B and observed her leg, she knew something was wrong, and notified LPN 4. During an interview on 9/15/22 at 11:30 A.M., the Administrator indicated on the evening, of 8/29/22, CNA 2 and CNA 3 had assisted Resident B into bed. CNA 3 asked CNA 2 if the resident was usually combative, CNA 2 indicated yes, but if you help her place her arm on the bedrail she would be able to hold onto the rail. CNA 2 then exited the room. CNA 3 had placed her hand on the resident's hip to assist with rolling. The resident did not indicate any sign of injury at the time. CNA 3 continued to provide care and placed the resident's bed in lowest position and exited the room. Staff had heard Resident B screaming and the staff had then went in to check on the resident. The staff indicated the resident was in bed and they observed a fracture/displacement of Resident B's hip. The nurse was then called into the room to assess the resident and then the hospital was called. The Administrator also indicated he thought the pressure placed on the resident's hip during care could have been too much. During an interview on 9/15/22 at 2:04 P.M., the DON indicated Resident B had fallen a couple days prior to 8/29/22, but the resident had no injuries. On the evening of 8/29/22, CNA 3 and CNA 2 transferred the resident into bed around 7:00 P.M., then CNA 2 exited the room and the resident was in a natural position. CNA 3 provided care and then left the room. At approximately 7:30 P.M. the staff overheard Resident B screaming. CNA 2 and LPN 4 walked into the resident's room and found her in an unnatural position. She had interview multiple staff, but all the stories were different. During an interview on 9/15/22 at 2:33 P.M., LPN 4 indicated she had assisted Resident B with dinner on 8/29/22 and the resident ate well. After dinner she had sat the resident in her wheelchair by the nursing station and went on a 15-minute break. She had returned from break and went to assist with another resident when she heard Resident B screaming. She went to check on Resident B with CNA 2. She observed the resident's gown and blanket off, the resident was holding onto her loose brief and grimacing. She went to reach for the resident's gown and observed the resident's foot was in an abnormal position. The back of the resident's knee was discolored and her foot was cool to touch. She called the NP and was instructed to send the resident to the emergency room (ER). She had told the Emergency Medical Services (EMS) that the resident was lying in bed and was found to have her foot/leg in an unnatural position facing the left leg. Resident B had fallen forward out of her wheelchair a couple days prior, but no injuries were noted. During an interview on 9/15/22 at 2:47 P.M., CNA 2 indicated on the night of 8/29/22, CNA 3 had asked CNA 2 for assistance with Resident B. She had transferred resident by bear hugging her, unsure on time, by herself. CNA 3 had asked her if it was normal for Resident B to be combative, CNA 2 indicated yes, but the resident would help with rolling if you placed her hand onto the side rail. CNA 3 indicated she then left the room, unsure of time. She later heard Resident B yelling, She and QMA 6 entered the room and observed Resident B's legs in a deformed position. She had then asked LPN 4 to observe the resident. During an interview on 9/15/22 at 4:35 P.M., the emergency room Charge Nurse 8 indicated on 8/29/22, Resident B was sent to the hospital due to the resident found in bed with a hip deformity per the facility. The story was inconsistent with the injuries observed. The physician's note, dated 8/29/22, indicated Resident B had a comminuted intertrochanteric right femur fracture with posterior lateral angulation (bone broken into 3+ pieces, compression fracture). The ER Charge Nurse was unable to provide any additional information. A corrective action form, dated 9/6/22, was provided by the Administrator on 9/15/22 at 12:00 P.M. The formed indicated CNA 2 had failed to provide a safe transfer for Resident B. During an interview on 9/15/22 at 5:17 P.M., CNA 2 indicated a proper transfer would not include a bear hug. A proper transfer included a gait belt and two staff lifting on each side of the resident. During an interview on 9/15/22 at 5:17 P.M., QMA 9 indicated a proper transfer for a resident who required extensive- total assistance would require two staff. The resident's wheelchair would be place close to the bed with wheels locked. Each staff would place their arms under the resident's arms on each side and grab the back of their pants and then pivot. The facility did not use gait belts. During an interview on 9/15/22 at 5:20 P.M., the Administrator and Regional Nurse indicated CNA 2 transferred Resident B by herself and should not have. The proper transfer would have included a 2-person transfer. An incident report, dated 8/29/22, was provided by the Director of Nursing (DON) on 9/15/22 at 10:00 A.M. The preliminary reports from the hospital indicated Resident B had a right femur fracture. The follow-up report, dated 9/1/22, indicated the investigation was completed. All staff were interviewed, and statements were received. The DON, Administrator and Regional Nurse had re-enacted the scenario based on the information gathered and was unable to determine the cause of the injury. The follow-up report, dated 9/3/22, indicated additional information was provided. The information provided indicated injury could have occurred while transferring the resident from the wheelchair to the bed. The NP also provided the facility information which indicated the resident had a diagnosis of osteopenia with a prior fracture from 3/2021. The staff were educated on proper transferring/ activities of daily living care and the resident's care plan was updated. A policy, titled Activities of Daily Living, dated 11/1/20, was provided by thee Administrator on 9/16/22 at 5:43 PM. The policy indicated . this policy is a guideline only. Each resident has his or her own set of circumstances which may require this policy not to be followed. The needs of each resident supersede the policy. The facility corrected the deficient practice prior to the beinginning of the current survey, on 9/9/2022, after completeding review of all residents, care plans, progress notes; staff education; monitoring; and clinical competency validations. This Federal tag relates to Complaint IN 595 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to follow CDC (Center for Disease Control) guidance during a pandemic and implement an infection control program to properly prevent/contain COVID-19. The facility failed to cohort and establish a red zone for COVID-19 positive residents, failed to cohort 4 COVID-19 positive residents (Resident B, Resident D, Resident F and Resident H) separately from 4 residents not testing positive (Resident C, Resident E, Resident G, and Resident J), and failed to implement PPE (Personal Protective Equipment) doffing and cleaning prior to exiting a room in TBP (Transmission Based Precautions) (CNA 1), to prevent the spread of COVID-19 in 2 of 2 wings (B-wing and C-wing) which included 4 of 6 halls (B-wing Hall #2, B-wing Hall #3, C-Wing Hall #1 and C-wing Hall #3). This deficiency affected 16 of 88 residents. (Resident B, Resident C, Resident D, Resident, E, Resident F, Resident G, Resident H, Resident J, Resident K, Resident L, Resident M, Resident N, Resident O, Resident P, and Resident Q) The immediate jeopardy began on 8-4-21 when Resident B tested positive for COVID-19 on 8-4-21. Resident C remained in the same room, despite testing negative on 8-4-21. Resident C continued to remain in the same room and subsequently tested positive for COVID-19 on 8-11-21. The Regional Director of Operations, the Director of Clinical Services, the Chief Operating Officer (COO), and the ADON (Assistant Director of Nursing) were notified of the immediate jeopardy on 8-11-21 at 4:28 p.m. The immediate jeopardy was removed, and the deficient practice corrected on 8-13-21 at 12:45 p.m. Findings include: 1. During an initial observation of the facility on 8-11-21 at 11:30 a.m., the following was observed: In B-wing, Hall #2, rooms 117, 118, 120, 124, 126 and 128 had TBP and donning/doffing instructions posted on the doors with PPE containers located outside the rooms. In B-wing, Hall #3, room [ROOM NUMBER] had TBP and donning/doffing instructions posted on the door with a PPE container located outside the room. In C-wing, Hall #1, rooms [ROOM NUMBERS] had TBP and donning/doffing instructions posted on the doors with PPE containers located outside the rooms. In C-wing, Hall #3, rooms [ROOM NUMBER] had TBP and donning/doffing instructions posted on the doors with PPE containers located outside the rooms. On 8-11-2021 at 1:30 p.m., the Director of Clinical Services provided a resident room list and identified the residents who were positive for COVID-19 and the date the residents tested positive. This list included residents not testing positive for COVID-19, but on TBP due to being recently admitted to the facility. The following rooms were identified with COVID-19 positive residents: room [ROOM NUMBER] - 2 residents room [ROOM NUMBER] - 1 resident positive and 1 newly admitted resident with a negative COVID-19 test on 8-11-2021. room [ROOM NUMBER] - 2 residents room [ROOM NUMBER] - 1 resident room [ROOM NUMBER] - 2 residents room [ROOM NUMBER] - 2 residents room [ROOM NUMBER] - 1 resident room [ROOM NUMBER] - 1 resident room [ROOM NUMBER] - 1 resident room [ROOM NUMBER] - 1 resident The following rooms were identified as yellow rooms with newly admitted residents in TBP: room [ROOM NUMBER] - 1 resident room [ROOM NUMBER] - 1 resident room [ROOM NUMBER] - 1 resident 2. Resident B tested positive for COVID-19 via a rapid test on 8-4-21. Resident C remained in the same room, despite testing negative on 8-4, 8-5, and 8-9-21. He subsequently tested positive for COVID-19 on 8-11-21. (Documentation was lacking in Resident C's record to indicate the resident was asked by facility staff about moving out of the room.) Resident D tested positive for COVID-19 via a rapid test on 8-9-21. Resident E remained in the same room, despite testing negative on 8-9-21. He subsequently tested positive for COVID-19 on 8-11-21. Resident F tested positive for COVID-19 via a rapid test on 8-9-21. Resident G was admitted to the facility on [DATE] at 10:00 a.m., from home, was unvaccinated, and her COVID-19 status was unknown. Resident G was placed in TBP in the same room as Resident F and continued to remain in the same room. Resident H tested positive for COVID-19 via a rapid test on 8-9-21. Resident J remained in the same room, despite testing negative on 8-9-21. He subsequently tested positive for COVID-19 on 8-11-21. 3. During an observation on 8-11-21 at 12:12 p.m., CNA 1 (Certified Nurse Aide) donned a gown, performed hand hygiene, then donned gloves and entered room [ROOM NUMBER]. The room had TBP signage on the door. At 12:16 p.m., CNA 1 was observed to exit room [ROOM NUMBER]. She had doffed her gown and gloves in the room but maintained wearing the same mask and goggles she wore into the room. The CNA then went and entered room [ROOM NUMBER] without changing her mask or changing/disinfecting her goggles. room [ROOM NUMBER] was identified as a room not needing TBP. During an observation on 8-11-21 at 12:10 p.m., Nurse 2 was observed to don a gown and gloves. She had a N95 mask and goggles already donned. She was observed then to enter room [ROOM NUMBER] for Resident N (a room identified with contact and droplet precaution signs) to administer medication. A few minutes later, the Nurse 2 came out of the room without the gown and gloves. The nurse indicated she disposed of the gown and gloves in the resident's room and washed her hands. Nurse 2 was asked about her N95 mask and goggles, and she indicated she wore the same mask/goggles throughout her shift. room [ROOM NUMBER] was in C-wing Hall #1 and there were 2 residents without TBP in this hall and 2 residents with their rooms in the yellow zone with TBP for COVID-19. An updated state line listing was provided by the Director of Clinical Services on 8-13-2021 at 11:46 a.m. and indicated from 8-4-2021 through 8-11-2021, there were 14 residents and 9 staff who tested positive for COVID-19. (This was the 3rd state line listing provided by the Director of Clinical Services. The first was on 8-11-2021 at 3:37 p.m. and the second was provided on 8-13-2021 at 11:24 a.m.) Conflicting COVID-19 positive date information on the state line list versus the initial resident by room list provided on 8-11-2021 at 1:30 p.m., indicated Resident B's positive date was 8-5-21 instead of 8-4-21, Resident K's positive date was 8-4-21 instead of 8-9-21, Resident N's positive date was 8-4-21 instead of 8-9-21, and Resident P's positive date was 8-5-21 instead of 8-4-21. The following positive 9 staff and 14 residents information was taken from the state line list provided by the Director of Clinical Services on 8-13-21 at 11:46 a.m. On 8-4-21, the DON (Director of Nursing) had signs and symptoms of a headache and tested positive for COVID-19 with a rapid test. The facility then tested the residents and staff for COVID-19 with a rapid test. On 8-4-21, Resident N had no signs and symptoms, tested positive for COVID-19, and was quarantined in room [ROOM NUMBER] in C-wing Hall #1 without a roommate. On 8-4-21, Resident K had no signs and symptoms, tested positive for COVID-19, and was quarantined in room [ROOM NUMBER] in B-wing Hall #2 without a roommate. On 8-5-21, Resident P tested positive for COVID-19 and was quarantined in room [ROOM NUMBER] in C-wing Hall #3, without a roommate. [MEDICATION(S)] 600 mg (milligrams) 2x a day for 30 days was ordered on 8-5-21 for congestion for Resident P. An interview with Nurse 3 on 8-12-21 at 9:58 a.m., indicated Resident P had body aches and chest congestion when he tested positive on 8-5-21. On 8-5-21, Resident B had no signs and symptoms, tested positive for COVID-19, and was quarantined in room [ROOM NUMBER] in B-wing Hall #2 with Resident C, who tested negative for COVID-19 on 8-9-21. Resident C remained in room [ROOM NUMBER]. On 8-9-21, CNA 5 had signs and symptoms of fatigue and tested positive for COVID-19. On 8-9-21, Staff 6 had signs and symptoms of fatigue and tested positive for COVID-19. On 8-9-21, Resident H had no signs and symptoms, tested positive for COVID-19, and was quarantined in room [ROOM NUMBER] in B-wing Hall #2 with Resident J, who tested negative for COVID-19 on 8-9-21. On 8-9-21, Resident F had no signs and symptoms, tested positive for COVID-19, and was quarantined in room [ROOM NUMBER] in B-wing Hall #2 with Resident G, who tested negative for COVID-19 on 8-9-21. Resident G remained in room [ROOM NUMBER]. On 8-9-21, Resident Q had no signs and symptoms, tested positive for COVID-19, and was quarantined in room [ROOM NUMBER] in C-wing Hall #3, without a roommate. On 8-9-21, Resident D had no signs and symptoms, tested positive for COVID-19, and was quarantined in room [ROOM NUMBER] in B-wing Hall #2 with Resident E, who tested negative for COVID-19 on 8-9-21. Resident E remained in room [ROOM NUMBER]. On 8-10-21, Nurse 7 had no signs and symptoms and tested positive for COVID-19. On 8-10-21, CNA 8 had no signs and symptoms and tested positive for COVID-19. On 8-10-21, the Administrator had no signs and symptoms and tested positive for COVID-19. On 8-10-21, Resident O had signs and symptoms of a headache, fever and a cough and tested positive for COVID-19. Resident O was quarantined in room [ROOM NUMBER] in C-wing Hall #3 On 8-10-21, Staff 9 had no signs and symptoms and tested positive for COVID-19. On 8-11-21, Resident L had signs and symptoms of a cough and shortness of breath, tested positive for COVID-19 and was quarantined in room [ROOM NUMBER] in B-wing Hall #3 with Resident M. On 8-11-21, Resident M had no signs and symptoms and tested positive for COVID-19. Resident M was quarantined in room [ROOM NUMBER] in B-wing Hall #3 with Resident L. On 8-11-21, Resident E had no signs and symptoms and tested positive for COVID-19. Resident E was quarantined in room [ROOM NUMBER] in B-Wing Hall #2 with Resident D who had tested positive on 8-9-21. On 8-11-21, Resident J had no signs and symptoms and tested positive for COVID-19. Resident J was quarantined in room [ROOM NUMBER] in B-wing Hall #2 with Resident H, who tested positive for COVID-19 on 8-9-21. On 8-11-21, Resident C had no signs and symptoms and tested positive for COVID-19. Resident C was quarantined in room [ROOM NUMBER] with Resident B who tested positive for COVID-19 on 8-5-2021. On 8-11-21, Staff 10 had no signs and symptoms and tested positive for COVID-19. On 8-11-21, Staff 11 had signs and symptoms of congestion and tested positive for COVID-19. On 8-12-21, another resident with signs and symptoms of a cough tested positive for COVID-19 and was quarantined in room [ROOM NUMBER] in C-wing hall #3. room [ROOM NUMBER] was next to room [ROOM NUMBER] and across from room [ROOM NUMBER], which had positive COVID-19 residents. The rest of the 9 residents in this hall were not in TBP. The state line list indicated no signs and symptoms for this resident when reported. During the entrance conference with the Regional Director of Operations, Chief Operating Officer, the Director of Clinical Services and the ADON on 8-11-21 at 11:32 a.m., it was explained when the new Named company began at the beginning of August, the new electronic system was not completely in place as the resident information from the previous electronic system did not transfer. The group indicated the residents' records were currently being transferred to the new electronic system and staff had been documenting resident information on paper forms until the transition and training was complete. The ADON (Assistant Director of Nursing) indicated since the change in ownership, they were unable to access the reporting systems for COVID-19 positive residents and staff as their email had changed. An interview with the Regional Director of Operations on 8-11-21 at 2:50 p.m., indicated the Named company assumed ownership of the facility on 8-1-21 and he returned today to assist after the Administrator tested positive for COVID-19 on 8-10-21. He indicated Resident F, who had been vaccinated, and had lacked signs or symptoms of COVID-19, was tested on [DATE] with a rapid test and was positive. He indicated the facility had just conducted PCR tests for the variant on 8-11-21 for Resident F and were waiting for the results. Resident F's roommate, Resident G was admitted to the facility on [DATE] at 10:00 a.m. Resident G was not vaccinated, had no signs or symptoms of COVID-19, and was placed in quarantine with Resident F. Resident G had a negative rapid test for COVID-19 done on 8-9-21. The Regional Director of Operations indicated Resident G was tested again on 8-11-21 and was negative. Resident G was moved out of the room she shared with Resident F on 8-11-21 in the afternoon. The Regional Director of Operations indicated he did not want to move residents because the move would be detrimental to the residents' psychosocial state and could spread the virus to the whole house. He indicated moving the residents around would encounter bigger problems. During the Immediate Jeopardy notification with the Regional Director of Operations, the Director of Clinical Services, the Chief Operating Officer and the ADON on 8-11-21 at 4:48 p.m., the ADON indicated the facility was bed locked and did not have the ability to move the COVID-19 positive residents to one area. The Regional Director of Operations indicated the most recent guidance from the State indicated they were not to move a resident without signs and symptoms and who tested positive for COVID-19 with the rapid test, until a PCR test was completed to confirm the positive status. He indicated there were no residents who had any signs and symptoms of COVID-19 when they tested positive with the rapid test. The Chief Operating Officer indicated the most recent guidance from the State indicated the facility did not have to create a COVID-19 unit. On 8-12-21 at 9:18 a.m., the Regional Director of Operations indicated he had the most recent COVID-19 LTC (Long Term Care) facility infection control guidance SOP (Standard Operating Procedure) updated by the state on 7-23-21. He indicated the facility was following the guidance on page 6, if an asymptomatic resident tested positive on an [MEDICATION(S)] (rapid) test, they were to be placed in TBP and not moved to a COVID-19 unit unless they had a confirmatory positive on a PCR test. He indicated the facility tested all the COVID-19 positive residents with a PCR test and they were not going to move the residents until the results of the PCR tests were back. The Regional Director of Operations was asked about the length of time the facility waited to do the PCR testing, as the first resident tested positive on 8-4-21, and he indicated they wanted to get the PCR tests which would test for the variant. He indicated he didn't know how long it would take the state to come to the facility with the PCR test which would test for the variant, so he opted to get an independent company to come and perform the PCR tests. He indicated the independent company did the PCR testing with the variant yesterday (8-11-21) and they were waiting on results. He indicated if the residents' results were positive, then the facility would implement their emergency plan and create a COVID-19 unit. An observation on C-wing Hall #3 on 8-12-21 at 9:58 a.m., indicated an additional room had TBP signage on the door, room [ROOM NUMBER]. This room was next to room [ROOM NUMBER] and across the hall from room [ROOM NUMBER]. Each of those 3 rooms had a resident positive for COVID-19. An interview with Nurse 3 at this time, indicated the resident in room [ROOM NUMBER] tested positive this morning and had signs of a cough without a fever. The nurse indicated this resident spent a lot of time with Resident N, who tested positive for COVID-19 on 8-4-21. Nurse 3 indicated the resident in room [ROOM NUMBER] was tested frequently and was negative until this morning. The nurse indicated Resident Q in room [ROOM NUMBER] tested positive for COVID-19 on 8-9-21 and had no symptoms until 8-11-2021. Resident Q's symptoms were congestion and a cough. The nurse indicated Resident P in room [ROOM NUMBER] had body aches and chest congestion when he first tested positive for COVID-19 on 8-5-21. Nurse 3 indicated Resident O in room [ROOM NUMBER] had a fever and pneumonia when she tested positive on 8-10-21. An interview with CNA 4 on 8-12-21 at 10:08 a.m., indicated in C-wing Hall #1, Resident L was moved from B-wing to room [ROOM NUMBER] yesterday, 8-11-21, as she was positive for COVID-19. CNA 4 indicated Resident G was moved from B-wing to a C-wing Hall #1 room [ROOM NUMBER] on 8-11-21 due to being exposed to the COVID-19 virus from her roommate. On 8-12-2021 at 12:53 p.m., the Regional Director of Operations and the ADON indicated Resident L had signs and symptoms of shortness of breath and a cough when she tested positive on 8-11-21. (The state line list provided by the Director of Clinical Services on 8-13-2021 at 11:46 a.m., indicated for Resident O, Resident P, and Resident L, signs and symptoms, N for no was entered, when all three residents had signs and symptoms when they tested positive for COVID-19.) A review of Resident O's nurse's notes on 8-12-21 at 3:00 p.m., indicated on 8-9-21 at 5:00 p.m., the resident complained of a headache and not feeling well. The notes indicated the resident did not have a fever and denied any shortness of breath or difficulty breathing. Tylenol 500 mg (milligrams) 2 tabs were administered with good effect. On 8-10-21 at 3:00 a.m., the resident complained of a severe headache, difficulty breathing and shortness of breath. Resident O's temperature was 99.5 degrees Fahrenheit and oxygen saturations were 83%. The NP (Nurse Practitioner) was notified and orders were received to administer [MEDICATION(S)] (an inhaler) every 6 hours prn (as needed), oxygen at 2 LPM (liters per minute) via N/C (nasal cannula) for oxygen saturations < 90. The nurse administered another COVID-19 test related to symptoms and was positive. On 8-10-2021 at 2:30 p.m., a chest X-ray was ordered and stat CMP and CBC (blood tests). Orders for [MEDICATION(S)] 600 mg by mouth 2 times a day x 14 days, Robitussin 15 milliliters every 8 hours for 3 days, then every 8 hours as needed x 14 days, oxygen as needed to titrate to keep oxygen saturations >92% were received. On 8-10-21 at 11:05 p.m., orders for [MEDICATION(S)] (an antibiotic) 250 mg, administer 2 tabs tonight, then 1 tab daily for 4 days and for [MEDICATION(S)] (antibiotic) 1 gram IM (intramuscular) daily x 3 days with first dose tonight were received. On 8-12-21 at 4:00 p.m., no additional COVID-19 positive residents had been moved and the facility had not provided any information regarding a removal plan. The current community transmission rate during the survey time period was listed as high from the CDC COVID-19 Data Tracker at https://covid.cdc.gov/covid-data-tracker/#county-view and the positivity rate for the county was 18.12% through 8-12-21. Upon arrival to the facility on [DATE] at 9:00 a.m., the National Guard was present (2 members) and indicated they had brought COVID-19 tests to the facility and would be testing today. An interview with the Director of Clinical Services indicated she had not checked to see if the results of the COVID-19 PCR tests from 8-11-2021 had been posted from the independent lab. An interview with the DON on 8-13-2021 at 9:01 a.m., indicated the COVID-19 positive residents had been moved to a COVID unit. An observation of B-wing Hall #2 with the DON on 8-13-2021 at 9:05 a.m., indicated from room [ROOM NUMBER] to the end of the hall, was a dedicated COVID-19 unit. There was a zippered wall and a PPE container outside the zippered wall. The DON indicated there were 15 residents in the unit and the COVID-19 unit had dedicated staff. An interview with the Director of Clinical Services on 8-13-2021 at 12:44 p.m., indicated the test results were beginning to come for the 8-11-21 PCR tests and most were positive. A Clinical Questions about COVID-19: Questions and Answers updated March 4, 2021 was obtained at the following web address, https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html and indicated .If a nursing home is concerned about a false-positive [MEDICATION(S)] test result, what confirmatory test should be performed .In most instances, CDC guidance currently recommends performing confirmatory testing when asymptomatic individuals are [MEDICATION(S)] positive .Use nucleic acid amplification tests (NAAT), such as reverse-transcriptase polymerase chain reaction (RT-PCR), as the confirmatory test .Optimize sensitivity of the confirmatory test by collecting a high-quality specimen .Perform the confirmatory test within 2 days of the initial test A current facility policy, COVID-19 LTC Infection Control Standard Operating Procedures dated 7-1-21, was provided by the COO on 8-11-21 at 1:30 p.m. The policy indicated .Identify dedicated employees to care for COVID-19 resident and provide infection control training .Cohort confirmed or presumed COVID-19 positive residents .Cohort, if possible, direct care providers caring for confirmed or presumed COVID-19 residents into one area of the building. Staff should be dedicated for the COVID unit .All LTC facilities, should have a plan to rapidly implement, or implement now, how they will cohort confirmed or presumed COVID-19 residents in their facilities. This can be by wing, floor, or if available, by building. This should be done with expediency. Residents should be cohorted depending on COVID-19 status. Colors can be used on facility maps to help visualize results to facilitate moving of residents .COVID-19 positive (red)- These are residents who are confirmed COVID-19 positive and who, based on CDC criteria, still warrant transmission-based precautions (TBP). Health care providers (HCP) will wear single gown with each resident, gloves, N95 mask and eye protection. These residents should be placed in TBP (droplet and contact) and cohort into a COVID-19 wing, floor, or building .For any resident who tests negative for COVID-19, but has had a roommate who is positive, it is not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test. They should be placed in TBP contact droplet and the positive resident moved to the COVID unit .Infection control steps when health care worker or resident test positive for COVID-19-facilities should follow the CDC guidelines for health care workers and personnel protective equipment. Cohort staff and equipment for COVID-19 residents to minimize transmission in the building A current facility policy, Long-term Care Facilities Guidelines in Response to COVID-19 vaccination, dated 8-11-21, was provided by the COO on 8-11-21 at 1:30 p.m. The policy indicated .New admissions or Readmissions: The CDC allows for options that may include placing the resident in a single-person room in general population area or in a separate observation area so the resident can be monitored for evidence of COVID-19 The Immediate jeopardy that began on 8-4-21 was removed and the deficient practice corrected on 8-13-21 when the facility created the COVID-19 unit to cohort the COVID-19 positive residents, moved a resident who tested negative for COVID-19 to another private room as the roommate had tested positive for COVID-19, provided dedicated staff to care for the positive COVID-19 residents and educated staff on correct use of PPE. 3.1-18(a) 3.1-18(b)(1) 3.1-18(b)(2) 3.1-18(b)(4)

Based on observation, interview and record review the facility failed to ensure timely interventions were in place to prevent weight loss for 1 of 1 resident reviewed for nutrition. This resulted in severe weight loss (8% in 30 days) for the resident. (Resident 43) Findings include: The Clinical record of Resident 43 was reviewed on 10/21/19 at 1:24 P.M. [DIAGNOSES REDACTED]. The resident's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was not interviewable and required assistance of 1 person to eat. The care plan dated 9/26/19, indicated the resident was at risk for alteration in nutritional status related to wears dentures, [MEDICAL CONDITION] and stroke with weakness. The goal was the resident's weight be maintained within 5 pounds of current weight. Thde interventions include the following: The care plan was updated 9/26/19 with intervention of diet as ordered and weigh and monitor as indicated. The care plan was updated 10/8/19 with the diet change to a regular puree. The Nurse's Note indicated the following: On 8/24/19 at 6:05 P.M., the resident was transported by EMS (Emergency Medical System)to the hospital. On 8/31/19 at 12:53 [NAME]M.: Resident 43 had returned from the hospital with a new [DIAGNOSES REDACTED]. On 8/31/19 at 2:54 P.M., the resident ate 50% of lunch without any difficulties. The physician's orders [REDACTED]. Dated 9/2/19 an order for [REDACTED]. The physician's orders [REDACTED]. The Vitals Report form for Resident 43 indicated the following weights: Delete the on 7/4: 173.2 8/12 169.6 8/30 171.8 9/2 171.8 10/5 157.8 (was a 8% weight loss in 33 days) 10/15; 153.6 10/18 : 153.6 10/24 156 A Referral to Rehab Services form dated 9/25/19 was received from the Speech Language Pathologist on 10/24/19 at 12:15 P.M., indicated the following .Decreased consumption of pureed diet. Screen to see if candidate for diet upgrade? .Rehab results: Skilled rehab intervention not indicated at this time Summary of status of patient referral: Trial of 2 bites of (mechanical) soft food items. Resident unable to masticate (chew) Severe pocketing noted Not (appropriate) for diet upgrade at this time. Recommend dietary supplements to avoid weight loss. ST to reassess for (possible dysphasia (management) at a later date. A Nurse's note dated 9/26/2019 at 1:38 P.M., indicated a new order for Speech Therapy (ST) to treat the resident 5 times a week for 4 weeks .for the development of cognitive skills for increased independence with participation in activities and socialization with others There was no documentation to indicate the Registered Dietician had been consulted or reviewed Resident 43's eating, swallowing, or nutritional status after the resident's return form the hospital on [DATE] until after the weight loss was documented on 10/5/19. An email titled Diet Order Clarification dated 10/3/19 at 11:56 [NAME]M., from Certified Dietary Manager (CDM) to Unit Manager (UM), Licensed Practical Nurse (LPN) 4 indicated the following: The CDM had clarified Resident 43's current diet order for a pureed diet with thin liquids and changed the diet order to regular textured puree consistency with thin liquids. An email titled Monthly weights dated 10/9/19 at 11:07 [NAME]M., from the CDM to the nurse Unit Manager, LPN 4 indicated the following: Resident 43 had a 14 pound weight loss in 1 month. The CDM requested the resident be re-weighed. A Reweight list dated 10/10/19 provided by LPN 4 on 10/24/19 at 10:00 [NAME]M., indicated the resident weighed 153.6 pounds. On 10/22/19 at 2:14 P.M., during an interview the CDM indicated the following: The CDM had noted Resident 43's weight loss from (MONTH) to the (MONTH) weight and requested on 10/9/19 the resident be reweighted. On 10/15/19 the resident's weight was 153.6 pounds and on 10/17/19 the CDM had compiled the past 6 month of weights for the Register Dietician (RD) to review at the Interdisciplinary Team meetings (IDT). The CDM indicated she and the RD both attended the IDT meetings. The resident's meal consumptio's were good and the resident received ensure once a day. The CDM indicated Resident 43 should have been seen by the IDT team on 10/17/19. On 10/23/19 at 2:47 P.M., during an interview, the DNS (Director of Nursing Services) indicated the following: Resident 43 should have been reviewed in the IDT meeting for nutrition at risk on 10/17/19. At the IDT meeting the physician and the family would have been notified of the resident's weight loss. On 10/24/19 at 9:33 [NAME]M., during an interview, LPN 4 indicated she had notified the CDM on 10/10/19 of the reweight at 153.6. The resident should have been referred to IDT meeting which included the RD and the IDT team would have notified Resident 43's Physician. On 10/24/19 at 12:31 P.M., during an interview the Speech Language Pathologist, she indicaterd she had previously evaluated the resident with mechanical soft food items and had given the resident 2 bites and the resident had held the food in his mouth. On 10/24/19 at 2:04 P.M., during an interview the Speech Language Pathologist she indicated she had not recommended an upgrade of the resident's diet but did recommend a supplement and had put the Rehab Evaluation form in the DNS's mail box on 9/25/19. On 10/24/19 at 2:22 P.M., during an interview the DNS indicated Resident 43 had received ensure supplement once a day since 8/2/19 and did not want to increase the supplement at this time because at times the resident's appetite would decline. On 10/24/19 at 3:15 P.M., during an interview the Certified Nursing Assistant 3, indicated the resident had a good appetite. On 10/23/19 at 12:12 P.M., Resident 43 was observed in the common area. The resident had received his lunch tray. The resident's meal card indicated the resident had a pureed diet level 1 and was to receive fortified mashed potatoes three times a day. The resident had milk, mashed potatoes, purred meat, a green pureed vegetable. The resident fed himself without difficulty and ate 100% of lunch. On 10/24/19 at 9:01 [NAME]M., during a observation with the DNS and CDM the resident weighed 158 pounds on the facility scale. The undated policy titled Weight Management Guidelines was received from the Director of Nursing Services (DNS). The policy indicated the Nursing Department should provide the Dietary Department with the monthly weights of each resident. Residents with indicant weight variance should be identified and appropriate intervention implemented. The resident should be re-weighed when there is a 5 pound weight gain or loss. A weight loss of greater than 5% in 30 days in considered severe. 3.1-46

Based on observation, interview and record review, the facility failed to update the plan of care following identification of a new pressure ulcer. The facility also failed to notify the physician of worsening of the newly identified pressure ulcer for 1 of 1 residents reviewed for pressure ulcers (Resident #56). This resulted in development of an unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the ulcer bed) pressure ulcer to the left heel. Findings include: On 11/14/16 at 3:14 P.M., Resident #56's record was reviewed. [DIAGNOSES REDACTED]. On 11/14/16 at 3:08 P.M., during a staff interview, the Regional Nurse Consultant indicated Resident #56 had a newly identified pressure ulcer to his left heel, identified on 10/28/16, which was not stageable and was covered by eschar . A quarterly MDS (Minimum Data Set) assessment, dated 9/15/16, indicated Resident #56 had severely impaired cognition and required extensive assistance of two staff member for bed mobility and was dependent on staff for all other ADL's (Activities of Daily Living). A care plan dated 7/27/16, indicated Resident #56 was at moderate risk for developing skin breakdown. Interventions included, but were not limited to, report changes in skin status to physician, float heels when in bed, provide pressure relieving or reduction mattress, and notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. The interventions did not indicate heel booties. A care plan dated 11/5/16, indicated Resident #56 had an unstageable disruption of skin surface to his left heel. A goal, dated 11/5/16, was that Resident #56's disruption of skin surface would remain free from infection and show evidence of healing. Interventions included, report changes in skin status to physician, notify responsible party of any new areas of skin breakdown, skin prep to right heel and [MEDICATION NAME] to left heel. The interventions did not indicate heel booties. On 11/14/16 at 2:37 P.M., Resident #56 was observed lying across his bed with both feet flat on the bedside mat. A heel bootie was observed attached by velcro, around the resident's right ankle and the cushion bootie part was sitting off to the side of Resident #56's heel. There was no heel bootie observed to the left foot/ankle. On 11/16/16 at 1:49 P.M., Resident #56 was observed lying in his bed. A pillow was lying on top of the covers and over his right calf. Resident #56's ankles/feet were not elevated. On 11/16/16 at 3:19 P.M., RN #9 was observed doing a treatment to Resident #56's left heel. RN #9 pulled back the resident's sheet and Resident #56 was observed to be wearing socks on both feet and heel booties which were sitting off to the sides of the resident's heels and attached with velcro around his ankles. Resident #56 was observed moving his feet back and forth across the mattress. At this same time, RN #9 indicated Resident #56 is always kicking heel protectors off and digging his heels into the mattress. RN #9 was observed to remove the sock from the resident's left heel at which time, Resident #56 flinched and pulled his foot up towards him. RN #9 was observed to apply [MEDICATION NAME] around the left heel wound followed by a dry dressing and then reapplied the heel protector. On 11/16/16 at 4:14 P.M., Resident #56 was observed lying in bed. A visiting family member pulled the covers off of Resident #56's feet where the resident was observed to have bilateral heel protectors attached by velcro at the ankles but off to the side of the resident's heels. Resident #56 was observed moving his feet back and forth on the bed with his heels rubbing against the mattress. Review of a CNA skin care alert sheet, dated 10/28/16 on the 3-11 shift, indicated Resident #56 had a mushy red area to his right heel. An order from the NP (Nurse Practitioner) dated 10/28/16 was for heel protectors to be on when in bed and skin prep to both heels twice per day. A progress note by the NP, dated 10/28/16, indicated Resident #56 has some breakdown and ulcers to bilateral heels due to non-floating. A nurse progress note, dated 10/30/16 at 10:55 A.M., indicated Resident #56 had a quarter sized blister on left heel and small linear blister at base of right great toe. There was no documentation indicating the physician had been notified of worsening of the left heel wound. There was no documentation to indicate the left heel wound had been assessed for appearance of the wound periphery/surrounding tissue or signs and symptoms of infection. A nurse progress note, dated 11/5/16 at 10:21 P.M., indicated the facility's wound nurse assessed Resident #56's heels. The nurse indicated Resident #56 kicks off his heel protectors often and digs his heels into the mattress while in bed. The NP was notified and new orders received to apply [MEDICATION NAME] to Resident #56's left heel wound. A wound care NP progress note, dated 11/7/16 indicated Resident #56's left heel wound measured length 2.5 cm (centimeters) by width 3 cm by depth 3 cm. The wound was 100% purple discoloration with loose cap. The progress note further indicated the NP removed the loose cap with scissors and the treatment of [REDACTED]. Nurse progress notes, dated 11/14 at 9:12 P.M, 11/15 at 2:46 A.M. and 10:01 P.M., 11/16 at 3:12 A.M. and 10:08 P.M. , and 11/17/16 at 2:03 A.M., all indicate Resident #56 frequently kicks off his heel protectors and digs his heels into the mattress. On 11/17/16 at 11:05 A.M., RN #10 was interviewed. During the interview, RN #10 indicated she did not report worsening of Resident #56's left heel wound when noted to be blistered on 10/30/16 because the NP had already been aware of the wound. The NP had ordered heel booties and skin prep to heels on 10/28/16 when the skin of the heels were intact with redness and no blisters. On 11/17/16 at 11:08 A.M., the RNC (Regional Nurse Consultant) was interviewed. During the interview, the RNC indicated the physician should've been notified when Resident #56's left heel wound changed from reddened skin to a blister. The RNC indicated the facility's wound nurse should've been notified of the change in Resident #56's left heel wound. The RNC indicated the wound nurse does rounds on resident's with wounds every Monday. Further, the RNC indicated there was no documentation available that the wound nurse had looked at, assessed, and measured Resident #56's left heel wound on the Monday following change in the resident's wound which would've been 10/31/16. On 11/17/16 at 11:10 A.M., the RNC (Regional Nurse Consultant) provided a current copy of the facility's wound policy titled Pressure Ulcer Management Resource which indicated the following: 1. Assessment is always the starting point for ulcer treatment .4. Reassess and measure weekly or sooner if deterioration of the ulcer is noted .5. Inform the physician of new pressure ulcers .Report the following to the physician .Overall appearance (new, healing, worsening, unchanged), current treatment and review of the past treatment, as appropriate .6. Revise the care plan to reflect the change in condition. Develop an effective plan of care . Update the care plan to reflect new treatment goals and approaches .7. Implement a preventive program to prevent additional new areas from developing. Ensure that preventive measures are listed on the care plan and flow sheets 3.1-40(a)(1)

Based on interview and record review the facility failed to complete skin assessments for 1 of 3 residents reviewed with low risk for skin impairment. This resulted in a resident at low risk for skin impairment developing a Stage 4 pressure area with bone exposure, hospitalization and surgical debridement. (Resident #O) The immediate jeopardy began on 7-31-2016 when a resident that was at low risk for pressure areas developed a Stage 4 pressure area on his heel which had not been previously assessed, which resulted in hospitalization and surgical debridement. The Administrator, Director of Nursing and Signature Care Consultant were notified of the immediate jeopardy on 8-3-2016 at 3:14 PM. The immediate jeopardy was removed on 8-4-2016. Findings include: Resident #O's record was reviewed on 8-3-2016 at 11:38 AM. Resident #O's [DIAGNOSES REDACTED]. A review of Resident #O's quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #O was ambulatory with standby supervision. Further, the document indicated Resident #O's Basic Interview for Mental Status Score was 7 which indicated Resident #O had poor decision making skills and was cognitively impaired. A quarterly nursing information assessment, dated 3-17-2016, indicated Resident #O had a Braden Skin Risk score of 18. This indicated Resident #O was at low risk for pressure ulcer development. A care plan, dated 12-22-2015, titled risk of skin breakdown indicated the facility was to inspect skin during bathing, especially over bony prominences. and Complete weekly skin check. A review of CNA shower sheets completed for Resident #O, between 7-18 and 7-31-2016, indicated only one skin check had been documented with the shower. A review of the Weekly Summary, dated 7-27-2016, for Resident #O indicated there were no skin conditions present. A review of Resident #O's progress notes indicated, on 7-31-2016 at 9:32 PM, Resident #O had been found with a heel wound that had a foul odor, brownish/ yellow tinged drainage, and discoloration throughout the wound bed. There were no measurements documented in the progress notes. A review of Resident #O's Weekly Skin Information, dated 7-31-2016 at 3:17 PM, indicated Resident #O had an open area on the bottom of the left foot 5 x 5.5 x 0 (length by width by depth). There was no unit of measurement or other description of the area attached to the report. A review of the progress notes, dated 8-1-2016 at 2:44 PM, indicated the family wanted to send Resident #O to the hospital for evaluation of the foot wound. A review of Resident #O's emergency room notes, dated 8-1-2016, indicated the foot wound was Stage 4 (according to the National Pressure ulcer Advisory Panel,a Stage 4 wound is one with full thickness skin and tissue loss with exposed bone, muscle, tissue or ligaments.) and located on the left heel. The report further indicated Resident #O was well nourished, and in no apparent distress. The left foot was noted to be brightly reddened, with a 4 cm (centimeters) in diameter open wound on the lateral aspect of the heel with purulent eschar around the edges. There was no depth noted in the emergency room report. A photo of Resident #O's heel had been taken by the resident's step daughter on 8-1-2016 at approximately 5 PM. It was shared and indicated the area was open on the bottom of the foot at the heel area with white irregularly shaped edges surrounding the the open wound. The wound itself had a maroon colored area about 1/3 the way around the exposed bony area which appeared to be about the size of a nickel. It appeared to be rough on the surface in the 6 o'clock to 10 o'clock positions, in the 1 o'clock to the 4 o'clock position next to the bone, the white area appeared as light greenish blue. The whitened area around the open area appeared to extend up the back of the heel about an inch. In an interview on 8-3-2016 at 1:45 PM, LPN #3 indicated Resident #O had been experiencing swelling in his feet, and in March, the family changed his tennis shoes for hard soled non-skid slippers. LPN #3 further indicated Resident #O sat leaning forward with his elbows on his knees and scooted his feet forward and backward while he was seated. In an interview on 8-3-2016 at 10:43 AM, CNA #1 indicated the nurse did not always do her skin checks when she was supposed to, even after the CNA told the nurse the resident was ready to have the skin check completed. In an interview on 8-3-2016 at 10:50 AM, Resident #T indicated sometimes the nurse would come in the shower and talk, but not really look at her skin. In an interview on 8-3-2016 at 10:35 AM, LPN #2 indicated the CNAs were to tell the nurse when the shower was completed, and the nurse was to check the resident's skin condition. A current undated policy titled Skin Assessments and Evaluations provided on 8-3-2016 at 11:49 AM by the Corporate Nurse indicated 10. Licensed Nurses, .must complete and document all weekly skin assessments . On 8-4-2016 at 2:20 PM, the Signature Care Consultant provided a document titled Allegation of Compliance dated 8-3-2016. The document indicated the facility had completed a 100% skin sweep of current resident skin condition on 8-1-2016. The document further indicated all resident care plans had been reviewed to ensure pressure injury prevention interventions were properly care planned on 8-4-2016. Additionally, the document indicated staff reeducation regarding skin prevention interventions, including skin assessments, accurate skin assessments, accurate skin assessment documentation, and documentation on shower sheets was completed on 8-3-2016. Nurse staff that did not attend the inservice would be reeducated prior to working their next assigned shift. Monitoring was outlined as follows: nurse management would complete follow up skin assessments on 25% of the weekly skin assessments; audit 25% of new developed care plans to ensure preventative interventions are present on care plans; and review completed shower sheets during clinical meeting to assist with any potential skin issues. Observations of resident skin on 8-3-2016 indicated residents had clear skin, or any area that was observed on a resident had been identified, matched the identified description, and was receiving treatment. Care plans reviewed on 8-3, and 8-4-2016 indicated pressure prevention interventions were in place according to the plan of care. Observations indicated nursing staff were being reeducated prior to the next shift worked and at formally scheduled inservices. According to interviews with selected staff, on 8-4 and 8-5-2016, staff were able to verbalize what to look for when doing a skin assessment and were able to verbalize if there was a question someone had completed an assessment to inform their superiors. Nurse management was observed reviewing care plans, skin assessments, and shower sheets on 8-5-2016. The immediate jeopardy that began on 7-31-2016 was removed on 8-4-2016 when the facility completed reeducation of nursing staff on skin prevention interventions, including skin assessments, skin assessment documentation, and shower sheet documentation, but the non compliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been reeducated and monitoring was not completed. This Federal Tag is related to Complaint IN 535. 3.1-40(a)(1)

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 2 of 3 residents reviewed for following physician orders (Resident #B and Resident #D) in a sample of 3 residents. Resident #B was transferred to the hospital emergency room for lethargy, shortness of breath, and fluid retention and was subsequently admitted to the hospital intensive care unit. The immediate jeopardy began on 2/15/2013 when Resident #B was admitted to the facility and was not administered medications as ordered by the discharging acute care hospital. The facility Executive Director and Director of Nursing were notified of the immediate jeopardy on 3/27/2013 at 11:25 A.M. The immediate jeopardy was removed on 3/28/2013, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The record for Resident #B was reviewed on 3/26/2013 at 9:45 A.M. [DIAGNOSES REDACTED]. The record indicated Resident #B was admitted to the facility on [DATE]. A Hospital Discharge Summary, with an admission date of [DATE] and a discharge date of [DATE], indicated discharge [DIAGNOSES REDACTED]. The summary indicated "...The grandfather would like him placed in a long -term care facility or some facility that can manage him appropriately. The patient has had recurrent hospitalization s that are clearly avoidable secondary to noncompliance." The note further indicated "...The patient was brought to the hospital due to [MEDICAL CONDITION] and shortness of breath. His chest x-ray has been consistent with [MEDICAL CONDITION] in the past. It was not repeat at this time (sic). He was started on higher dose diuretics with significant improvement in his lower extremity swelling and shortness of breath. The patient was also started on only a partial dose of insulin, whereupon his sugars were consistently in the 100 range." The discharge summary indicated discharge medications included, but were not limited to, [MEDICATION NAME] (a diuretic medication used to treat fluid retention or [MEDICAL CONDITION] related to [MEDICAL CONDITION]) 50 mg (milligrams) every day), Atrovent and [MEDICATION NAME] nebulizer (respiratory medications) treatments 4 times per day, [MEDICATION NAME] (diabetic medication)1000 mg twice daily, [MEDICATION NAME] (a diuretic medication used to treat fluid retention or [MEDICAL CONDITION] related to [MEDICAL CONDITION]) 40 mg twice daily and quinapril (medication used to treat high blood pressure) 20 mg daily. A hospital medication summary, with a print date of 2/15/13, indicated the resident was to receive medications that included aspirin 81 mg daily, [MEDICATION NAME] daily , a multivitamin daily, children's vitamin D daily, Atrovent 0.02% solution for inhalation four times daily as needed, [MEDICATION NAME] 1000 mg twice daily, [MEDICATION NAME] 70/30 insulin three times daily, [MEDICATION NAME] 20 mg at bed time, [MEDICATION NAME] nasal spray twice daily, [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication also used to manage behavior) 50 mg twice daily, oxacarbazepine (an anti-[MEDICAL CONDITION] medication also used to manage behavior) 300 mg twice daily, [MEDICATION NAME] (medication used to treat depression) 50 mg at bedtime, [MEDICATION NAME] (medication used to treat fluid retention) 250 mg every other day, [MEDICATION NAME] sulfate inhaler four times daily as needed, [MEDICATION NAME] (generic for [MEDICATION NAME]) 40 mg twice daily, [MEDICATION NAME] sodium 100 mg twice daily, potassium 20 meq (milliequivalents) daily and quinapril 20 mg daily. Facility admission orders [REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A pharmacist for the facility's contract pharmacy was interviewed by telephone on 3/27/2013 at 12:45 P.M. During the interview, the pharmacist indicated the pharmacy had not received orders from the facility for the [MEDICATION NAME], Atrovent, [MEDICATION NAME], or quinapril and had not sent any of those medications to the facility for Resident #B. A nursing note, dated 2/23/2013 at 2:35 P.M., indicated "...Res (resident) slept late the A.M. and slept on Lt (left) side. Upon awakening res Lt side of face with [MEDICAL CONDITION] present. Lt eye swollen almost shut. Res denies pain. No abnormalities noted to the eye. NP (Nurse Practitioner) notified and family (sic), no N.O. (new orders) at this time just monitor and notify if any changes." A nursing note, dated 2/24/2013 at 12:49 P.M., indicated "Res Lt side of face remains swollen. Denies pain. BrSo (breath sounds) clr (clear), SOB (shortness of breath) with exertion at times. Amb (ambulation) indep (independent). Gait steady. Informed by grandparents that res has been going into (memory care) unit to pet the cat and he is extremely allergic. Staff alerted, mother notified, edu (educated) res, NP notified. No adverse reaction to increased insulin. No adverse reaction to increased [MEDICATION NAME] (generic of [MEDICATION NAME])." A nursing note, dated 2/25/2013 at 3:23 P.M., indicated "Res difficult to awaken again today. Requires tactile and verbal stimuli for a lengthy period of time. Res falling asleep while eating and conversing. Lt eye remains swollen. No adverse reaction r/t (related to) increased insulin and Topomax. NP in and N.O. to start Claratin Q D (once daily) and that res must wear C PAP (a device that provides continuous positive airway pressure to keep air ways open when sleeping) at noc (night) d/t hypersomnolence (excessive sleeping). Family notified." A nursing note, dated 2/26/2013 at 1:01 P.M., indicated "res alert at this time took several attempts to waken res...." The note further indicated "...l (left) eye remains slightly swollen 0 (no) c/o (complaints of) pain or discomfort noted this shift." A nursing note, dated 2/26/2013 at 10:02 P.M., indicated "No adverse reactions noted to new med order of Claratin. Res non compliant with wearing C PAP while sleeping...." The note further indicated "...Res very lethargic and hard to arouse. " A nursing note, dated 2/27/2013 at 3:21 P.M., indicated "res fell in dinning (sic) room was sitting in chair and fell asleep which caused res to fall off chair doctor and family notified no injuries." A nursing note, dated 2/27/2013 at 2:41 A.M., indicated "Res received n.o. for affected left eye. [MEDICATION NAME] (antibiotic) to lt eye, et (and) remains sl (slightly) puffy...." A nursing note, dated 2/28/2013 at 10:25 P.M., indicated "Res sent to ER (emergency room ) from scheduled appt (appointment) . Family in this evening to gather some belongings. DON (Director of Nursing) notified, will follow up in the am." A review of a blood sugar summary for Resident #B indicated the following blood sugar levels: 2/17/2013 at 11:03 A.M. - 350 2/18/2013 at 7:33 A.M. - 426 2/18/2013 at 11:33 A.M. - 437 2/19/2013 at 7:30 A.M. - 461 2/19/2013 at 11:30 A.M. - 447 2/19/13 at 10:36 P.M. - 441 2/20/2013 at 7:17 A.M. - 463 2/20/2013 at 11:17 A.M. - 439 2/20/2013 at 4:43 P.M. - 218 2/20/2013 at 8:43 P.M. - 219 2/21/2013 at 11:00 A.M. - 387 2/22/2013 at 6:05 A.M. - 297 2/22/2013 at 11:12 A.M. - 254 2/22/2013 at 4:00 P.M. - 247 2/22/2013 at 8:00 P.M. - 390 2/23/2013 at 7:15 A.M. - 214 2/23/2013 at 11:15 A.M. - 164 2/23/2013 at 4:33 P.M. 159 2/23/2013 at 8:33 P.M. - 163 2/24/2013 at 8:08 A.M. - 226 2/24/2013 at 11:15 A.M. - 156 2/24/2013 at 4:02 P.M. - 250 2/24/2013 at 8:44 P.M. - 178 2/25/2013 at 11:21 A.M. - 85 2/25/2013 at 4:37 P.M. - 142 2/25/2013 at 10:37 P.M. - 157 2/26/2013 at 11:00 A.M. - 143 2?26/2013 at 4:00 P.M. - 91 2/26/2013 at 8:00 P.M. - 200 2/27/2013 at 4:27 P.M. - 286 2/27/2013 at 8:27 P.M. - 272 A review of Resident #B's weights indicated the following: 2/15/2013 - 301.4 lbs 2/17/2013 - 294 lbs 2/24/2013 - 303.2 lbs A note by the Nurse Practitioner, dated 2/18/2013, indicated "Elevated accuchecks (blood sugar checks) on no sliding scale, recent DKA (diabetic ketoacidosis) hospitalization ; followed by (physician's name) in hospital. On 70/30 INPH (type of insulin). Resident is using vending machine - eating candy, drinking pop. Discussed treatment w (with) family." The note further indicated "Will call (physician's name) regarding DM (diabetes mellitus) management. Monitor use of vending machines. Add sliding scale (insulin administration based on blood sugar levels)." An addendum to the note, dated 2/18/2013, indicated the physician agreed with the sliding scale. A Physician Order, dated 2/18/2013 indicated Resident #B was to receive additional insulin based on a sliding scale. An Occupational Therapy note, signed 2/26/2013, indicated "Pt has been very fatigued as noticed by therapy staff due to allergic reaction from petting facility cat in alz (Alzheimer's) unit..." An Occupational Therapy Discharge Summary, dated 2/28/2013, indicated "pt d/c (discharged ) to hospital. Pt participated in program for balance & fatigue. Progress was minimal 2 (secondary to) (increased) fatigue & [MEDICAL CONDITION]." Physical Therapist Assistant (PTA) #5 was interviewed on 3/27/2013 at 10:00 A.M. During the interview, PTA #5 indicated Resident #B had been in therapy and one of the therapies he had been receiving was "progressive resistive breathing" to help with his shortness of breath. A note from the ophthalmologist, dated 2/28/2013, indicated "...Pt's mother and grandfather states that for the last week the left eye has been very swollen with very little redness or mattering. He is unable to open the left eye. They recently found out that he is allergic to cats and the home where he stays has a cat but the family believes that if it were allergies [REDACTED]." The note further indicates "...pt having trouble staying awake, rapid respiratory rate and pulse of 88, very lethargic." Under "discussion/plan", the note further indicated "Swelleing (sic) of left upper lid seems more just [MEDICAL CONDITION] than infection...." The note further indicated "....Shortness of breath, lethargy, nearly unresponsive today. This plus fluid retention and history [MEDICAL CONDITION] plus blood sugar 400 this am have brought us to call EMS (emergency medical service) to bring patient to ER for evaluation." A hospital Emergency Department Notes report, dated 2/28/2013, indicated "Patient is a (resident's age) male who presents emergency room via EMS from his nursing home. At this time patient is obtunded (decreased alertness) and the history is provided per grandfather and mother. Grandmother (sic) states the patient was recently placed in a nursing home. He has mental [MEDICAL CONDITIONS], massive obesity. He states that patient's medications have changed from [MEDICATION NAME] 50 mg once a day to 100 mg once a day and they are concerned. They state patient has had altered mental status for the past 3 days during change of this medication. They also state patient fell out of his chair at the nursing home yesterday. Patient was seen at the ophthalmologist today for swelling to the left eye and at that time they were told to come straight to the emergency Department due to patient's altered mental status. They state patient has not been alert and oriented for the past 3 days. I was able to arouse the patient with multiple sternal rubs patient denied any pain or difficulty breathing. Patient is currently on 4L (liters) of oxygen nasal cannula at all times. I did review his previous records noted last time he was here he was in diabetic ketoacidosis as well. Grandmother states patient appears to be pale and diaphoretic. They state patient has been just sleeping for the past 3 days and is a complete change in behavior." Under the "physical exam" section, the note indicated "...bilateral lower extremity swelling and [MEDICAL CONDITION]." The note further indicated "...Patient is able to arouse with multiple sternum rubs. He answered the question to what his name was correctly. He did not stay awake to answer any further questions." The note further indicated "Critical care was necessary to treat or prevent life-threatening deterioration of the following conditions: [MEDICAL CONDITION]." A hospital discharge summary, dated 3/10/2013 indicated Resident #B was admitted to the hospital on [DATE] and was discharged on [DATE]. The summary indicated under "Hospital Course," "The patient is well-known to me with chronic [MEDICAL CONDITION] secondary to obesity, [DIAGNOSES REDACTED] and sleep apnea syndrome. He had been transferred to a nursing home more than a week ago...." The note further indicated "...with increasing problems with lethargy, (ophthalmologist's name) who happened to see him as an outpatient ophthalmologic consultation sent him to the emergency room where he was treated aggressively and after discussions with me, admitted to intensive care unit (ICU)...." The note further indicated "He was in obvious acute [MEDICAL CONDITION]. His blood gases revealed a pH of 7.16, pCO2 of 85, pO2 of 100 and oxygen (O2) saturation of 96%. He was treated aggressively with bi-level positive airway pressure (Bi-PAP) and much closer control of his sugars and diet and he showed gradual improvement. He was on diuretics." The note indicated admission [DIAGNOSES REDACTED]." The final discharge [DIAGNOSES REDACTED]." The note further indicated the resident's discharge medications included, but were not limited to, [MEDICATION NAME] (Atrovent), [MEDICATION NAME] ([MEDICATION NAME]), and [MEDICATION NAME] ([MEDICATION NAME]). LPN #3 was interviewed on 3/26/2013 at 1:45 P.M. During the interview, LPN #3 indicated the nurses were to transcribe the hospital discharge orders to the the facility admission orders [REDACTED]. LPN #3 further indicated the facility should have transcribed the facility admission orders [REDACTED]. The facility Director of Nursing (DON) was interviewed on 3/26/2013 at 1:55 P.M. During the interview, the DON indicated a second nurse was expected to verify any new admission orders [REDACTED]. The DON indicated it appeared the second nurse had not verified the orders and some of the medications had not been accurately transcribed from the hospital discharge orders onto the the facility's admission orders [REDACTED]. The facility's Nurse Practitioner (NP) was interviewed by telephone on 3/27/2013 at 3:15 P.M. During the interview, the NP indicated she had treated Resident #B's swollen left eye as a possible allergic reaction, as the swelling appeared to be localized. The NP further indicated she had not been aware that the resident had been receiving [MEDICATION NAME], [MEDICATION NAME], Atrovent, [MEDICATION NAME], or quinapril prior to admission to the nursing facility and had not been aware the medications had been indicated on the hospital discharge orders but had not been transcribed onto the facility's admission orders [REDACTED] Resident #B's physician/facility Medical Director was interviewed by telephone on 3/27/2013 at 3:45 P.M. During the interview, the physician indicated he had not been aware the hospital discharge orders had included [MEDICATION NAME], Atrovent or quinapril. He further indicated he would have continued the medications listed on the hospital discharge orders. He further indicated he did not routinely compare the facility admission orders [REDACTED]. The facility DON was interviewed on 3/28/2013 at 2:15 P.M. During the interview, the DON indicated the facility had not been aware Resident #B had not received the medications in question until 3/26/2013. A facility policy entitled "Physician Orders", dated 11/21/2012, was provided by the DON on 3/27/2013. The policy indicated "Once new admission /readmission orders [REDACTED]." The policy further indicated "Double check to ensure there were no transcription errors." The immediate jeopardy that began on 2/15/2013 was removed on 3/28/2013 when the facility audited the charts of all residents admitted or readmitted within the past 60 days to validate the accuracy of medication orders and corrected identified concerns. The facility also re-educated all licensed nursing staff on the transcription of orders, instituted a policy of review of all admission orders [REDACTED]. 2. Resident #C's clinical record was reviewed on 3/26/13 at 1:30 P.M.. The record indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #C's physician's order upon admission on 3/13/13 included [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) 100 milligrams (mg) three times daily for [MEDICAL CONDITION]. On 3/18/13 a physician's order was received to increase [MEDICATION NAME] to 200 mg three times daily. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 3/14/13 through the last dose (4:00 P.M.) on 3/18/13. The MAR indicated [REDACTED].M. dose of [MEDICATION NAME] 100 mg on 3/16/13, 3/17/13 and 3/18/13 along with the 4:00 P.M. dose on 3/18/13. The MAR indicated [MEDICATION NAME] 200 mg three times daily was to have started on 3/19/13 at 8:00 A.M. and was to continue through 3/26/13 including the 12:00 P.M. dose. The MAR indicated [REDACTED].M. dose of [MEDICATION NAME] 200 mg on 3/20/13, 3/21/13, 3/22/13, 3/25/13 and 3/26/13. An interview with LPN #1 on 3/26/13 at 3:00 P.M. indicated she administered the resident's 12:00 P.M. dose of [MEDICATION NAME] 200 mg on 3/26/13, but had not documented the administration yet. Review of Resident #C's medication cards for [MEDICATION NAME] on 3/26/13 at 2:30 P.M. indicated the resident currently had 2 medication cards for [MEDICATION NAME] 100 mg which were delivered on 3/13/13. The [MEDICATION NAME] card marked two of three, originally had 30 capsules, but had 23 capsules currently in the card, indicating 7 doses had been administered out of the card. A second card for Resident #C's [MEDICATION NAME] 100 mg indicated it was the third of three cards and had 30 capsules of [MEDICATION NAME] 100 mg currently. An interview with LPN #1 indicated the resident had a third card of [MEDICATION NAME] 100 mg which would have been card one of three which had been administered previously. The total of administered [MEDICATION NAME], according to the medication cards, was 37 capsules of 100 mg had been administered since admission on 3/13/13, starting on 3/14/13. An interview with the Director of Nursing (DON) on 3/26/13 at 3:00 P.M. included an examination of the resident's [MEDICATION NAME] medication cards indicated resident #C was administered 37 capsules of [MEDICATION NAME] 100 mg since 3/14/13. The DON verified the resident should have received 15 [MEDICATION NAME] capsules between 3/14/13 and 3/18/13 (when the physician's order was [MEDICATION NAME] 100 mg three times daily) and 46 capsules of [MEDICATION NAME] 100 mg between 3/19/13 and 3/26/13 at 12:00 P.M. (when the physician's order was [MEDICATION NAME] 200 mg three times daily). The DON verified the resident received a total of 37 [MEDICATION NAME] capsules between 3/14/13 and 3/26/13 at 12:00 P.M. and should have received 61 capsules. The DON indicated she contacted the pharmacy to verify the amount of [MEDICATION NAME] 100 mg which was sent to the facility on [DATE] and the pharmacy indicated they sent 3 cards with 30 capsules of [MEDICATION NAME] 100 mg on 3/13/13. According to the DON the pharmacy indicated they would not send new [MEDICATION NAME] medication cards for 200 mg three times daily until the [MEDICATION NAME] 100 mg three times daily cards were used up. The DON indicated the nurse who received the physician order change on 3/18/13 should have put a sticker on the [MEDICATION NAME] 100 mg cards indicating the directions had changed, and to refer to medical record. An interview with Resident #C's wife on 3/27/13 at 10:00 A.M. indicated her husband had not had any [MEDICAL CONDITION] since admission to the facility on [DATE]. Review of the resident's clinical record indicated the resident had not had a [MEDICAL CONDITION] since admission to the facility on [DATE]. Review of the facility policy "Change of Medication Direction", dated 4/28/09, provided by the DON on 3/27/13 at 11:00 A.M. indicated: "4. Notify the provider pharmacy of the change of directions so that the refilled prescription has current directions. 5. Place a change of direction sticker on the medication's label. 6. When giving a medication with a change of direction sticker, refer to the medication sheet and/or physician's orders for the current medication directions." This federal tag relates to Complaint IN 6204. 3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure a resident received medications for [MEDICAL CONDITION], respiratory problems, and diabetes as ordered by the physician for 1 of 3 residents reviewed for medications (Resident #B) in a sample of 3 residents. Resident #B was transferred to the hospital emergency room for lethargy, shortness of breath, and fluid retention and was subsequently admitted to the hospital intensive care unit. The immediate jeopardy began on 2/15/2013 when Resident #B was admitted to the facility and was not administered medications as ordered by the discharging acute care hospital. The facility Executive Director and Director of Nursing were notified of the immediate jeopardy on 3/27/2013 at 11:25 A.M. The immediate jeopardy was removed on 3/28/2013, but noncompliance remained at the scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The record for Resident #B was reviewed on 3/26/2013 at 9:45 A.M. [DIAGNOSES REDACTED]. The record indicated Resident #B was admitted to the facility on [DATE]. A Hospital Discharge Summary, with an admission date of [DATE] and a discharge date of [DATE], indicated discharge [DIAGNOSES REDACTED]. The summary indicated "...The grandfather would like him placed in a long -term care facility or some facility that can manage him appropriately. The patient has had recurrent hospitalization s that are clearly avoidable secondary to noncompliance." The note further indicated "...The patient was brought to the hospital due to [MEDICAL CONDITION] and shortness of breath. His chest x-ray has been consistent with [MEDICAL CONDITION] in the past. It was not repeat at this time (sic). He was started on higher dose diuretics with significant improvement in his lower extremity swelling and shortness of breath. The patient was also started on only a partial dose of insulin, whereupon his sugars were consistently in the 100 range." The discharge summary indicated discharge medications included, but were not limited to, [MEDICATION NAME] (a diuretic medication used to treat fluid retention or [MEDICAL CONDITION] related to [MEDICAL CONDITION]) 50 mg (milligrams) every day), Atrovent and [MEDICATION NAME] nebulizer (respiratory medications) treatments 4 times per day, [MEDICATION NAME] (diabetic medication)1000 mg twice daily, [MEDICATION NAME] (a diuretic medication used to treat fluid retention or [MEDICAL CONDITION] related to [MEDICAL CONDITION]) 40 mg twice daily and quinapril (medication used to treat high blood pressure) 20 mg daily . A hospital medication summary, with a print date of 2/15/13, indicated the resident was to receive medications that included aspirin 81 mg daily, [MEDICATION NAME] daily , a multivitamin daily, children's vitamin D daily, Atrovent 0.02% solution for inhalation four times daily as needed, [MEDICATION NAME] 1000 mg twice daily, [MEDICATION NAME] 70/30 insulin three times daily, [MEDICATION NAME] 20 mg at bed time, [MEDICATION NAME] nasal spray twice daily, [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication also used to manage behavior) 50 mg twice daily, oxacarbazepine (an anti-[MEDICAL CONDITION] medication also used to manage behavior) 300 mg twice daily, [MEDICATION NAME] (medication used to treat depression) 50 mg at bedtime, [MEDICATION NAME] (medication used to treat fluid retention) 250 mg every other day, [MEDICATION NAME] sulfate inhaler four times daily as needed, [MEDICATION NAME] (generic for [MEDICATION NAME]) 40 mg twice daily, [MEDICATION NAME] sodium 100 mg twice daily, potassium 20 meq (milliequivalents) daily and quinapril 20 mg daily. Facility admission orders [REDACTED] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A pharmacist for the facility's contract pharmacy was interviewed by telephone on 3/27/2013 at 12:45 P.M. During the interview, the pharmacist indicated the pharmacy had not received orders from the facility for the [MEDICATION NAME], Atrovent, [MEDICATION NAME], or quinapril and had not sent any of those medications to the facility for Resident #B. A nursing note, dated 2/23/2013 at 2:35 P.M., indicated "...Res (resident) slept late the A.M. and slept on Lt (left) side. Upon awakening res Lt side of face with [MEDICAL CONDITION] present. Lt eye swollen almost shut. Res denies pain. No abnormalities noted to the eye. NP (Nurse Practitioner) notified and family (sic), no N.O. (new orders) at this time just monitor and notify if any changes." A nursing note, dated 2/24/2013 at 12:49 P.M., indicated "Res Lt side of face remains swollen. Denies pain. BrSo (breath sounds) clr (clear), SOB (shortness of breath) with exertion at times. Amb (ambulation) indep (independent). Gait steady. Informed by grandparents that res has been going into (memory care) unit to pet the cat and he is extremely allergic. Staff alerted, mother notified, edu (educated) res, NP notified. No adverse reaction to increased insulin. No adverse reaction to increased [MEDICATION NAME] (generic of [MEDICATION NAME])." A nursing note, dated 2/25/2013 at 3:23 P.M., indicated "Res difficult to awaken again today. Requires tactile and verbal stimuli for a lengthy period of time. Res falling asleep while eating and conversing. Lt eye remains swollen. No adverse reaction r/t (related to) increased insulin and Topomax. NP in and N.O. to start Claratin Q D (once daily) and that res must wear C PAP (a device that provides continuous positive airway pressure to keep air ways open when sleeping) at noc (night) d/t hypersomnolence (excessive sleeping). Family notified." A nursing note, dated 2/26/2013 at 1:01 P.M., indicated "res alert at this time took several attempts to waken res...." The note further indicated "...l (left) eye remains slightly swollen 0 (no) c/o (complaints of) pain or discomfort noted this shift." A nursing note, dated 2/26/2013 at 10:02 P.M., indicated "No adverse reactions noted to new med order of Claratin. Res non compliant with wearing C PAP while sleeping...." The note further indicated "...Res very lethargic and hard to arouse. " A nursing note, dated 2/27/2013 at 3:21 P.M., indicated "res fell in dinning (sic) room was sitting in chair and fell asleep which caused res to fall off chair doctor and family notified no injuries." A nursing note, dated 2/27/2013 at 2:41 A.M., indicated "Res received n.o. for affected left eye. [MEDICATION NAME] (antibiotic) to lt eye, et (and) remains sl (slightly) puffy...." A nursing note, dated 2/28/2013 at 10:25 P.M., indicated "Res sent to ER (emergency room ) from scheduled appt (appointment) . Family in this evening to gather some belongings. DON (Director of Nursing) notified, will follow up in the am." A review of a blood sugar summary for Resident #B indicated the following blood sugar levels: 2/17/2013 at 11:03 A.M. - 350 2/18/2013 at 7:33 A.M. - 426 2/18/2013 at 11:33 A.M. - 437 2/19/2013 at 7:30 A.M. - 461 2/19/2013 at 11:30 A.M. - 447 2/19/13 at 10:36 P.M. - 441 2/20/2013 at 7:17 A.M. - 463 2/20/2013 at 11:17 A.M. - 439 2/20/2013 at 4:43 P.M. - 218 2/20/2013 at 8:43 P.M. - 219 2/21/2013 at 11:00 A.M. - 387 2/22/2013 at 6:05 A.M. - 297 2/22/2013 at 11:12 A.M. - 254 2/22/2013 at 4:00 P.M. - 247 2/22/2013 at 8:00 P.M. - 390 2/23/2013 at 7:15 A.M. - 214 2/23/2013 at 11:15 A.M. - 164 2/23/2013 at 4:33 P.M. 159 2/23/2013 at 8:33 P.M. - 163 2/24/2013 at 8:08 A.M. - 226 2/24/2013 at 11:15 A.M. - 156 2/24/2013 at 4:02 P.M. - 250 2/24/2013 at 8:44 P.M. - 178 2/25/2013 at 11:21 A.M. - 85 2/25/2013 at 4:37 P.M. - 142 2/25/2013 at 10:37 P.M. - 157 2/26/2013 at 11:00 A.M. - 143 2?26/2013 at 4:00 P.M. - 91 2/26/2013 at 8:00 P.M. - 200 2/27/2013 at 4:27 P.M. - 286 2/27/2013 at 8:27 P.M. - 272 A review of Resident #B's weights indicated the following: 2/15/2013 - 301.4 lbs 2/17/2013 - 294 lbs 2/24/2013 - 303.2 lbs A note by the Nurse Practitioner, dated 2/18/2013, indicated "Elevated accuchecks (blood sugar checks) on no sliding scale, recent DKA (diabetic ketoacidosis) hospitalization ; followed by (physician's name) in hospital. On 70/30 INPH (type of insulin). Resident is using vending machine - eating candy, drinking pop. Discussed treatment w (with) family." The note further indicated "Will call (physician's name) regarding DM (diabetes mellitus) management. Monitor use of vending machines. Add sliding scale (insulin administration based on blood sugar levels). An addendum to the note, dated 2/18/2013, indicated the physician agreed with the sliding scale. A Physician Order, dated 2/18/2013 indicated Resident #B was to receive additional insulin based on a sliding scale. An Occupational Therapy note, signed 2/26/2013, indicated "Pt has been very fatigued as noticed by therapy staff due to allergic reaction from petting facility cat in alz (Alzheimer's) unit..." An Occupational Therapy Discharge Summary, dated 2/28/2013, indicated "pt d/c (discharged ) to hospital. Pt participated in program for balance & fatigue. Progress was minimal 2 (secondary to) (increased) fatigue & [MEDICAL CONDITION]." Physical Therapist Assistant (PTA) #5 was interviewed on 3/27/2013 at 10:00 A.M. During the interview, PTA #5 indicated Resident #B had been in therapy and one of the therapies he had been receiving was "progressive resistive breathing" to help with his shortness of breath. A note from the ophthalmologist, dated 2/28/2013, indicated "...Pt's mother and grandfather states that for the last week the left eye has been very swollen with very little redness or mattering. He is unable to open the left eye. They recently found out that he is allergic to cats and the home where he stays has a cat but the family believes that if it were allergies [REDACTED]." The note further indicates "...pt having trouble staying awake, rapid respiratory rate and pulse of 88, very lethargic." Under "discussion/plan", the note further indicated "Swelleing (sic) of left upper lid seems more just [MEDICAL CONDITION] than infection...." The note further indicated "....Shortness of breath, lethargy, nearly unresponsive today. This plus fluid retention and history [MEDICAL CONDITION] plus blood sugar 400 this am have brought us to call EMS (emergency medical service) to bring patient to ER for evaluation." A hospital Emergency Department Notes report, dated 2/28/2013, indicated "Patient is a (resident's age) male who presents emergency room via EMS from his nursing home. At this time patient is obtunded (decreased alertness) and the history is provided per grandfather and mother. Grandmother (sic) states the patient was recently placed in a nursing home. He has mental [MEDICAL CONDITIONS], massive obesity. He states that patient's medications have changed from [MEDICATION NAME] 50 mg once a day to 100 mg once a day and they are concerned. They state patient has had altered mental status for the past 3 days during change of this medication. They also state patient fell out of his chair at the nursing home yesterday. Patient was seen at the ophthalmologist today for swelling to the left eye and at that time they were told to come straight to the emergency Department due to patient's altered mental status. They state patient has not been alert and oriented for the past 3 days. I was able to arouse the patient with multiple sternal rubs patient denied any pain or difficulty breathing. Patient is currently on 4L (liters) of oxygen nasal cannula at all times. I did review his previous records noted last time he was here he was in diabetic ketoacidosis as well. Grandmother states patient appears to be pale and diaphoretic. They state patient has been just sleeping for the past 3 days and is a complete change in behavior." Under the "physical exam" section, the note indicated "...bilateral lower extremity swelling and [MEDICAL CONDITION]." The note further indicated "...Patient is able to arouse with multiple sternum rubs. He answered the question to what his name was correctly. He did not stay awake to answer any further questions." The note further indicated "Critical care was necessary to treat or prevent life-threatening deterioration of the following conditions: [MEDICAL CONDITION]." A hospital discharge summary, dated 3/10/2013 indicated Resident #B was admitted to the hospital on [DATE] and was discharged on [DATE]. The summary indicated under "Hospital Course," "The patient is well-known to me with chronic [MEDICAL CONDITION] secondary to obesity, [DIAGNOSES REDACTED] and sleep apnea syndrome. He had been transferred to a nursing home more than a week ago...." The note further indicated "...with increasing problems with lethargy, (ophthalmologist's name) who happened to see him as an outpatient ophthalmologic consultation sent him to the emergency room where he was treated aggressively and after discussions with me, admitted to intensive care unit (ICU)...." The note further indicated "He was in obvious acute [MEDICAL CONDITION]. His blood gases revealed a pH of 7.16, pCO2 of 85, pO2 of 100 and oxygen (O2) saturation of 96%. He was treated aggressively with bi-level positive airway pressure (Bi-PAP) and much closer control of his sugars and diet and he showed gradual improvement. He was on diuretics." The note indicated admission [DIAGNOSES REDACTED]." The final discharge [DIAGNOSES REDACTED]." The note further indicated the resident's discharge medications included, but were not limited to, [MEDICATION NAME] (Atrovent), [MEDICATION NAME] ([MEDICATION NAME]), and [MEDICATION NAME] ([MEDICATION NAME]). LPN #3 was interviewed on 3/26/2013 at 1:45 P.M. During the interview, LPN #3 indicated the nurses were to transcribe the hospital discharge orders to the the facility admission orders [REDACTED]. LPN #3 further indicated the facility should have transcribed the facility admission orders [REDACTED]. The facility Director of Nursing (DON) was interviewed on 3/26/2013 at 1:55 P.M. During the interview, the DON indicated a second nurse was expected to verify any new admission orders [REDACTED]. The DON indicated it appeared the second nurse had not verified the orders and some of the medications had not been accurately transcribed from the hospital discharge orders onto the the facility's admission orders [REDACTED]. The facility's Nurse Practitioner (NP) was interviewed by telephone on 3/27/2013 at 3:15 P.M. During the interview, the NP indicated she had treated Resident #B's swollen left eye as a possible allergic reaction, as the swelling appeared to be localized. The NP further indicated she had not been aware that the resident had been receiving [MEDICATION NAME], [MEDICATION NAME], Atrovent, [MEDICATION NAME], or quinapril prior to admission to the nursing facility and had not been aware the medications had been indicated on the hospital discharge orders but had not been transcribed onto the facility's admission orders [REDACTED] Resident #B's physician/facility Medical Director was interviewed by telephone on 3/27/2013 at 3:45 P.M. During the interview, the physician indicated he had not been aware the hospital discharge orders had included [MEDICATION NAME], Atrovent or quinapril. He further indicated he would have continued the medications listed on the hospital discharge orders. He further indicated he did not routinely compare the facility admission orders [REDACTED]. The facility DON was interviewed on 3/28/2013 at 2:15 P.M. During the interview, the DON indicated the facility had not been aware Resident #B had not received the medications in question until 3/26/2013. A facility policy entitled "Physician Orders", dated 11/21/2012, was provided by the DON on 3/27/2013. The policy indicated "Once new admission /readmission orders [REDACTED]." The policy further indicated "Double check to ensure there were no transcription errors." The immediate jeopardy that began on 2/15/2013 was removed on 3/28/2013 when the facility audited the charts of all residents admitted or readmitted within the past 60 days to validate the accuracy of medication orders and corrected identified concerns. The facility also re-educated all licensed nursing staff on the transcription of orders, instituted a policy of review of all admission orders [REDACTED]. This Federal tag relates to Complaint IN 204. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident was transferred with a mechanical lift as care planned and incurred an acute left distal fracture of the femur (thigh bone) for 1 of 3 residents reviewed from the sample of 7 residents who met the criteria for accidents (Resident #95). Findings include: At 9:40 a.m., on 8/9/12, Resident #95 was observed asleep, sitting in a wheelchair in the Dining room, where an activity was in progress. The clinical record for Resident #95 was reviewed at 9:48 a.m., on 8/9/12, and indicated the resident was initially admitted on [DATE], and readmitted to the facility on [DATE] following surgical repair of a left leg fracture. [DIAGNOSES REDACTED]. The care plan, dated on 7/11/12 and updated 7/31/12, indicated the resident was at risk for falls, was non ambulatory, and dependent for transfers. A resident progress note, dated 7/15/12, at 5:30 a.m., and signed by LPN #1, indicated a Certified Nursing Assistant (CNA) reported the resident's leg was slightly swollen and flaccid when repositioning the resident. The note indicated the LPN assessed the resident and the left leg was slightly swollen to the thigh, there was a slight bulge noted to the left knee area and it was slightly warm to the touch under the knee area. The note revealed the physician was notified, an xray ordered, and the resident was a Hoyer (mechanical lift) transfer, but no transfer had occurred. There was no previous documentation in the clinical record of any incidents occurring regarding this finding. Review of a follow-up report to the Indiana State Department of Health (ISDH), provided by the Administrator at 10:45 a.m., on 8/9/12, and dated 7/20/12, indicated on 7/15/12, at 5:30 a.m., Resident #95 was noted to have a flaccid left leg which was normally contracted related to congenital [DIAGNOSES REDACTED]. The leg was warm to the touch behind the left knee, edema was noted to the left upper thigh, and the resident was essentially non-verbal. The resident pushed the staff away with care but this was normal for the resident, but the resident did moan with movement. The report indicated the resident returned to the facility on [DATE] following repair of a femur fracture, and the resident was to receive therapy. The report indicated the exact cause of the fracture remained unknown, however a history and physical from the Orthopedic physician revealed an acute left distal femur fracture versus subacute pathological fracture, and due to the resident's [DIAGNOSES REDACTED]. The report also indicated the resident was up in a wheelchair daily with the use of a Hoyer lift with two staff assistance. The Director of Nursing Services was interviewed at 11:20 a.m., on 8/9/12, and provided further investigative interviews with various staff members regarding the incident. She indicated an investigation was completed and the facility could not determine a reason for the fracture. The statements from staff were reviewed at 11:30 a.m., on 8/9//12. A statement documented on a resident progress note, dated 7/14/12 at 2:00 p.m., and signed by CNA#3 indicated, "When I came in (Resident#95) was still in her chair. I came in her room and got linen to clean her up. I got (CNA#5) to spot me using the Hoyer lift to change her clothes, her pants brief and shirt were wet I changed all her clothes and put lift back under her got her back in the chair for dinner. (sic)" The statement from CNA#3 further indicated after dinner she got CNA#4 to spot her using the Hoyer lift to put the resident to bed. CNA#3 indicated she and CNA #4 attached the pad back to the lift and put the resident in bed, undressed her bottom half, and noticed her leg was "not right. " CNA#3 indicated she immediately notified the nurse. The Director of Nursing Services was interviewed at 1:47 p.m., on 8/9/12, and indicated she thought the incident occurred on 2nd shift. She indicated CNA #3 did not tell the truth, but this was not discovered until 4 days after the incident occurred. The Director of Nursing Services indicated she and the Administrator interviewed CNA #3 and CNA #4 on either 7/18 or 7/19/12, and discovered CNA #3 and CNA #4 lifted the resident into bed, and did not use the Hoyer lift. The Director of Nursing Services indicated during this meeting, CNA #3 admitted she had lied about the incident, and said she and CNA #4 did not use a Hoyer for the transfer. The Director of Nursing Services indicated LPN #6 did not have care of the resident on 7/14/12, but CNA #3 had reported to her regarding the resident's leg. LPN #6 however did not document what she had assessed until 7/15/12. CNA #4 was interviewed at 2:16 p.m., on 8/9/12, and indicated she had only taken care of the resident one time prior to 7/14/12 . She indicated she worked the day shift on 7/14/12, but did not have care of the resident that day. She indicated she also worked the evening shift on 7/14/12, but did not have care of the resident. She indicated at approximately 8:30 p.m., on 7/14/12, CNA#3 asked her to come and spot her for a transfer. CNA#4 indicated when she went into the room, the resident was in her wheelchair, but had a "grimacing look" on her face. She indicated the resident did not say anything, but had her left hand on her left thigh, and was clutching her thigh. She indicated she and CNA#3 proceeded to place the resident into bed using a 2 man lift. She indicated she didn't remember seeing a lift pad under the resident in her chair when they transferred the resident. CNA#4 indicated the resident was moaning and groaning when they transferred her to bed. She indicated when the resident was in bed, CNA#3 noticed her leg was "funny" and also said the leg did not look right. CNA #4 indicated she told CNA #3 that she should tell the nurse immediately . CNA #4 also indicated when she first started working in April, she was asked to assist with a transfer of Resident #95 and they had lifted the resident using a 2 man lift. She indicated she was not aware the resident was a Hoyer, 2 person assist, until this incident had occurred. LPN #6 was interviewed at 3:15 p.m., on 8/9/12. She indicated she had worked at the facility for a few months, but had previous experience as a nurse. She indicated she was working on another hall on 7/14/12, and CNA #3 asked her to come into Resident #95's room. She indicated this occurred sometime after supper, but she was not sure of the time. She indicated CNA #3 told her the resident's leg looked "strange," so CNA #3 wanted her to check the resident. LPN #6 indicated when she went into the room, the resident was laying in bed, and she looked at her leg. She indicated the resident was not in acute distress, and was smiling and giggling, and LPN #6 asked the resident if her leg hurt, and the resident shook her head, "no." LPN #6 indicated the leg looked swollen and looked a little deformed and the resident's legs were contracted. LPN #6 indicated she told CNA #3 she needed to let her nurse know about this. She indicated when she left the resident's room, she saw the resident's nurse in another room, and CNA #3 was right behind her (LPN#6). LPN #6 indicated she did not know if CNA #3 reported the incident to the resident's nurse, but indicated she (LPN #6) did not. LPN #6 also indicated she did not document what she had observed. LPN #6 indicated she was scheduled to work the next day on 7/15/12, and the Director of Nursing asked her to document a statement about the incident. She indicated as far as she could recall, there was a Hoyer pad under the resident, but indicated, "can't be 100% positive Hoyer pad was under her." She indicated she had taken care of this resident prior to this incident, and had helped to put resident in bed several times using the Hoyer lift. CNA #2 was interviewed on the telephone, at 3:27 p.m., on 8/9/12. She indicated she was working the night shift on 7/14 to 7/15/12, and had care of the resident. She indicated normally if the resident was not wet on first rounds, she would be on 2nd and 3rd rounds. She indicated that night the resident was dry on the 1st and 2nd rounds, but had been incontinent on the 3rd round. She indicated when she went into the resident's room, the resident was whimpering more than usual that morning, and when she turned the resident, she was whimpering more and pushing at the CNA. She indicated when she turned the resident the other way, her "leg moved like jello" so she went and got LPN #1 who came down and checked the resident. CNA#2 indicated the resident's leg was more swollen than usual and "looked funny" and she knew something was not right. She indicated she came to work at 10:00 p.m., on 7/14/12, and started passing ice in the resident's room about 10:15 p.m., after she got report. She indicated she did not check or turn the resident at this time. She indicated she went back to the resident's room about 12:30 a.m. or so, and checked the resident and pulled her blanket back and the pads under the resident were not wet. She indicated the resident did not wear briefs at night, only a gown, and the pad under her was dry, so she did not turn the resident. She indicated she checked the resident again at 2-2:30 a.m., and the pad was still dry, so she did not touch the resident. She indicated the next time she went into the resident's room was approximately 4:30-5:00 a.m., and at this time, the resident was soaking wet. When she started washing the resident, she started whimpering more. She indicated the resident did not normally like to be bothered. She indicated when she turned the resident, her leg "looked like jello," so she reported this to the nurse. CNA #2 indicated she did not notice anything unusual until that morning, and no one had reported there was anything wrong with the resident. CNA #3 was interviewed by telephone at 3:35 p.m., on 8/9/12 and indicated she had worked on 7/14/12, the evening shift. She indicated she didn't normally take care of Resident #95, but usually worked the opposite side of the hall. She indicated she had assisted with the resident before but never taken care of her. She indicated she had assisted with Hoyer transfers on the resident prior to this incident. She indicated on 7/14/12, she was assigned to the resident. She indicated all of the CNAs worked as a group, and would talk and communicate with each other. She indicated the CNA on the prior shift would report about the residents regarding their care. CNA #3 indicated the day shift CNA had told her she had not laid the resident down and the resident needed changed and had to get up for supper. CNA #3 indicated the facility policy on the Hoyer lift required 2 staff be present during a Hoyer transfer. She indicated the resident was in her wheelchair when she came to work. She indicated she asked CNA #5 to spot her using the Hoyer lift so she could transfer the resident to bed and change her. She indicated CNA #5 spotted her during the transfer, but did not touch the Hoyer. CNA #3 indicated she changed the resident, cleaned her, that she was still on the Hoyer pad, then CNA #5 spotted her using the Hoyer to place the resident back in her chair for supper. CNA#3 indicated after supper, she completed care on the other residents, and could not find a Hoyer to use to put Resident #95 to bed. She indicated she asked CNA #4 to come to the resident's room, and together they transferred the resident to bed, using a 2 person lift, but did not use the Hoyer. She indicated after she and CNA #4 had transferred the resident to bed and changed her, she removed the resident's pants and noticed from the resident's knee to her thigh was "just huge," so she told CNA#4 to get the nurse. She indicated LPN #6 then came into the room and assessed the resident. She indicated LPN #6 did not report her findings to the other nurse, and she would have told the other nurse, but could not find her. She indicated LPN #6 did not tell her to report to the other nurse and she left without telling the resident's nurse. She indicated she received a disciplinary action for not using the Hoyer lift and received additional inservicing regarding use of the Hoyer. Review of the Certified Nursing Assistant assignment sheet, dated 7/14/12, provided by the Director of Nursing Services, at 9:10 a.m., on 8/10/12, and with CNA#3's name on the sheet, indicated the resident was a Hoyer 2 person assist for transfers. 3.1-45(a)(1)

Based on interviews and record review, the facility failed to prevent a cognitively impaired resident from leaving the facility unattended and failed to assure the safety of the resident when he was initially found outside of the facility. This resulted in the potential for serious harm for 1 of 1 resident, who left the facility unattended, in a sample of 6. (Resident #C) The immediate jeopardy began on 7/5/11, when Resident #C left the facility unattended. The Executive Director, Director of Nursing and Corporate Nurse were notified of the immediate jeopardy on 8/11/11 at 3:30 p.m. The immediate jeopardy was removed on 8/11/11, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record of Resident #C was reviewed on 8/11/11 at 10:30 a.m. and indicated the resident was readmitted from the hospital on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) Assessments, dated 4/26/11 and 7/7/11, indicated resident #C had scores of 10 and 8, respectively, on the BIMS (Brief Interview of Mental Status) indicating the resident had moderate cognitive impairments. The Wander/Elopement Risk Evaluations, dated 4/11/11 and 6/30/11, indicated Resident #C was not an elopement risk. On 7/4/11 at 10:30 a.m., nursing notes indicated Resident #C went out the back therapy door with a vendor. On 8/11/11 at 1:30 p.m., CNA #1 was interviewed regarding the incident. CNA #1 indicated, on 7/4/11, she was sitting at the smoking bench at the back of the building and saw Resident #C standing outside the therapy door by the back parking lot. She approached the resident and redirected him back into the building. The CNA indicated Therapist #2 came to meet them just as they entered the building. On 8/11/11 at 1:35 p.m., Therapist #2 was interviewed regarding the incident. She indicated Resident #C walked out of the facility with a vendor and the vendor went back into the facility and told her a resident had gone out of the door. On 7/5/11 at 5:45 p.m., nursing notes indicated the resident was seen in the assisted dining room. On 7/5/11 at 6:00 p.m., nursing notes indicated Resident #C was seen by an employee outside of the facility by the bus stop. A statement from Speech Therapist #5, who is no longer employed by the facility, dated 7/5/11, indicated: "When I was leaving from work at 5:40 PM on 7/5/11, I saw (Resident #C's name) by (Name of Pharmacy) walking toward Maplecrest Road; so I returned back to the facility & (and) checked with therapy whether he is allowed to be out of the facility for which they said; they did not know: then I went to (MDS Co-ordinators names #3 and #4) about what happened & (and) they went immediately to look for him; I was given a picture of (Resident #C's name) & (and) was asked to check for him in (Name of Pharmacy): I parked my car at (the Pharmacy) parking lot & (and) was about to go in (the Pharmacy) to check ; when I saw (resident's name) walking out of the pizza shop; I crossed the road & (and) helped him cross the road, got him in my car & (and) got him back into the nursing home/facility." A statement by the DON (Director of Nursing) indicated Resident #C was returned to the facility at 6:00 p.m., and when he was questioned, indicated he went out the side door. On 7/5/11 at 6:10 p.m., nursing notes indicated Resident #C was escorted back into the building and "..when asked how he got out res (resident) said he waited @ (at) the door til it opened..." The note indicated the resident was assessed and placed on one to one supervision. Subsequent nursing notes and monitoring sheets indicated Resident #C remained on one to one supervision through 7/9/11, when he was transferred to the secured unit. The incident was reported to the ISDH on 7/6/11 and the follow up report indicated the following preventive measures were taken: *Resident C's elopement risk evaluation was updated; *Pizza delivery numbers were posted and provided to the resident along with encouragement to request assistance from staff; *The door code was changed by the Maintenance Director, on 7/5/11; *All door alarms were inspected and were in working order; *A door inspection was completed by the door security vendor and the report indicated the elopement was not a result of system failure; *Resident #C's nutritional status was re-assessed to verify needs were being met; *Resident #C's care plan and CNA assignment sheet were updated; *Resident was transferred to the secure unit, on 7/9/11; *All facility residents' elopement risk evaluations, care plans and assignments were updated; *Elopement binders were updated; *Education on elopement policy and the elopement binders was provided to all staff including therapy, housekeeping and laundry staff; *Elopement drills were conducted each day from 7/6/11 through 7/11/11 and will be done monthly for 90 days. *Door security audits were reviewed between 1/11 through 6/11 with 100 percent compliance. *Door security audits were done and reviewed each day between 7/5/11 and 7/11/11. The immediate jeopardy that began on 7/5/11 was removed on 8/11/11, when the facility developed a systematic plan to provide inservice training, elopement drills, security audits, and safety reminder letters to families/vendors, post safety signs at the doors, assess all residents, develop care plans for residents at risk of elopement and develop elopement binders with information regarding procedures and residents. Although the immediate jeopardy was removed, the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy for residents at risk for elopement because of the need for ongoing monitoring. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to accurately complete physical assessment for 3 of 4 residents reviewed for change in condition in a total sample of 9, resulting in a rapid decline in condition for Resident #B. (Resident #B, #E, #J) The facility further failed to assess a surgical incision for 1 of 1 residents reviewed for surgical incisions (Resident #E) in a total sample of 9 residents. The wound eventually dehisced (opened up) and developed an infection. Findings include: 1a. Resident #B's record was reviewed on 11/17/10 at 11:50 a.m. Resident B's [DIAGNOSES REDACTED]. During the initial tour on 11/17/10 at 10:30 a.m., Resident #B was noted to be laying in a low bed with her eyes closed. She had a dark bluish bump noted in the middle of her forehead approximately 3 cm (centimeters) x 3 cm. "Doctor's Progress Notes", dated 10/20/10, indicated Resident #B had no complaints or medical concerns. Vital signs were temperature 96.8, pulse 85, respirations 18, blood pressure 110/48. The plan was to continue with present care and there was no indication decline was imminent. The current Minimum Data Set (MDS) assessment, dated 9/10/10, indicated Resident #B had short term memory deficit with long term memory intact, had moderately impaired decision making, and was able to make herself understood. "Resident Progress Notes" for Resident #B indicated the following: 11/5/10 at 6:10 a.m., Resident #B bumped her forehead above the right eye on the Hoyer lift during a transfer. Vital signs were temperature 96.4, pulse 84, respirations 18, and blood pressure 138/58 at the time of the occurrence. Neurological checks were monitored over the next 24 hours without a noticeable change. 11/05/10 at 10:20 a.m., Resident #B was alert and oriented to self only. 11/05/10 at 11:00 p.m., Resident #B had been moaning in pain during care/transfers, but the staff were unable to pinpoint or rate the discomfort. Routine pain medication was utilized successfully. There was no indication of assessment of Resident #B's level of consciousness. 11/7/10 at 11:45 a.m., Resident #B had complained of nausea at 8:30 p.m. Vital signs taken on 11/7/10 at 11:50 p.m. were temperature 97.0, pulse 98, respirations 18, blood pressure 102/52. There was no indication a blood sugar check had been completed or assessment of Resident #B's level of consciousness. 11/8/10 at 12:50 p.m., the Power of Attorney had been notified of nausea and vomiting. 11/8/10 at 10:30 p.m., Resident #B had been non-responsive to stimuli the entire shift. An oxygenation saturation was noted at 98-99% on room air, but no other vital signs were completed. There was no indication the physician had been notified. 11/9/10 at 3:25 a.m., did not indicate vital signs, a blood sugar check, or assessment of Resident #B's level of consciousness was performed. 11/9/10 at 2:30 p.m., indicated Resident #B had been non-responsive that shift. The nurse's note indicated vital signs were temperature 97.4, pulse 97, respirations 20, and blood pressure 104/53; oxygen saturation was 98%, and blood sugar was 143. The physician was notified of Resident #B's condition at that time. 11/9/10 at 11:00 p.m., vital signs temperature 98.3, pulse 125, respirations 18, blood pressure 140/64 and oxygen saturation 98%. An assessment of level of consciousness, only included that Resident #B did not arouse to take medications, fluids, or evening meal. 11/10/10 at 3:35 a.m., Resident #B remained unresponsive, vital signs were temperature 96.5, pulse 108, respirations 20, blood pressure 129/69 and oxygen saturation 95%. Blood sugar was listed as 170. A note for 1:30 p.m., indicated Resident #B was non-responsive. Vital signs were temperature 97.1, pulse 108, respirations 20, blood pressure 110/64 and oxygen saturation 97%. Although, it is noted the Power of Attorney did not want any pain management put into effect, intravenous fluids were acceptable, and the physician was notified. 11/10/10 at 3:30 p.m., Resident #B was nonresponsive with vital signs temperature 97.3, pulse 92, respirations 28, blood pressure 109/60 and oxygen saturation 92%. The note further indicated the resident's skin was warm, dry to touch and her mouth was dry. Resident #B's physician ordered intervenous fluids on 11/10/10 at 6:00 p.m. for dehydration. 11/10/10 at 10:15 p.m. Resident #B remained nonresponsive. There was no further assessment of vital signs. 11/11/10 at 8:30 a.m. indicated the intravenous fluids were not wanted by the Power of Attorney. A call was placed to the physician and the order for intravenous fluids was discontinued. 11/12/10 at 11:30 p.m. Resident #B took sips of water, two bites of dinner with coughing, and oxygen saturations were 83%. Oxygen was applied at 3 liters per minute by nasal cannula and oxygen saturations improved to 97%. A nursing measure was added to begin nectar thick liquids. 11/13/10 at 6:00 p.m. note indicated Resident #B opened eyes to verbal stimuli but included no other assessment of level of consciousness. 11/14/10s at 8:00 p.m., indicated Resident #B was awake, eyes were open, but without verbal response. 11/15/10 at 12 midnight, Resident #B had eyes open, but would not look at writer when called by name. 11/15/10 at 4:00 a.m., indicated Resident #B's respirations were 20, oxygen saturations were fluctuating between 83-94%, and she remained unresponsive. 11/15/10 at 10:40 a.m., family and Resident #B's physician were notified the resident had become unresponsive to verbal and physical stimuli and was not able to eat or take fluids. 11/15/10 at 3:00 p.m., the physician and family had made the decision to make a referral to hospice. A "Physician's Progress Note", dated 11/17/10, indicated Resident #B had experienced a significant decline in condition and that her condition was terminal. Resident #B's respirations ceased 11/18/10 at 3:45 a.m. During an interview on 11/19/10 at 10:15 a.m., Resident #B's physician indicated he was in the office on 11/8/10, but was not aware the resident was not responsive until the facility notified him on 11/09/2010. During an interview on 11/22/10 at 10:25 a.m., the Director of Nursing indicated Resident #B had non responsive episodes prior to the occurrence on 11/05/10, but no unresponsive episode had been associated with nausea and vomiting or lasted longer than one shift. 1b. During the initial tour on 11/17/10 at 10 :30 a.m., Resident #B was noted to be in a low bed with her eyes closed and a dark bluish bump was noted in the middle of her forehead approximately 3 cm x 3 cm. "Resident Progress Notes" for Resident #B indicated the following: On 11/05/10 at 6:10 a.m., indicated Resident #B bumped her forehead above the right eye on the Hoyer lift during a transfer. Vital signs were temperature 96.4, pulse 84, respirations 18, and blood pressure 138/58 at the time of the occurrence. Neuro checks were monitored over the next 24 hours without noticeable changes. On 11/05/10 at 10:20 a.m., indicated Resident #B was alert and oriented to self only. On 11/05/10 at 11:00 p.m., indicated Resident #B had been moaning in pain during care/transfers, but the staff were unable to pinpoint or rate the discomfort. A Pain assessment dated [DATE] indicated Resident #B was not able to indicate her severity of pain and the non-verbal pain scale was utilized. A nurse's note, dated 11/7/10 at 11:45 p.m., indicated Resident #B was complaining of nausea at 8:30 p.m. A "Pain Assessment", dated 11/8/10 indicated Resident #B's verbal pain score was zero. A nurse's note on 11/8/10 at 10:30 p.m., indicated Resident #B was non-responsive to stimuli that shift. A "Pain Assessment", dated 11/10/10 labeled R/T (related to) non responsive indicated Resident #B's verbal pain score was 0. No assessment of non verbal pain indicators had been completed. During an interview on 11/18/10 at 1:48 p.m., the Director of Nursing indicated a non-verbal pain assessment should have been completed. 2. Resident #J's record was reviewed on 11/18/10 at 2:30 p.m. Resident J's [DIAGNOSES REDACTED]. Nurse's notes, dated 11/16/10 at 8:00 p.m., a new order for a chest x-ray had been obtained for shortness of breath. The note contained the order, that the family and pharmacy were notified and a statement "...continue to monitor...." The note contained no other information regarding Resident #J's breath sounds, vital signs, oxygen saturation, or lung sounds. There was no indication in the nursing notes of breath sounds for the dates of November 15, 16 or 17. In an interview on 11/18/10 at 1:40 p.m., LPN #2 indicated Resident #J's son notified the nurse on duty of Resident J's shortness of breath. LPN #2 further indicated the nurse on duty should have assessed Resident #J's breath sounds and oxygen saturation and she was unsure if the nurse assessed Resident #J. In an interview on 11/18/10 at 2:43 p.m., the Staff Development Coordinator indicated when the nurse was informed of Resident #J's shortness of breath, he should have been assessed. A current policy entitled "Condition Change of a Resident", dated 10/31/06, was provided by the Staff Development coordinator on 11/18/10 at 2:40 p.m. The policy indicated "... Assess Resident...Take Vital Signs...." 3. The clinical record for Resident #E was reviewed on 11/17/10 at 10:30 a.m. [DIAGNOSES REDACTED]. Hospital discharge orders, dated 10/5/10, indicated [DIAGNOSES REDACTED]. A facility nursing admission assessment, dated 10/5/10, indicated "healed surg (surgical) wound on neck." A Resident Progress Note (nursing note), dated 10/5/10 at 11:00 p.m., indicated Resident #E had been admitted to the facility that day at 3:26 p.m. The nurse's admission assessment note did not indicate any surgical incision on the back of the resident's neck. A History and Physical completed by the physician, dated 10/6/10, indicated Resident #E had a cervical fusion (surgery of the spine in the neck) for spinal stenosis. The physical indicated the neck was within normal limits. A Physical Therapy evaluation for Resident #E, dated 10/6/10, indicated under "Sensation, Skin Integrity, [MEDICAL CONDITION]"... "staples over surgical incision (approx 5" ( five inches)) over posterior (back) of neck, no [MEDICAL CONDITION] (swelling) noted." A Weekly Skin Check Sheet for the month of October 2010 indicated Resident #E's skin was warm, dry, and intact each week it was checked. The sheet did not indicate any surgical incision on Resident #E's neck. A nurse note, dated 10/8/10 at 10:00 p.m., indicated "skin W/D/I (warm, dry, and intact)." A nurse note, dated 10/9/10 at 5:00 p.m., indicated "skin W/D/I." A nurse note, dated 10/10/10 at 5:00 p.m., indicated "skin clean, dry, & intact." A nurse note, dated 10/12/10 at 10:15 a.m., indicated "neck incision healed and appears as thin white line." There was no observation of staples to the area noted. A nurse note, dated 10/12/10 at 10:00 p.m., indicated "skin W/D/I/." A nurse note, dated 10/13/10 at 10:00 p.m., indicated "skin W/D/I." A nurse note, dated 10/16/10 at 10:40 p.m., indicated "skin W/D to touch." A nurse note, dated 10/21/10 at 8:00 p.m., indicated "skin W/D/I." A nurse note, dated 10/26/10 at 8:05 p.m., indicated "Skin clean, dry & intact." A nurse note, dated 10/26/10 at 2:50 p.m., indicated "Skin warm, dry, intact..." A nurse note, dated 10/28/10 at 10 p.m., indicated "Skin W/D/I." A nurse note, dated 10/31/10 at 10:12 a.m., indicated "Skin warm, dry , et (and) intact." A nurse note, dated 11/3/10 at 5:30 a.m., indicated "Skin warm et dry." Except for the nurse's note, dated 10/12/10 at 10:15 a.m., there were no documented assessments of Resident #E's surgical incision on his neck in the nursing notes until a note, dated 11/3/10 at 1:30 p.m., indicated "Incision to back of neck top area well healed, has one staple to middle of incision c (with) bump below staple area appear open c some yellow drainage (sic). Call placed to (surgeon's) office informed of above, will speak c (physician) call back (sic)." A nurse's note, dated 11/3/10 at 2:15 p.m., indicated "Return call from (physician). N.O. (new order) for [MEDICATION NAME] (antibiotic) 100 mg (milligrams) po (by mouth) BID (twice daily) x 10 days. Obtain wound cultures. Appointment made for [DATE]th 10:45 AM. Leave staple in place." A physician order, dated 11/3/10, indicated [MEDICATION NAME] 100 mg twice daily for 10 days was ordered. The order also indicated the drainage from the incision to Resident #E's neck incision was to be cultured and an appointment was to be scheduled with the surgeon on 11/9/10. A nurse's note, dated 11/3/10 at 2:50 p.m., indicated the culture of the neck wound was obtained. A Weekly Non-Pressure Skin Condition Report form for Resident #E, dated 11/3/10, indicated the date of the first observation as 11/3/10. The site/location was indicated as "post (posterior or back) neck incision." A note on the back of the report form dated 11/3/10 indicated "Incision now appears c one staple and opening up. Has scant amt. of yellow drng (drainage). Wound clinic appt - 11/9/10. Staple left in place. ABT (antibiotic) ordered." A report from the laboratory, dated 11/6/10, indicated the results from the culture of the drainage from the incision to Resident #E's neck were positive for Staphylococcus aureus (bacteria) and Streptococcus agalactiae (bacteria). A nurse's note dated, 11/9/10 at 2:00 p.m., indicated "Res (resident) LOA (leave of absence) to (surgeon) office R/T (related to) incision site back of neck. Area has reopened & small amt (amount) yellow tinged drainage. Has i (one) staple remaining." A nurse's note, dated 11/9/10 at 2:30 p.m., indicated "Return from (surgeon). N.O. for (wound clinic) appointment set for 11-12-10 at 12:30. POA (power of attorney) aware." A nurse's note, dated 11/9/10 at 2:30 p.m., indicated "N.O. also received to cont (continue) [MEDICATION NAME] 100 mg BID for a total of 14 days." A physician order, dated 11/9/10, indicated orders were received from the surgeon to place a dry, sterile dressing to the incision on Resident #E's neck and the [MEDICATION NAME] 100 mg twice daily was continued. An appointment at the wound clinic was to be scheduled that week. A dictated physician note, dated 11/9/10, indicated Resident #E was seen by the surgeon on that date. The note indicated "On physical examination there is an area of opening in the mid-portion of his wound with some evidence of drainage." The note also indicated "As a part of his treatment I cultured the incision and placed him on an oral antibiotic, 100 mg of [MEDICATION NAME] 1 po bid. I would also like him treated at the (wound clinic) for local care." A note on the back of the Weekly Non-Pressure Skin Condition Report form, dated 11/10/10, indicated "Area c small amt yellow drainage (tinged yellow) i (one) staple out now. Remains ABT continues (sic). Opened up more. Appt 11/12/10 c wound clinic." A nurse's note, dated 11/12/10 at 3:00 p.m., indicated "Res ret'd (returned) from wound clinic approx 1500 (3:00 p.m.). N.O. wash cervical wound c soap et H20 (water), apply [MEDICATION NAME] (antibiotic ointment) (small amt) xeroform (petroleum gauze dressing), et cover with dry gauze QD (every day). Recheck 11/22/10 @ 11:10 A.M.." A progress note from the (wound clinic), dated 11/12/10, indicated Resident #E was referred for the evaluation and management of a dehisced surgical incision. The note indicated the incision was 1.5 cm (centimeters) in length by 0.5 cm in width at the top of the incision and 1.2 cm in length by 0.2 cm in width at the bottom portion of the incision. The note described the incision as being pink and yellow with serous drainage (drainage containing serum, a clear watery fluid). The surgical incision to Resident #E's neck was observed on 11/18/10 at 1:20 p.m. The incision was on the back of the residents neck, midline over the spinal column. The incision was approximately 3 ,cm in length. The edges of the incision were well approximated (together and closed) at each end of the incision. There was an open area in the center of the incision which was approximately 0.6 centimeters in length and 0.3 cm in width. Depth could not be assessed. There was no redness or drainage noted. LPN #2 was interviewed on 11/18/10 at 1:20 p.m. during the observation of Resident #E's surgical incision. During the interview, LPN #2 indicated Resident #E had worn a cervical collar on his neck when he was first admitted to the facility. LPN #2 further indicated the incision to Resident #E's neck had been dong well, but then a small bump had developed and the incision had opened up. LPN #2 also indicated there were one or two staples in the incision at the time. LPN #2 indicated she thought the physician had removed the staples when Resident #E had gone to see him after the incision had opened up. The facility Assistant Director of Nursing (ADN) was interviewed on 11/18/10. During the interview, the ADN indicated she had assessed the incision on 10/12/10 and had not noted any staple in the incision. She further indicated the incision appeared to be healed at the time. The ADN further indicated if the incision had a staple in it, the incision should have been assessed a minimum of once per day by nursing staff and the assessments documented in the Nurse's Notes until the staple was removed and the incision was healed. She also indicated the incision should also have been assessed weekly during the weekly skin assessments and documented on the weekly skin sheets until the incision was resolved. The ADN also indicated nursing staff might have assumed the incision had been healed and no assessment was necessary because the admission assessment note had indicated the incision was healed and because there were no orders regarding incision care or staple removal on the hospital discharge orders. The ADN further indicated the Physical Therapist who had completed the physical therapy assessment on 10/6/10 and had noted the staples in the physical therapy assessment note was on vacation and was not available for interview. The ADN was interviewed again on 11/19/10 at 9:40 a.m. During the interview, the ADN indicated the facility did not have a policy on the assessment of surgical wounds. The ADN indicated surgical incisions were to be assessed at least once daily until healed and the assessment was to be documented in the nursing notes. This Federal tag relates to Complaint #IN 117. 3.1-31(c)(3)